Dụng Cụ Chỉnh Hình Và Chân Tay Giả Trong Phục Hồi Chức Năng (Ấn Bản Thứ 3)

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14
Orthoses in the Management of Hand Dysfunction
Noelle M. Austin and MaryLynn Jacobs
He who works with his hands is a laborer,
He who works with his hands and his mind is a craftsman,
He who works with his mind and his heart is an artist.
Unknown
The hand is the body's tool to interact with the surrounding
environment. A hand afflicted with disease or injury greatly
impairs the ability to function, even if normal functioning
proximal joints and muscles are present. The therapist's abil­
ity to provide clinical intervention can positively affect the
use of the hand and therefore overall function. One tool at
a therapist's disposal is orthotic intervention. The appropri­
ate use of orthoses during specific phases of tissue healing,
depending on the diagnosis, can be an effective adjunct to
traditional therapy techniques for restoring use of the limb.
Treatment decisions must be based on an integration of
knowledge and clinical experience along with information
specific to the individual patient, including diagnosis, general
medical status, and the physician's prescription. Clinicians
need to understand the principles associated with orthotic
design and fabrication.
This chapter focuses on orthotic fabrication for the hand
and upper extremity and includes discussion of ­nomenclature,
materials, mechanical and anatomical ­principles, and case
studies to provide examples of orthotic ­intervention with an
emphasis on critical thinking.
NOMENCLATURE
In the medical literature, the terms splint, brace, support, and
orthosis have similar definitions.1,2 This is often ­confusing to
physicians, therapists, students, insurance companies, and
even those who fabricate these devices. Are splints made by
a therapist? Is an orthosis made by an orthotist? In 1989, the
American Society of Hand Therapists (ASHT) put together a
task force to address issues such as proper nomenclature and
redefinition of orthoses in an attempt to enhance and clarify
communication among all ­disciplines.1 The task force devel­
oped a Splint Classification System (SCS) and addressed the
similarity in definitions of the words splint, brace, support,
and orthosis (Figure 14-1). The task force's review confirmed
that these words were so ­similar in nature that they were
used interchangeably in the hand therapy literature. Another
key issue that challenged the task force was how to define
orthoses to provide universal comprehension and approval.
Currently, there is a shift in nomenclature from the word
‘splint’ to ‘orthosis’ in order to follow Center for Medicare
and Medicaid Services (CMS) guidelines for billing and reim­
bursement purposes. Therefore, the word orthosis will be
utilized throughout this chapter and should be adopted in
clinical and billing documentation as well.3
Traditionally, orthoses have generally been described accord­
ing to their form (e.g., thumb spica splint, wrist cock-up splint,
ulnar gutter splint).4 This form-based nomenclature, however,
can often lead to confusion and misunderstanding regarding
the actual orthosis requested. The SCS painstakingly describes
most universally used orthoses according to their specific func­
tion (e.g., thumb immobilization splint, wrist/hand exten­
sion mobilization splint). This functional-based description of
orthoses gives clinicians a clear ­concept of what the orthosis
must look like and what its function should be. The specific cat­
egories described by the SCS are outlined in Figure 14-1.
Articular and Nonarticular Orthoses
Orthoses are classified into two broad categories: articu­
lar and nonarticular. Articular orthoses, the most ­common
14
LEARNING OBJECTIVES
On completion of this chapter, the reader will be able to:
1. Define immobilization, mobilization, and restriction or­thoses
and give examples of orthoses in each category.
2. Explain the differences among static, dynamic, serial static,
and static progressive orthoses and discuss which may be
appropriate at each of the three wound healing stages.
3. Identify the three arches of the hand along with creases
and discuss their significance.
4. Identify a 90-degree angle of pull and explain its impor­
tance in the application of force.
5. Describe the various handling and physical characteris­
tics of thermoplastic materials and discuss how they affect
orthotic fabrication.
6. Explain the importance of patient education related to
proper orthosis wear, care, and precautions.

Chapter 14  Orthoses in the Management of Hand Dysfunction
393
type of fabricated orthosis, are those that cross a joint or
series of joints. Examples of articular orthoses include a
wrist immobilization orthosis, proximal interphalangeal
(PIP) joint extension mobilization orthosis, and elbow
­flexion restriction orthosis. The word articular is implied
in the orthosis description and is not necessary in the title
of the orthosis.
Nonarticular orthoses do not cross a joint; instead,
they stabilize the body segment to which they are applied.
The ASHT recommends that clinicians include the term
­nonarticular before an orthosis description; an orthosis
used to ­stabilize the humerus would be called a ­nonarticular
humerus ­orthosis, and an orthosis designed to soley stabi­
lize a metacarpal would be called a nonarticular metacarpal
­orthosis. Without this designation, the orthosis fabricator
may not know whether to include or exclude proximal or
distal joints in the orthotic design.
Location
Location refers to the specific body part or joint levels acted
on by the orthosis. The primary joint is the target joint.
The secondary joints are included for protection, stabiliza­
tion, or comfort. When several primary joints are involved
(e.g., crush injury to the hand), the description of the orthosis
can be simplified by grouping all the joints together, such as
hand orthosis or digit orthosis.
Direction
Direction refers to the primary direction of the force applied
when the orthosis is worn. This includes flexion, extension,
radial or ulnar deviation, supination, pronation, abduction,
and adduction. Information regarding direction is essen­
tial because it tells the clinician the desired joint position­
ing. Direction notation is also critical when fabricating a
mobilization orthosis; accurate application of the direction
of force is essential to achieve the goal of joint or soft ­tissue
mobility.
Purpose of Orthosis
The purpose or intent of the orthosis is the single most impor­
tant aspect documented in the description. The purpose of
the orthosis can be to (1) immobilize a structure, (2) mobilize
a tissue, or (3) restrict an aspect of joint motion.
Immobilization
The purpose of an immobilization orthosis is simply to
place a structure in its anatomical or most comfortable rest­
ing ­position. Immobilization orthoses are perhaps the most
­common and simple form, although it can be used for com­
plex injuries. Immobilization orthoses immobilize the joints
they cross.
Mobilization
Mobilization refers to moving or stretching specific soft tis­
sues or joints to create change. The benefits of using mobi­
lization orthoses as a treatment modality have been well
documented in the literature.5–8 The effectiveness of mobi­
lization does not rely on stretching tissue but rather on the
facilitation of cell growth. The target tissue lengthens when
the living cells of the contracted tissues are stimulated (by
the application of force) to grow. This stimulation occurs
when steady tension is applied through the orthosis over a
specific period of time. The living cells recognize the ten­
sion applied and permit the older ­collagen cells to be actively
absorbed and replaced with new collagen cells oriented in
the direction of ­tension.9–16 Tissue growth has been clearly
demonstrated in certain ­cultures in which elongating certain
body parts, such as ­earlobes and lips, is popular. In these cul­
tures, dowels are used to serially increase the diameter of the
intended structure, slowly allowing expansion and accom­
modation of the new tension and diameter. Another com­
mon example includes the use of braces and retainers in the
dental field. There are three choices of orthotic design to
mobilize tissue, including serial static, static progressive, and
dynamic orthoses.
Splint or Orthosis
Nonarticular
Location
Articular
Location
Direction
Mobilization
Restriction
Immobilization
FIGURE 14-1  The American Society of Hand Therapists Splint Classification System.

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Section II  Orthoses in Rehabilitation
Restriction
Restriction orthoses restrict or block an aspect of joint
motion. These are generally simple orthoses applied in such
a way that they limit motion. Therapists can construct static
orthoses, dynamic orthoses, and forms of taping to become
types of restrictive orthoses because they can be made to
restrict some portion of joint motion while allowing full
motion in the opposite direction.
Examples
Figure 14-2 demonstrates the critical impact that the words
immobilization, mobilization, and restriction can have when
describing an orthosis. Within the PIP immobilization
orthosis (see Figure 14-2A), the PIP joint is immobilized in
a comfortable resting position to allow the involved struc­
tures to heal, commonly used for a PIP ligament sprain. The
PIP flexion mobilization orthosis stretches the PIP joint into
flexion to address a PIP extension contracture (using a static
progressive approach) (see Figure 14-2B). The PIP joint is
restricted from full extension but allowed to flex fully within
the boundaries of the PIP extension restriction orthosis,
which is commonly used for swan neck deformities when
the PIP joint pulls into hyperextension (see Figure 14-2C).
Design Descriptors
Design descriptors are used to increase clarity of the specific
orthosis request and provide detail in notes or for correspon­
dence to physicians or reimbursement sources. The design
descriptors are non-SCS nomenclature but are commonly
used by the hand therapy and surgery community.17 The most
commonly used descriptors are summarized in Box 14-1.
Choices of Orthotic Designs
The choices of orthotic design include familiar terminology:
static, serial static, dynamic, and static progressive orthoses.
An orthotic design should be chosen to achieve the goals of
immobilization, mobilization, or restriction of a specific tissue.
Static Orthoses
Static orthoses have a rigid base, immobilizing the joints they
traverse (Figure 14-3). A static orthosis provides stabilization,
protection, and support to a body segment such as the elbow,
wrist, or finger. Static orthoses are perhaps the most common
orthoses made. They can be used as an adjunct to treatment,
an exercise device, by blocking a distal or proximal joint to
increase glide of another joint or improve tendon excursion.
Serial Static Orthoses
Serial static orthoses or casts are applied with the joints, soft
tissue, or musculotendinous units they cross in a lengthened
position (near maximum) and are worn for extended ­periods
A
B
C
FIGURE 14-2  Three different proximal interphalangeal (PIP) joint
orthoses. A, PIP immobilization orthosis. B, PIP flexion mobiliza­
tion orthosis. C, PIP extension restriction orthosis.
Digit-based: Originates from the digit, allowing metacar­
pophalangeal joint motion
Hand-based: Originates from the hand, allowing wrist
motion
Thumb-based: Originates from the thenar eminence or
thumb, incorporating one or more joints of the thumb
Forearm-based: Originates from the forearm, allowing
full elbow motion
Circumferential: Encompasses the entire circumference
of the involved body part or limbsegment
Gutter: Includes only the radial or the ulnar portion of
the limb
Radial: Incorporates the radial aspect of the limb
Ulnar: Incorporates the ulnar aspect of the limb
Dorsal: Traverses the dorsal (posterior) aspect of the
hand or forearm
Volar: Traverses the volar (palmar, anterior) aspect of the
hand or forearm
Anterior: Traverses the anterior aspect of the body part
Posterior: Traverses the posterior aspect of the body part
BOX 14-1  Orthosis Design Descriptors

Chapter 14  Orthoses in the Management of Hand Dysfunction
395
of time (Figure 14-4). Tissue held in this end-range ­position
should react and accommodate by stretching into the desired
direction of correction. Serial static orthoses are often removed
during therapy and exercise sessions so that the ­clinician and
patient can work on the involved ­structures with modali­
ties such as heat, ultrasound, joint mobilization, and range
of motion (ROM). The orthosis or cast is then remolded to
maintain the gains made during the ­exercise ­session. This
design may provide greater patient ­compliance and ensures
that the tissue is being continually stressed without the risk
of the tissue rebounding (reverting back to ­original short­
ened state) upon removal of the orthosis. Some therapists use
an approach with serial static orthoses when the orthosis is
worn continuously for a few days and then removed in therapy.
In other cases, using these orthoses at night only can help
maintain the gains made throughout the day with exercise and
stretching. Nonremovable serial static orthoses may also be a
better choice for patients who are young, who have cognitive or
behavioral issues, or who have fluctuating tone and spasticity.
Dynamic Orthoses
Dynamic orthoses use an elastic-type force to mobilize spe­
cific tissues to achieve increases in ROM (Figure 14-5). Most
dynamic orthoses have a base that permits the attachment of
various outriggers and components. The mobilizing forces
applied through a dynamic orthosis are elastic (stretchy) in
nature, such as rubber bands, springs, or wrapped ­elastic
cord. The dynamic force applied continues as long as the
­elastic component can contract, even when the tissue reaches
the end of its elastic boundary.18
Static Progressive Orthoses
Static progressive orthoses achieve tissue mobilization by
applying low-load force to the tissue's end range in one direc­
tion over a long period of time (Figure 14-6).5 The goal is
that the tissue will eventually accommodate to this position.
The fabrication of a static progressive orthosis is similar to a
dynamic orthosis, but the force applied is static or nonelastic.
The mobilization force can be generated through static line,
nonelastic strapping materials, hinges, turnbuckles, and vari­
FIGURE 14-3  This anterior elbow mobilization orthosis, including
the wrist, is used to prevent forearm rotation.
FIGURE 14-4  This proximal interphalangeal extension ­mobilization
orthosis is designed to address a flexion contracture using a serial
static approach.
FIGURE 14-5  This elbow flexion mobilization orthosis uses a ­rubber
band to apply a dynamic force.

396
Section II  Orthoses in Rehabilitation
ous types of inelastic tape. When the joint position is achieved
and the tension on the static progressive ­component is set,
the orthosis will not continue to stress the tissue beyond its
elastic limit.18 Force can be altered by the patient or ­therapist
through progressive adjustments. Some patients may ­tolerate
static progressive orthoses better than dynamic. One ­reason
may be that the joint position is constant while the tissue
accommodates gently and gradually to the tension, without
the influences of gravity and motion.18,19
Objectives for Orthotic Intervention
The key objective for orthotic fabrication may not always be
straightforward. The objectives for orthotic intervention may
be multiple, as in a wrist and hand immobilization ­orthosis
(resting hand orthosis) used on a patient with rheumatoid
arthritis. The orthosis may be constructed to immobilize
inflamed arthritic joints, yet place the metacarpophalangeal
(MP) joints serially in a gently extended and radially ­deviated
position to minimize ulnar drift and periarticular deformity.
Critical thinking is a necessary process when fabricating
orthoses; multiple injuries, wound status, age, and lifestyle
are a few of the key factors that must be taken into consider­
ation. More skilled clinicians can appreciate that there can be
several purposes for one orthosis; therefore creative problem
solving must be used when fabricating orthotic devices for
the more involved, complex injury.
Immobilization Orthoses
Orthoses designed to hold or immobilize a joint or limb
­segment can be used to do the following17:
• Provide symptom relief
• Protect and position edematous structures
• Aid in maximizing functional use
• Maintain tissue length
• Protect healing structures and surgical procedures
• Provide support and protection for soft tissue healing
• Maintain and protect reduction of fracture
• Improve and preserve joint alignment
• Block and transfer muscle and tendon forces
• Influence a spastic muscle
• Prevent possible contracture development
Mobilization Orthoses
Orthoses designed to change or mobilize tissues or structures
are used to do the following17:
• Remodel long-standing, dense, mature scar
• Elongate soft tissue contractures, adhesions, and musculo­
tendinous tightness
• Increase passive joint ROM
• Realign or maintain joint and ligament profile
• Substitute for weak or absent motion
• Maintain reduction of an intraarticular fracture with
­preservation of joint mobility
• Provide resistance for exercise
Restriction Orthoses
Orthoses designed to restrict or limit motion may be used to
do the following17:
• Limit motion after nerve injury or repair
• Limit motion after tendon injury or repair
• Limit motion after bone or ligament injury or repair
• Provide and improve joint stability and alignment
• Assist in functional use of the hand
ANATOMY-RELATED PRINCIPLES
Therapists treating the upper extremity need to have a thor­
ough understanding of the complex anatomical features of the
hand and arm to manage patients with dysfunction effectively.
Disturbance of the delicate relationship between the bones, mus­
cles, nerves, and other soft tissue structures, either by disease or
trauma, can result in disruption of ­normal ­function. Knowledge
of normal anatomical features and how pathological conditions
affect them is important for ­therapists to make appropriate clin­
ical decisions regarding treatment interventions.11,20–22
Arches of the Hand
The configuration of the bones in the hand, along with the
tension of the muscles and ligaments in this region, contrib­
ute to the creation of an arch system composed of the prox­
imal transverse, distal transverse, and longitudinal arches
(Figure  14-7).23,24 This arch system is vital for positioning
FIGURE 14-6  This metacarpophalangeal flexion mobilization ortho­
sis uses a static line and component to apply a static progressive force.
Longitudinal
arch
Proximal
transverse
arch
Distal
transverse
arch
FIGURE 14-7  The fixed proximal transverse arch, the flexible dis­
tal transverse arch, and the mobile longitudinal arch of the hand.

Chapter 14  Orthoses in the Management of Hand Dysfunction
397
the hand to allow for normal function related to grasp and
­prehension.24,25 Incorporating these arches within an orthosis
is essential to allow maximal function and comfort. Including
the arches also prevents orthosis migration on the extremity.
The fixed proximal transverse arch is created by the config­
uration of the distal row of the carpal bones and the taut volar
carpal ligament. This region is also referred to as the carpal
tunnel, through which the long flexors and median nerve pass
en route to the hand.26 This fixed structure provides mechani­
cal advantage to the flexors, maximizing grasp function.
The mobile distal transverse arch is located at the level of
the metacarpal heads. This arch is adaptive by the mobile ulnar
fourth and fifth carpometacarpal (CMC) joints and highly
mobile thumb trapeziometacarpal joint.27 This increased mobil­
ity of the peripheral digits allows for optimal grasping abilities.
The longitudinal arch spans the length from the metacar­
pal to the distal phalanx. A disruption of this arch occurs in
patients who have sustained an ulnar nerve injury with result­
ing loss of intrinsic muscle function. In this situation, the
hand takes on an intrinsic minus position with the MP joints
hyperextended and the PIP and distal interphalangeal joints
flexed (clawlike deformity).23
Palmar Creases
The regular arrangement of creases is easily visible on the volar
surface of the hand (Figure 14-8). The thick palmar skin is fixed
to the underlying structures by fibrous connections that aid in
formation of these creases.27 Therapists need to appreciate the
location of these creases and how they ­correlate with the under­
lying anatomy. Commonly, these creases are used by therapists
as an anatomical guide when creating orthosis patterns. For
example, the distal palmar crease and proximal palmar crease
must be fully cleared when fabricating a wrist immobiliza­
tion orthosis to allow for unrestricted ROM at the MP joints.
However, care must be taken not to clear too much because the
mechanical advantage of the orthosis can be adversely altered.17
Metacarpal Length and Mobility
Dual obliquity is a concept relating to the anatomy of the meta­
carpals.23,25 Because of the differing lengths of the metacar­
pals (radial side of hand longer than ulnar), when an object is
held in the hand, an oblique angle is formed compared with
the distal ends of the radius and ulna (Figure 14-9A). In addi­
tion, the object is angled in accordance with the distal trans­
verse arch and increasing mobility of the ulnar metacarpals (see
Figure 14-9B). This dual obliquity should be incorporated into
the orthosis to provide a comfortable and functional orthosis
that resists migration because of the incorporation of the arches.
Distal
Middle
Proximal digital
crease
Distal
Proximal
thumb
crease
Proximal palmar
crease
Distal palmar
crease
Thenar crease
FIGURE 14-8  Creases of the hand can provide helpful landmarks
during the orthotic fabrication process.
FIGURE 14-9  The dual obliquity of the hand, from the dorsal (A)
and transverse (B) perspectives.

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Section II  Orthoses in Rehabilitation
Positioning the Hand
When deciding how to position the hand within an ortho­
sis, many factors must be considered, including the patient's
diagnosis, healing time frame, and intervention goals. Being
mindful of proper positioning within an orthosis initially can
help prevent future joint and soft tissue contractures. The two
most common positions described in the literature include the
­position of function and the position of rest.17,28 See Figure 14-10
for the general joint angles described for each position.
The antideformity position considers the unique
­anatomical characteristics of the MP and PIP. The length of
the ­collateral ligaments at the MP joint varies according to
the position of the MP joint (Figure 14-11).29 The collateral
­ligaments are slack with MP joint extension, whereas tension
in the ­collateral ligaments increases with greater amounts
of MP joint flexion. Placing the joints in flexion within an
­orthosis helps prevent MP joint extension contractures
­(limited ­flexion). If the joints were placed in extension with
­resulting MP ­contractures, the disruption of the longitudinal
arch would greatly impair grasping abilities.
Similarly at the PIP joint level, the volar plate is placed
on tension with PIP joint extension, whereas flexion at
the PIP joint places the volar plate at risk for shortening
(see Figure  14-11A and B).29 Shortening of the volar plate
could result in debilitating PIP joint flexion contractures,
which can significantly affect the ability to grasp and espe­
cially release objects. Therefore careful positioning of the
PIP joint in extension (as long as not contraindicated per the
diagnosis) is crucial to maintain the length of the volar plate.
Tissue Precautions
In the upper extremity, a number of areas exist where bony
protuberances or superficial nerves are highly susceptible to
compression from orthoses (Box  14-2).30 If these areas are
not accounted for in the fabrication process, the orthosis will
likely be uncomfortable for the patient and therefore possibly
not worn. Special consideration must be given to the patient
with impaired sensation (those with peripheral nerve injury,
neuropathy, nerve root compression, or ­central ­nervous
­system disorders). Those with limited or absent ­sensation do
not have the normal ability to feel or detect areas of excess
pressure; instead, they must rely on visual inspection to
­determine integrity of skin and soft tissue.
Because superficial bony prominences have minimal soft
tissue coverage, they are vulnerable to compression. Excessive
external pressure can place the tissue at risk for irritation and
eventual breakdown (necrosis). Older adults may be at most
risk because they commonly have minimal subcutaneous
fat combined with extremely fragile skin, making the bony
areas more apparent. Patients may report pain, redness, and
­irritation over the bone area. To prevent such occurrences,
these at-risk areas on the orthosis can either be ­padded
with foam/gel or flared away during the molding process
(Figure 14-12).17
FIGURE 14-10  The functional position of the hand (A) places the wrist in 20 to 30 degrees of extension, the metacarpophalangeal (MP)
joints in 35 to 45 degrees of flexion, the proximal interphalangeal (PIP) joints in 45 degrees of flexion, the distal interphalangeal joints in a
relaxed flexed position, and the thumb in palmar abduction. The antideformity position of the hand (B) places the wrist in 30 to 40 degrees
of extension, the MP joints in 60 to 90 degrees of flexion, the PIP and distal interphalangeal joints in extension, and the thumb in palmar
abduction.

Chapter 14  Orthoses in the Management of Hand Dysfunction
399
Therapists must also appreciate peripheral nerve anatomy
and how orthoses and strapping may place undue pressure over
these regions where nerves become relatively superficial, poten­
tially leading to nerve compression.31 Patients may report pain,
redness, paresthesias (tingling), and numbness in that nerve's
distribution. Timely modification of the orthosis is necessary to
prevent long-term nerve irritation. Orthotic fabrication over gel
or the use of wider straps to disperse the pressure better are two
techniques that may be useful to address this issue.17
Also of note is the potential for compression of vascular
structures when an orthosis is worn or an elasticized prod­
uct is applied.32 Symptoms of vascular compromise include
throbbing, color changes, temperature changes, and pain
should immediately be dealt with. Reporting these symp­
toms is especially important if any surgical reconstruction of
­vascular structures was performed. Wide straps and slings to
distribute pressure maximally along with the appropriate use
of elasticized wraps can aid in preventing this ­problem.24 Most
important, educating the patient regarding these ­potential
signs and symptoms of bony and neurovascular compro­
mise is key to preventing any long-term problems caused by
orthotic application.
TISSUE HEALING
The phases of specific tissue healing (e.g., bone, nerve,
­tendon, ligament) aid in directing appropriate orthosis selec­
tion, fabrication, and wearing schedule.33,34 Appreciation of
what role an orthosis can play during each phase is a critical
step in the critical thinking process (i.e., knowing when to rest
­tissue versus mobilize tissue). Clinicians must recognize that
although the stages of tissue healing are described as chrono­
logical, overlap in their incidence can occur. For example, in
a patient who has suffered a traumatic snow blower injury
and sustained soft tissue, bone, tendon, and nerve damage,
BONY PROMINENCES
• Olecranon process at the elbow
• Lateral and medial epicondyles of the humerus
• Ulnar and radial styloid processes at the wrist
• Base of the first metacarpal
• Dorsal thumb and digit metacarpophalangeal and
interphalangeal joints
• Pisiform bone
SUPERFICIAL NERVES
• Radial nerve at the radial groove of the humerus
• Ulnar nerve at the cubital tunnel
• Superficial branches of the ulnar and radial nerves
at the distal forearm
• Median nerve at the carpal tunnel
• Digital nerves on the volar aspect of digits
BOX 14-2  Superficial Structures Vulnerable
to Pressure
FIGURE  14-12  Padding bony prominences, such as the ulnar
­styloid, before molding of the orthosis can decrease the risk of high-
pressure areas and potential for skin irritation or breakdown.
FIGURE  14-11  Soft tissue length changes associated with joint
positioning. A, Placing the metacarpophalangeal (MP) joint in
extension will cause the MP collateral ligaments and the proximal
interphalangeal (PIP) volar plate to become “slack” and at risk of
becoming shortened. B, Placing the MP joint in flexion elongates
both the MP collateral ligaments and the volar plate of the PIP joint
to minimize risk of shortening (contractures) of these structures.
A
B

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Section II  Orthoses in Rehabilitation
depending on the severity of each of these injuries, healing
rates of each specific tissue may be different even though it is
the same hand. As the healing stages overlap, so may the time
frames for using specific orthosis designs.
Stages of Tissue Healing
Therapists must understand how each specific injury affects
the surrounding tissues. For example, ­immobilization
­orthoses may be indicated throughout the length of the
­healing process but are most commonly used during the
inflammatory stage. The three main phases of tissue healing
are the inflammatory, proliferative (fibroplasia), and remod­
eling (maturation) phases (Figure 14-13).
During the inflammatory phase, an influx of white blood
cells occurs to cleanse the area (edema).35,36 Clinically the tis­
sue feels soft, boggy, and easy to mobilize. This stage typically
lasts for 1 week or less. Rest is normally more important than
exercise during the inflammatory stage, so immobilization
orthoses are appropriate in the days immediately after tissue
injury or surgery.24
During the proliferative phase, collagen is laid down
and the wound gains strength. The clinician begins to see
and feel more tissue resistance (scar adherence), although
the ­tissue is still soft and “movable” with tension. This
phase lasts from 1 to 6 weeks. Mobilization orthoses that
­gently stretch tissue can be effective during this time frame.
They provide ­gentle stress that can facilitate tissue growth,
­resulting in tissue lengthening.1,13
The last phase of tissue healing is referred to as the remod­
eling phase. During this stage the collagen is organized as
it remodels along lines of stress. The tensile strength of the
­tissue is enhanced. Clinically, the tissues involved feel dense,
hard, and inelastic. Tissues may actually shorten because of a
decrease in elasticity; therefore stretching is a valuable tool to
address unwanted contractures. Superficial scars also begin to
soften during this stage. This stage begins as early as 6 weeks
and can last up to 12 to 24 months. Serial static and static
­progressive approaches (or a combination of the two with day
and night orthoses) to mobilize tissue during this phase are
most appropriate.5
Factors That Influence Tissue Healing
Tissue healing is influenced by several factors. For ­example, tis­
sue that is deprived of oxygen requires a longer healing time
and influences the orthosis wearing time. Therapists must thor­
oughly discuss medical history and lifestyle ­habits with the
patient to determine any factors that may delay or impair tissue
healing. Tobacco (nicotine), for example, diminishes the body's
ability to heal, decreasing blood flow and ­nutrition to the tis­
sue.37 Excessive alcohol intake can impair the immune system,
leading to malnourishment and liver damage.38 There are vari­
ous factors that influence the rate of tissue healing (Box 14-3).17
MECHANICAL PRINCIPLES
Before fabricating an orthosis, therapists need to know basic
mechanical principles and be able to integrate this information
into the orthotic design and construction process.17,24,33,39,40
This section briefly reviews the most common principles to
consider. Careful attention to the following principles will
improve the fabrication, function, and fit of an orthosis.
Levers
Levers are rigid structures through which a force can be
applied to produce rotational motion about a fixed axis.17
A lever system is composed of a fulcrum, or fixed axis, and
two arms: the effort arm and resistance arm. The effort arm,
also referred to as the force arm, is the segment of the lever
between the fulcrum and the effort force that is attempting
to stabilize or mobilize a structure. In orthotic design, the
­fulcrum corresponds with the anatomical axis of the ­target
joint, the effort arm is the segment of the orthosis that applies
the effort force, and the resistance arm is the segment of the
limb that resists the effort force. Ideally, the effort and resis­
tance forces work in concert to create opposing torques
Stage of Healing
Inflammatory
Proliferative
Remodeling
Splint Type
Static
Serial static
Static progressive
Dynamic
FIGURE 14-13  An algorithm for the uses of various types of ortho­
ses according to the stages of healing.
COMMON FACTORS
• Age
• Nutritional status
• Tobacco use
• Diabetes
• Edema
• Infection
• Rheumatoid arthritis
LESS COMMON FACTORS
• Alcohol use
• Sickle cell disease
• Steroids
• Radiation therapy
• Peripheral vascular disease
• Raynaud's disease
• Systemic lupus erythematosus
BOX 14-3  Factor That Influence Tissue Healing

Chapter 14  Orthoses in the Management of Hand Dysfunction
401
about the fulcrum. However, cases occur in which the axis
of ­rotation (fulcrum) has been interrupted from disease or
injury (e.g., fracture, rheumatoid arthritis).
Most orthoses are categorized as first-class levers in
which the fulcrum is between the effort and resistance arms
(Figure 14-14). Common examples of first-class lever ­systems
are a seesaw, a pair of scissors, or a pair of pliers. The goal
when designing an orthosis is to create the most efficient
work. The length of the resistance arm greatly influences the
mechanical advantage of the force applied. The effort arm of
the orthosis can also influence mechanical advantage by how
carefully it is molded about the body part.
Both the effort and resistance arms should be vigilantly
formed, incorporating arches, clearing for creases, and allow­
ing adequate surface area for maximal distribution of pressure.
As forces actively influence a joint, a balance-counterbalance
effect must occur. If the opposing force (effort arm) is not dis­
tributed well to counterbalance the distal forces (resistance arm),
the orthosis may not sit flush with the body part. This may create
high-pressure areas, shear stress, and an unproductive applica­
tion of force. Clinicians can ­generate “mechanical advantages”
through careful application of orthotic principles and meticu­
lous attention to detail while molding. Clinically, orthoses tend
to be most comfortable when well molded, incorporating ade­
quate length and depth. Short, narrow, and shallow orthoses can
cause increases in localized pressure and overall discomfort.
Stress
Stress can occur in various forms. The most common types
that relate directly to application of orthoses are compres­
sion, shear, tension, bending, and torsion.17 Compressive
stress (also referred to as pressure) is defined as force per
unit area. In the process of creating and planning an orthosis
design, ­therapists must understand the various forms of stress
that can be produced by the external forces of an ­orthosis.
For example, compression can be minimized by ­increasing
the surface area (designing the orthosis base wider and lon­
ger) over which the force can be maximally distributed.
Optimizing the conformity of materials to the shape of the
body part can minimize compressive stress.
A number of factors can result in areas of high pressure.
Narrow strap width, especially in conjunction with “shallow”
orthoses, can produce high compressive stress on the soft
­tissue. Orthosis borders should lie flush with the skin surface
that the strap traverses. The strap should not bridge the two
borders of the orthosis; it should come in contact with the skin.
The slings used in mobilization orthoses are another pos­
sible source of compression stress that should be consid­
ered, especially if edema or neurovascular issues are evident
in the patient's limb. Compression to the lateral, dorsal, or
volar aspects of the digit can be avoided by using several tech­
niques. The orthosis line can be attached to each side of a
sling (two pieces of line), then joined after they pass through
the pulley. This design prevents the circumferential compres­
sion created when one line is threaded through both ends of
the sling. Alternatively, a custom-fabricated thermoplastic
“pan” can be placed under the sling as a support. The digi­
tal pan disperses the compressive forces applied through the
sling by lifting the borders away from the skin and increasing
the area of force application (see Figure 14-2B).
Shear stress results from a parallel force applied to the sur­
face and produces a tendency for an object to either deform or
slide along the surface.17 When fabricating mobilization ortho­
ses, the mobilizing force, which is attached to the proximal
orthosis base, usually traverses the length of the orthosis and
terminates distally at the body segment. If the proximal portion
(base) of the orthosis is not adequately secured to the limb with
appropriate strapping, there will be an undesirable migration
or dragging and shearing of the proximal base over the skin
when the mobilization force is distally applied (Figure 14-15).
Being mindful of incorporating the arches of the hand as well
Resistance arm
Fulcrum
Effort arm
FIGURE 14-14  The fulcrum of a orthosis is placed at the axis of joint
motion. The resistance arm is applied by the proximal segment of the
orthosis; the effort arm is applied by the distal segment of the orthosis.
FIGURE 14-15  When tension is applied to this wrist flexion mobi­
lization orthosis, shear stress is created as the proximal orthosis
migrates distally on the forearm.

402
Section II  Orthoses in Rehabilitation
and obtaining a well-contoured orthosis during the mold­
ing process aid in preventing this migration. In some cases, a
nonskid material such Dycem (Dycem Technologies Limited,
Bristol, England) or foam tape to line the orthosis can also help
keep the orthosis stable on the extremity.
Angle of Force Application
The angle of force application is critical to the proper design
and fabrication of mobilization orthoses. Ideally, the force
should be applied 90 degrees to the body segment being
mobilized (Figure 14-16), which maximizes the therapeutic
effect of the force being applied.17,24 With a pure 90-degree
orientation to the part being mobilized, there are virtually no
forces disseminated in other directions (compression or dis­
traction). However, if the angle is other than 90 degrees, a
portion of the force is dissipated elsewhere, thereby dimin­
ishing the therapeutic effect and causing potentially harmful
compression or shear stress.
Clinically, the use of custom-made or prefabricated line
guides or pulleys can be helpful to achieve a 90-degree angle
of application. The therapist must view the orthosis from
all angles to ensure that the line of application is directed
­centrally over the segment and oriented properly in all planes.
To improve flexion of the digits with a mobilization ortho­
sis, the anatomical configuration of the hand necessitates the
line of force application to converge toward the scaphoid.
If this orientation is not incorporated into the design of the
orthosis, excessive stress is placed on the digit joints, causing
­discomfort and potential harm. Occasionally, a force applied
in either a radial or ulnar direction is indicated, as with post­
operative MP joint arthroplasties or sagittal band repairs.
Except for special circumstances such as these, the line of
application should be centrally located over the longitudinal
axis of the bone being mobilized.
Force Application
When using elastic force to mobilize stiff structures, thera­
pists must consider the therapeutic objectives.41–43 Is the goal
mobilization of a mature, dense joint contracture, or is ­it sta­
bilization of the MP joints in extension after MP joint arthro­
plasty? Both situations may require an elastic force; however,
both the amount of force and the materials used to achieve
these goals can vary considerably.44 The amount of force
necessary to mobilize various tissues depends on such fac­
tors as ­individual tolerance, ­diagnosis, stage of ­tissue ­healing,
chronicity of problem, severity of ­contracture, ­density of
contracture (end feel), age, smoking, alcohol use, and other
health-related issues. Ranges of 100 to 300 g have been
­suggested for mobilization of the small joints of the hand,
whereas higher parameters (350+ g) may be more effective for
larger structures.1,24 This 300 g of force is based on what is tol­
erated per unit of surface area of the skin, not the tolerance of
the contracted tissue to ­tension. In most cases, skin ­tolerance
becomes the limiting factor in ­determining ­appropriate
­tension, not the risk of injury to the specific targeted tissue.
The therapist can almost always rely on the tissue's response
to the tension to help determine the ­effectiveness of the mobi­
lizing forces. Signs of too much stress include edema, skin
blanching, ­vascular changes, and pain. The amount of time
the force is applied is another ­factor to consider with mobili­
zation orthoses.45 In general, the goal is to provide a low load
stress to the tissue over a long period of time.
MATERIAL AND EQUIPMENT
Numerous companies market and distribute supplies for
orthotic fabrication (Box 14-4), which include many types of
thermoplastic material, strapping, component systems, and
equipment. The best way to become educated regarding what
is on the market is by spending time reviewing the catalogs/
websites and contacting local sales representatives to request
samples. In addition, attending orthotic fabrication work­
shops and hand therapy conferences can be a helpful means
to gain knowledge and practice skills that can be used in the
clinical setting.
Thermoplastic Materials
Low-temperature thermoplastics are the most commonly
used material by therapists to fabricating custom orthoses.
The ­material is sold in sheets or precut designs also known
as ­orthosis banks. The material is softened in warm water
before application to the body part. Once on the body part,
FIGURE  14-16  Note the optimal 90-degree angle formed by the
proximal phalanx and the monofilament line in this metacarpopha­
langeal flexion mobilization orthosis.

Chapter 14  Orthoses in the Management of Hand Dysfunction
403
the material cools and hardens into shape. Therapists can
select from a wide range of thermoplastic material, ­making
the choice of which to use for a specific patient confusing
for novice ­practitioners. The orthosis fabricator must have
a sound understanding of the differences to be able to make
an informed decision, ­taking into account the purpose of the
orthosis and the specifics of a particular patient's ­diagnosis.
In addition to considering the patient's needs, other ­factors
therapists must consider include level of orthotic ­fabrcation
­experience, ­availability of materials, and any cost constraints.
Few studies have examined the characteristics of ther­
moplastic materials in an attempt to categorize their differ­
ences.46–48 However, a knowledge of handling and physical
characteristics and the different categories of thermoplastic
materials can help therapists make informed selections.
Handling Characteristics
Handling characteristics refer to the way a material behaves
during the molding process. The three most important
­characteristics of orthosis materials that must be considered
are conformability and resistance to stretch, memory, and
bonding characteristics.
Conformability and Resistance to Stretch
The ability for a material to conform to a body part is related
to its level of resistance to stretch (Figure 14-17).49,50 A help­
ful system for organizing thermoplastic materials is to group
them into categories according to their degree of resistance
to stretch (Table 14-1).49,50 Materials with minimal ­resistance
to stretch are highly conforming and may not be the best
choice for novice orthosis fabricators. The less hands-on the
better during the fabrication process because this ­material
tends to contour well without much assistance. Gravity-
assisted ­positioning during the molding process is essential.
These materials may be appropriate for the patient who has a
high level of pain and would not tolerate hands-on ­molding
or for those orthoses for which achieving an intimate fit is
crucial to maximize comfort. Smaller orthoses such as finger
or hand-based can be made with these highly conforming
materials.
Materials with maximal resistance to stretch are
­minimally conforming and demand more hands-on work
from the orthosis fabricator to obtain a desireable fit.
Therapists with nominal orthotic fabrication experience
may do ­better with these materials because they tolerate
more aggressive ­handling. These materials are appropri­
ate for use when ­fabricating larger orthoses such as for the
elbow or in situations in which fabrication against gravity
is not an option (e.g., in patients who are either wheelchair
or bed bound). Because this material does not contour as
precisely, it may be the best choice when fabrication over
wound dressings when the dimensions are altered with each
dressing change.
Memory
Memory refers to a material's ability to revert to its orig­
inal shape once heated, ranging from 0% to 100% mem­
ory.49,50 Materials with this property are good choices for
orthoses that need to be frequently remolded, such as when
fabricating a serial static orthosis that needs to be reheated
and reformed to the body part as ROM increases. Caution
must be used when removing the orthosis from the body
part after molding to be sure the material is completely
cool, or the material may shrink and the fit achieved within
the orthosis lost. Also, spot heating is not advised with
this material because of the possibility of altering adjacent
regions.
AliMed
297 High Street, Dedham, MA 02026
Phone: 800-225-2610
Fax: 800-437-2966

DeRoyal
200 DeBusk Lane, Powell, TN 37849
Phone: 800-251-9864
Fax: 800-543-2182

North Coast Medical
18305 Sutter Blvd, Morgan Hill, CA 95037
Phone: 800-821-9319
Fax: 877-213-9300

Orfit Industries America
350 Jericho Turnpike, Suite 101, Jericho, NY 11753
Phone: 888-673-4887
Fax: 877-935-8505

Patterson Medical (Sammons Preston Rolyan)
1000 Remington Boulevard, Bolingbrook, IL 60440
Phone: 800-323-5547
Fax: 800-547-4333

UE Tech
PO Box 2145, Edwards, CO 81632
Phone: 800-736-1894
Fax: 970-926-8870

WFR Corporation
30 Lawlins Park, Wyckoff, NJ 07481
Phone: 800-526-5274
Fax: 800-831-8174

3-Point Products
1610 Pincay Court, Stevensville, MD 21666
Phone: 888-378-7763
Fax: 410-604-6398

BOX 14-4  Distributors of Orthotic Fabrication
Products

404
Section II  Orthoses in Rehabilitation
Bonding
Bonding is the ability of a material to adhere to itself when
heated fully.49,50 The presence of a protective coating prevents
this occurrence. The coating can allow two pieces of material to
be popped apart after the orthosis is formed, which can be par­
ticularly helpful when applying a circumferential design such as
around the thumb (Figure 14-18). The ­coating must be removed
with solvent or disrupted by scratching the surface to allow for
adherence, which is commonly required for attaching mobili­
zation components. The coating may make the orthosis easier
to clean. Without a coating, the material may stick to a wound
dressing, the patient's body hair, or itself. When using material
without a coating, apply a ­barrier between the two pieces such
as a wet paper towel or hand lotion to prevent adherence.
FIGURE 14-17  The drape, or contouring of the material, placed over the hand on the left indicates a low resistance to stretch, whereas the
less moldable material on the right is more resistant to stretch.
TABLE 14-1  Characteristics of Thermoplastic Materials
Stretch Resistance
Company Name
Minimum
Moderate
Maximal
AliMed
Polyform
Multiform
Multiform Clear
Orthoplast II
Polyflex II
Ezeform
Orthoplast
DeRoyal
LMB Drape
LMB Blend
LMB Flex
LMB Royal
North Coast Medical
NCM Clinic
Encore
NCM Preferred
NCM Vanilla
NCM Spectrum
Prism
Omega Max
Solaris
Omega Plus
NCM Classic
Orthoplast
Orfit Industries
Orfit Drape
Orfilight
Orfit Classic Soft
Soft Fit
Orfit Soft
Orfit Natural
Colors
Bluelight
Orfit Ease
Orfit Classic
Orfit Ortho
Patterson Medical
Polyform
Aquaplast ProDrape
Polyflex II
Kay-Splint II
Aquaplast
Watercolors
ProPlast
Tailorsplint
Kay-Splint III
Orthoplast II
Ezeform
Aquaplast Resilient
Synergy
San Splint
Orthoplast
WFR Corporation
Reveals XS
Reveals
Reveals Colors
Reveals LS

Chapter 14  Orthoses in the Management of Hand Dysfunction
405
Physical Characteristics
Physical characteristics are evident on visual inspection. The
most relevant include the material's thickness, the presence of
perforations, and the color of the material.17
Thickness
Low temperature thermoplastics are available in a variety of
thicknesses, including 1⁄16, 3⁄32, and 1⁄8 inches.49,50 The appropri­
ate thickness for an orthosis depends on the body part, diagno­
sis, and required rigidity of the orthosis. For example, an elbow
immobilization orthosis for a patient who sustained a fracture
and underwent surgical fixation would best be made from a
thick 1⁄8-inch material for a more rigid support. On the contrary,
a hand-based thumb ­orthosis for an elderly patient with arthritis
might be better served with a thinner 1⁄16-inch orthosis to achieve
a light, unbulky ­support. The goal should be to provide the least
bulky, ­lightest weight orthosis possible that still performs its
intended function. Thinner materials are generally quicker to
heat and harden faster than their thicker counterparts.
Perforations
Thermoplastic materials with perforations allow for air ex­change
and produce a lighter-weight orthosis compared with those
made with solid materials.49,50 Materials with a high density
of perforations create an orthosis that is flexible (less rigid),
which may not be appropriate for specific ­diagnoses. Caution
must be used to ensure that the edges of the orthosis, cut-
through perforations, are smoothed to ­prevent irritation to
the patient's skin.
Colors
A wide array of colors is available, making the fabrication
process even more creative.48,49 Choices in thermopal­
stic material and strap colors can improve compliance with
orthosis wear in children. Providing orthosis straps in a color
other than white can be helpful for patients to prevent loss
within bed linens. Be sure to ask for requests from patients to
make them feel they have contributed in the construction of
the orthosis and hopefully improve their acceptance for wear.
Categories of Orthosis Materials
Thermoplastic materials can be categorized according to their
chemical composition.46–48 This composition determines the
way the material behaves during the fabrication process and
affects how the finished orthosis functions. Thermoplastic
materials may be made of plastics (e.g., Polyform [Patterson
Medical, Bolingbrook, Ill.] or Multiform [AliMed, Dedham,
Mass.]), rubber or rubberlike materials (e.g., Ezeform
[Patterson] or Orthoplast [AliMed]), combination ­plastic and
rubberlike materials (e.g., Tailorsplint, PolyFlex II [Patterson],
or Encore [North Coast Medical, Morgan Hill, Calif.),
and elastic materials (e.g., Aquaplast [Patterson] or Reveal
[WFR Corporation, Wyckoff, N.J.]).
Plastic materials typically have a low resistance to stretch,
allowing a highly contoured finished ­orthosis. Rubber or
­rubberlike materials are highly resistant to stretch but offer
more control during the fabrication process. Combination
plastic and rubberlike materials offer the best of both worlds
in terms of conformability and control during the ­molding
process. Elastic materials possess memory and may be
­suitable for the beginner orthosis fabricator who wishes to
have the ability to remold the orthosis if necessary.
Orthoses may also be fabricated from alternative materi­
als.17,49,50 These materials include lined materials (e.g., Rolyan
AirThru [Patterson], Silon-LTS [Patterson], or Multiform Soft
[Alimed]), mesh-type materials (e.g., X-Lite [Patterson]), cast­
ing materials (e.g., plaster of Paris or QuickCast [Patterson]),
and soft materials (e.g., neoprene or Kinesio Tape [Patterson]).
Strapping
Many different strapping systems are offered through
­distributors.49,50 The choice of appropriate strapping depends
on the patient diagnosis, orthosis design and availability in
the same way that the choice of the appropriate thermoplas­
tic material does. Strapping is essential to secure the orthosis
to the body part properly. If the strapping is not adequate, the
orthosis will likely be uncomfortable or ineffective in ­achieving
its desired goals. Generally, adhesive hook-and-loop mate­
rial (e.g., Velcro; Velcro USA, Manchester, N.H.) is applied
to the orthosis base, and strapping material secures the seg­
ment within the orthosis. The most ­commonly used ­strapping
mechanisms consist of traditional loop, foam, ­neoprene, or
elasticized straps. In small areas where ­adhesive hook may
continually pull off, rivets may be used to ­permanently secure
the loop material onto the thermoplastic (Figure 14-19).
Other adjuncts to strapping include D-rings that offer the
ability to easily adjust the tension on the straps or circum­
ferential wrapping (with an elasticized bandage) for those
patients with significant edema. Straps should be wide and
conforming to distribute the pressure maximally, but not so
wide that they inhibit ROM of adjacent joints.17,24 The patient
should be educated in how to apply the straps snugly enough
to secure the orthosis in place without compromising the
neurovascular system.
FIGURE 14-18  The presence of coating on this material allows the
circumferential segment around the thumb to be pulled apart after
cooling to form a “trap door” on this wrist and thumb mobilization
orthosis.

406
Section II  Orthoses in Rehabilitation
Padding and Lining
Padding and lining products are available in a wide variety
of thicknesses, textures, and materials.49,50 Therapists may use
padding in specific regions during the orthotic fabrication
process to accommodate bony prominences or ­superficial
nerves. Ideally, this padding should be applied to the ­target
area before molding the orthosis so that the device can contour
to its proportions. Attaching the padding after the orthosis is
made can potentially cause a shift in pressure distribution and
lead to problematic areas of high stress. Foam padding can
also be adhered to straps at strategic places to improve joint
position and prevent migration within the orthosis.
Lining an orthosis with an adhesive product may be
­indicated in rare cases, such as when the patient has very
­fragile skin. Application of these adhesive liners should be
used sparingly because of hygienic concerns; they are not
­easily cleaned or removed. As an alternative, disposable liners
on the body part can be a way to improve comfort within an
orthosis by placing a barrier between the skin and the plastic
(see Figure 14-19). Cotton or elasticized stockinettes are the
most commonly used products.
Components
Component systems are an important element of mobiliza­
tion orthoses.49,50 Rehabilitation catalogs help therapists keep
abreast of what is available. In general, outrigger systems
are designed to help provide optimal force application to a
body part. Ideally these devices should be highly adjustable
to allow the therapist to maintain the crucial 90-degree angle
of force application. If the commercial systems are not acces­
sible, therapists can fabricate homemade ones with wire and
scrap pieces of thermoplastic material. Four basic elements of
an outrigger system are used in a digit mobilization orthosis:
the proximal attachment device, mobilization force, pulley
­system, and finger slings (Figure 14-20).
The proximal attachment device provides the means to
secure the mobilization force to the orthosis. The mobilization
force, whether it be static line (static progressive approach) or
elastic (dynamic approach), traverses through a pulley system
to maintain the 90-degree angle of force ­application. Distally,
the force is imparted to the body part, in this example the
­finger, by a sling or loop.
Mobilization orthoses can be challenging to fabricate for
a new therapist. Learning through practicing and obtaining
feedback from more experienced colleagues are important
ways to improve fabrication skills. Patients must consistently
receive follow-up in the clinic to assess and modify the ortho­
sis to achieve a positive outcome; the orthoses need frequent
adjustments as the tissue responds to the stress.
Equipment
Quality tools in the clinic can help make the orthotic ­fabrication
process easier for the therapist. Sharp scissors ­designated for
thermoplastic use only are essential; if the scissors are used for
all products, most notably adhesive products, the blades can
retain the residue and make cutting the ­thermoplastic ­difficult.
FIGURE  14-19  A rivet can be applied to permanenetly secure
strapping to the orthosis by forming holes in the thermoplastic
material and the strap with a hole punch; pliers are used to set the
rivet in place.
Pulley
system
Finger
sling or
loop
Mobilization
force
Proximal
attachment
device
FIGURE 14-20  Elements of this forearm-based metacarpophalangeal
joint extension mobilization orthosis include a proximal attachment
device, a mobilization force through a pulley system, and finger slings.

Chapter 14  Orthoses in the Management of Hand Dysfunction
407
Scissors with a nonstick coating are now available and are quite
effective when cutting adhesive-backed products. Dull scissors
do not provide a clean cut, which can lead to frustration and
unsightly orthoses. Other tools helpful to keep on hand include
a hole punch and blunt nose pliers for rivet application, a hand
drill for creating a hole or series of perforations, and a heat gun
to make minor adjustments.
OVERVIEW OF ORTHOTIC FABRICATION
PROCESS
A comprehensive prescription from the referring physician is
essential for appropriate orthotic application and therapeutic
intervention. In addition to the patient's name, the prescrip­
tion must contain the following information:
• Diagnosis, including surgical procedures if applicable
• Date of injury and surgery
• Any precautions that must be followed
• Orthosis goals, including purpose, joint positions, and
wearing schedule
Radiographs and the patient's surgical report can assist
the therapist in gaining a clear understanding of the tissue
involvement. As always, good communication with the phy­
sician is key in terms of gathering and sharing information
regarding a patient's status.
After obtaining all the essential information regarding the
patient's diagnosis and the physician's orders, the therapist
should perform a comprehensive examination. This begins
with a patient interview for gathering subjective informa­
tion and continues with a review of systems and a detailed
physical examination.9,22 The therapist uses the results of the
history and examination to form a clinical judgment and
movement dysfunction diagnosis, including a list of prob­
lems. From these problems the therapist determines the
­prognosis for improvement of function, goals and formulates
an appropriate plan of care.
To prepare a comprehensive therapeutic plan of care, thera­
pists must use critical thinking skills to integrate all their knowl­
edge with the information obtained from the physician and
patient. The therapist has many modalities that can be used
to treat the patient, only one of which is orthotic fabrication.
Not all patients are appropriate for orthoses; determining if and
when orthoses may be appropriate is the challenge of the ther­
apist. Some patients may require ­orthoses initially and others
may need one later in their rehabilitation. An individualized
approach is necessary to address a patient's unique needs.51
If orthoses are deemed appropriate, the patient must be
thoroughly educated regarding its use. This education must
always include a written handout outlining the specifics of
wear, care, and precautions. The key points to stress include
the following:
• Purpose of orthosis, specific to the patient's diagnosis
• Key indicators of problems that might occur and informa­
tion about what to do if they occur
• Any functional limitations that might result from wear­
ing the orthosis and suggestions of how to compensate for
such limitations
• Wearing schedule
• Information about washing or cleaning the orthosis
• Information or diagrams about how to properly don and
doff the orthosis (if applicable)
• Precautions related to the patient's diagnosis and indica­
tors of tissue tolerance (signs and symptoms of neurovas­
cular compromise or bony irritation)
• Avoidance of heat to prevent loss of orthosis shape
• Contact information (the therapist's name and clinic phone
number) with encouragement to call if any ­questions or
problems should arise
M. F. presents to the hand surgeon with progressive onset of
thumb pain. Symptoms of aching and tenderness are exacer­
bated by activities such as turning keys, opening jars, hold­
ing a book, and writing. Deformity from joint subluxation
at the first carpometacarpal (trapeziometacarpal) joint and
osteoarthritis (OA) are evident (Figure 14-21). The patient
also has a positive grind test—the manual application of
longitudinal compression force of the first metacarpal into
the trapezium. (This test is positive for carpometacarpal
OA when pain and crepitation are present.) M. F. receives a
steroid injection into the joint space to decrease local
inflammation and a prescription for therapy.
Questions to Consider
• Given this patient's current presentation, what additional
tests and measures might be important in the evaluation
process?
• What is your movement dysfunction–related diagnosis
for this patient?
• What do you think the prognosis will be for this patient?
What are the patient's goals for intervention? What are your
rehabilitation goals? How long do you think it will take to
achieve the goals that you and the patient agree on?
• On the basis of the patient's goals and expectations as well as
your understanding of the underlying disease process, what
recommendations would you make for intervention at this
point in time? What evidence from the clinical research lit­
erature supports your recommendations? What have you
chosen or prioritized from these possible interventions?
• What type of follow-up would you recommend? How
might the goals and interventions change as the patient
progresses through the stages of tissue healing? How
would you assess the outcomes of your interventions?
CASE EXAMPLE 1
Patient with Osteoarthritis of the Carpometacarpal Joint
Continued

408
Section II  Orthoses in Rehabilitation
Recommendations for a Patient with OA
of the Carpometacarpal Joint
A custom thumb orthosis is fabricated from a light­
weight thermoplastic material (thickness: 1⁄16 inch) (see
Figure 14-21B). M. F. is instructed to use this during the day
to decrease stress on the joint during activities of daily living
(ADLs). She is also educated in activity modification and
joint protection principles. Some of the ­strategies include
avoiding forceful, repetitive, and ­sustained ­pinching along
with using pens and kitchen utensils with larger handles.
Despite these interventions, M. F. continues to have
symptoms and returns to the physician to discuss her treat­
ment options. M. F. undergoes a ligament reconstruction
with tendon interposition arthroplasty, which includes a
trapezium excision with a slip of the flexor carpi ­radialis
interposed between the scaphoid and the first metacar­
pal.24 For the initial 3-week postoperative period, during
the ­initial inflammatory stage of healing when resting the
­tissue is important, a cast is used to immobilize the region.
As healing progresses into the proliferative stage at 3 weeks,
the patient is placed in a removable forearm-based wrist/
thumb immobilization orthosis that is removed for periodic
range of motion exercises (see Figure 14-21C).
At approximately 6 weeks after surgery, as the ­healing con­
tinues to progress, the patient uses a prefabricated ­neoprene
thumb orthosis to aid in the transition from the rigid ther­
moplastic orthosis (see Figure 14-21D). The neoprene mate­
rial offers a restrictive support combining warmth and gentle
support for use during ADLs. At 12 weeks, all orthoses are dis­
continued and M. F. returns to normal activities without pain.
A
B
C
D
FIGURE 14-21  A, A radiograph indicat­ing osteoarthritis at the carpometacarpal (CMC) joint of the thumb. B, A custom thumb orthosis
designed to reduce stress on the CMC joint during activities of daily living (ADLs). C, After ligament reconstruction and arthroplasty, a forearm-
based wrist and thumb immobilization orthosis is used during the proliferative stage of healing. D, When adequate healing and fixation have
occurred, the patient transitions into a ­neoprene orthosis to support the thumb during ADLs.
V. A. presents to the hand surgeon's office after a fall onto an
outstretched hand. The radiograph reveals a comminuted wrist
fracture requiring surgical fixation. The ­surgeon ­performs
an open reduction internal fixation with a plate and screws
(Figure 14-22). At 5 days after surgery, the patient is referred to
therapy for a protective orthosis and an early ROM program.
Questions to Consider
• Given this patient's current presentation, what additional
tests and measures might be important in the evaluation
process?
• What is your movement dysfunction–related diagnosis
for this patient?
CASE EXAMPLE 2
Patient with a Wrist Fracture

Chapter 14  Orthoses in the Management of Hand Dysfunction
409
• What do you think the prognosis will be for this patient?
What are the patient's goals for intervention? What are
your rehabilitation goals? How long do you think it will
take to achieve the goals that you and the patient agree on?
• On the basis of the patient's goals and expectations, as well as
your understanding of the underlying disease process, what
recommendations would you make for intervention at this
point in time? What “evidence” from the clinical research
literature supports your recommendations? What have you
chosen or prioritized from these possible interventions?
• What type of follow-up would you recommend? How do
you anticipate your intervention will need to be modi­
fied as the patient progresses through the phases of ­tissue
healing? How would you assess the outcomes of your
interventions?
Recommendations for a Patient with Open Reduction
and Internal Fixation of Wrist Fracture
A forearm-based wrist immobilization orthosis is fabricated
with a 1⁄8-inch material to obtain a rigid support to be used
during the proliferative stage of healing (see Figure 14-22B).
The patient is instructed to remove the orthosis six times a day
for gentle range of motion of the wrist and digits. As expected,
all wrist motions are significantly limited. He is encouraged
to move the digits frequently while in the orthosis between
exercise sessions and incorporate the hand in light ADLs.
At 4 weeks after surgery, because the radiograph revealed
adequate healing along with the stable fixation provided by
the plate and screws, the wrist orthosis is discontinued
(except for stressful activities) and therapy progresses with
the addition of gentle passive range of motion. All ­movements
of the wrist improve except wrist extension and forearm
supination, which are significantly restricted passively. At
6 weeks, these limitations continue to be problematic and the
physician recommends the addition of a wrist extension
mobilization orthosis (see Figure  14-22C) and a forearm
supination mobilization orthosis (see Figure 14-22D).
The wrist extension mobilization orthosis is fabricated
with a standard hook-and-loop material to provide the
mobilization force by a static progressive approach. This
method is chosen because of the high degree of wrist stiff­
ness. The supination mobilization orthosis is fabricated
with a tubing mechanism to provide the stretching force.
The patient is instructed to wear each device four times a
day for 30 minutes, increasing the passive stretch on the
tissue as tolerated. The previously used wrist immobiliza­
tion orthosis continues to be used at night as a serial static
device, by remolding to position the wrist at maximal exten­
sion to maintain all the gains made throughout the day.
After 4 weeks of use, V. A. begins to plateau at 55 degrees of
wrist extension and 70 degrees of supination, which is func­
tional and, because of the severity of the injury, quite acceptable.
A
C
B
D
FIGURE 14-22  A, A radiograph of open reduction and internal fixation of a comminuted wrist fracture. B, A forearm-based wrist immo­
bilization orthosis used during the initial stages of ­healing. When adequate healing had occurred, a wrist extension mobilization orthosis
(C) and a forearm ­supination mobilization orthosis (D) are fabricated to help increase functional range ofmotion.

410
Section II  Orthoses in Rehabilitation
SUMMARY
Orthotic fabrication is a commonly used intervention for
­clinicians treating the upper extremity. Gaining an appreci­
ation for how different orthoses can be created for ­specific
­purposes aids in obtaining maximal patient outcome.
This ­chapter reviews many aspects of orthotic fabrication,
including nomenclature, tissue healing, and anatomical
and mechanical principles, and provides an overview of the
­various products on the market. Through comprehensive
study and practice, fabrication of orthoses can be another tool
used successfully in the clinic.
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2. Fess EE. A history of splinting: to understand the present, view
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3. Coverdell J. An editorial note on nomenclature: Orthosis versus
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5. Schultz-Johnson K. Static progressive splinting. J Hand Ther.
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AL, et al., eds. Rehabilitation of the Hand and Upper Extremity.
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11. Brand P, Hollister A. Clinical Mechanics of the Hand. 3 rd ed.
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14. Gyovai JE, Wright Howell J. Validation of spring forces applied
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15. Prosser R. Splinting in the management of proximal interphalan­
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TM, Osterman AL, Fedorczyk JM, et  al., eds. Rehabilitation
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2011:1599–1609.
17. Jacobs M, Austin NM. Splinting the Hand and Upper Extremity:
Principles and Process. Baltimore: Lippincott Williams &
Wilkins; 2003.
18. Schultz-Johnson KS. Splinting: a problem solving approach. In:
Stanley BG, Tribuzi SM, eds. Concepts in Hand Rehabilitation.
Philadelphia: FA Davis; 1992:238–271.
19. Schultz-Johnson KS. Splinting the wrist: mobilization and pro­
tection. J Hand Ther. 1996;9(2):165–175.
20. Skirven TM, Osterman AL, Fedorczyk JM, et  al., eds.
Rehabilitation of the Hand and Upper Extremity. 6th ed. St. Louis:
Mosby; 2011.
21. Wolf SW, Hotchkiss RN, Pederson WC, et al. Green's Operative
Hand Surgery. 6th ed. New York: Churchill Livingstone; 2010.
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Philadelphia: FA Davis; 1992.
23. Tubiana R, Thomine JM, Mackin E. Examination of the Hand
and Wrist. 2nd ed. St. Louis: Mosby; 1996.
24. Fess EE, Gettle KS, Philips C, et al. Hand and Upper Extremity
Splinting: Principles and Methods. 3rd ed. St. Louis: Mosby Year
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25. Kiel J. Basic Hand Splinting: A Pattern Designing Approach.
Boston: Little, Brown; 1983.
26. Rotman MB, Donovan JP. Practical anatomy of the carpal
­tunnel. Hand Clin. 2002;18(2):219–230.
27. Pratt NE. Anatomy and kinesiology of the hand. In: Skirven TM,
Osterman AL, Fedorczyk JM, et  al., eds. Rehabilitation of the
Hand and Upper Extremity. 6th ed. St. Louis: Mosby; 2011:3–17.
28. Coppard BM, Lohman H. Introduction to Splinting: A Clinical
Reasoning & Problem-Solving Approach. 3 rd ed. St. Louis:
Mosby; 2008.
29. Austin N. The wrist and hand complex. In: Levangie PK, Norkin
CC, eds. Joint Structure and Function: A Comprehensive Analysis.
5th ed. Philadelphia: FA Davis; 2011.
30. Fess EE. Splints: mechanics versus convention. J Hand Ther.
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31. Cannon NM, Foltz RW, Koepfer J, et al. Manual of Hand Splinting.
New York: Churchill Livingstone; 1985.
32. Bell-Krotoski JA, Breger-Stanton DE. Biomechanics and evalu­
ation of the hand. In: Mackin EJ, Callahan AD, Osterman AL,
et al., eds. Rehabilitation of the Hand and Upper Extremity. 5th ed.
St. Louis: Mosby; 2002:240–262.
33. Van Lede P, van Veldhoven G. Therapeutic Hand Splints: A
Rational Approach. Antwerp, Belgium: Provan; 1998.
34. Fess EE, McCollum M. The influence of splinting on healing
­tissue. J Hand Ther. 1998;11(2):157–161.
35. Strickland JW. Biologic basis for hand and upper extremity
splinting. In: Fess EE, Gettle KS, Philips C, et  al., eds. Hand
and Upper Extremity Splinting: Principles and Methods. 3rd ed.
St. Louis: Mosby Year Book; 2005:87–103.
36. Smith KL, Dean SJ. Tissue repair of the epidermis and dermis.
J Hand Ther. 1998;11(2):95–104.
37. Smith J, Feske N. Cutaneous manifestations and consequences
of smoking. J Am Acad Dermatol. 1996;34(5 pt 1):717–726.
38. Rund C. Postoperative care of skin graft, donor sites, and myo­
cutaneous flaps. In: Krasner D, Kane D, eds. Chronic Wound
Care: A Clinical Source Book for Healthcare Professionals. 2nd ed.
Wayne, NJ: Health Management Publication; 1997.
39. Wilton JC. Hand Splinting: Principles of Design and Fabrication.
Philadelphia: Saunders; 1997.
40. McKee P, Morgan L. Orthotics in Rehabilitation. Philadelphia:
FA Davis; 1998.
41. Bell Krotoski JA, Breger-Stanton D. The forces of dynamic orthotic
positioning: ten questions to ask before applying a dynamic ­orthosis
to the hand. In: Skirven TM, Osterman AL, Fedorczyk JM, et al.,
eds. Rehabilitation of the Hand and Upper Extremity. 6th ed.
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411
42. Flowers KR. A proposed decision hierarchy for splinting the stiff
joint, with an emphasis on force application parameters. J Hand
Ther. 2002;15(2):158–162.
43. McClure PW, Blackburn LG, Dusold C. The use of splints in the
treatment of joint stiffness: biological rationale and an algorithm
for making clinical decisions. Phys Ther. 1994;74(12):1101–1107.
44. Mildenberger LA, Amadio PC, An KN. Dynamic splinting: a
systematic approach to the selection of elastic traction. Arch
Phys Med. 1986;67(4):241–244.
45. Glasgow C, Wilton J, Tooth L. Optimal daily total end range
time for contracture: resolution in hand splinting. J Hand Ther.
2003;16(3):207–218.
46. Lee DB. Objective and subjective observations of low-temperature
thermoplastic materials. J Hand Ther. 1995;8(2):138–143.
47. Breger Lee DE, Buford WL. Properties of thermoplastic splint­
ing materials. J Hand Ther. 1992;5(3):202–211.
48. Breger Lee DE, Buford WL. Update in splinting materials and
methods. Hand Clin. 1991;7(1):569–585.
49. Patterson Medical Hand Rehab Catalog. Bolingbrook, IL 2011.
50. North Coast Medical Inc. Hand Therapy Catalog. San Jose, CA;
2007–2008.
51. McKee PR, Rivard A. Biopsychosocial approach to orthotic
intervention. J Hand Ther. 2010;1–8.

412
15
Splinting, Orthoses, and Prostheses in the Management
of Burns
R. Scott Ward
Rehabilitation of a patient with burns involves programs
that focus on restoring functions compromised by the burn
injury.1 Treatment strategies used by therapists address five
important goals:
1. Improve or promote wound healing by reducing wound
infection
2. Prevent or reduce deformity
3. Increase mobility and strength to achieve maximal function
4. Reduce effects of hypertrophic scarring
5. Educate the patient about recuperation
The rehabilitation plan for patients with burns centers on
wound care, positioning, range-of-motion (ROM) exercises,
splinting, strengthening exercises, endurance and functional
exercises, gait training, and scar control. Burn care empha­
sizes the need for a comprehensive team approach to achieve
maximal clinical results.1,2
BURN INJURY
Each year in the United States, 450,000 to 500,000 individ­
uals sustain and seek medical care for burn injuries and an
estimated 3500 of these injuries result in death.3 Estimates
are that burn injuries result in approximately 45,000 hos­
pitalizations per year.3 The American Burn Association
has outlined criteria for determining the severity of burn
injury, which include cause of the injury, burn depth, total
body surface area (TBSA) burned, location of the burn, and
patient age.4,5 A burn injury of any given size is more severe
for patients who are very young or very old. The deeper the
injury, the more serious the burn. Involvement of the face,
eyes, ears, perineum, hands, and feet make the injury more
critical. Associated trauma, smoke inhalation injury, and
poor preinjury health status are factors that increase sever­
ity of the injury.6 An appropriate understanding of the nature
of burn injury and the location and depth of the burn wound
is important in understanding and anticipating the possible
problems a patient may face during rehabilitation.
Causes of Burns
Types of burn injury include flame, scald, flash (radiant heat
explosions), contact, chemical, electrical, and other (e.g., irradia­
tion, radioactivity) burns.7 Scald and flame injuries are common
causes of burn injury. Preschool-aged children are at the high­
est risk for suffering scald injuries.8–10 Flame burns are generally
the leading cause of burn injury in other age groups.8,11 Chemical
and electrical burns present differently than other burn injuries.
Burns resulting from chemical agents require identification of
the causative agent so that proper neutralization of the chemical
can take place. Assessment of the depth of chemical burns is dif­
ficult at first, but these wounds are predictably deep.12 An elec­
trical injury may have areas of significant surface burn; however,
these areas are often the result of associated flash burns. Small,
deep wounds where the current enters or exits the body are
more typical.13 The major complication with rehabilitative con­
sequence of electrical injury is musculoskeletal necrosis, which
frequently results in the need for amputation.14,15
Burn Depth
Thomsen16 has studied Indian writings dating back to approxi­
mately 600 bc that describe four levels or degrees of burn depth
and declare that deep burns heal slowly and with scarring.16 There
are two methods to describe burn depth: by degree (first, second,
or third degree) or thickness (superficial, partial thickness, and
full thickness).17 The thickness terminology is more commonly
used in clinical practice. A superficial injury ­corresponds to a
first-degree injury, a partial thickness to a second-degree injury,
and a full thickness to a third-degree injury (Figure 15-1).
Clinical characteristics associated with the injury thick­
ness are helpful in identification of the depth of burn.17
15
LEARNING OBJECTIVES
On completion of this chapter, the reader will be able to:
1. Identify the elements of burn injury that contribute to deci­
sion making regarding splints, orthotics, and prosthetics.
2. Describe how wound care may affect the use and applica­
tion of splints, orthotics, and prosthetics.
3. Discuss components of rehabilitation interventions that
may incorporate or affect the use of splints, orthotics, and
prosthetics.
4. Describe the use of splints and orthotics in the care of
patients with burn injuries.
5. Describe the use of prosthetics for patients with amputa­
tions associated with burn injuries.

Chapter 15  Splinting, Orthoses, and Prostheses in the Management of Burns
413
Superficial (first degree) injuries involve only the epidermis.
They are often painful, erythematous, and mildly edema­
tous. Superficial burn injuries usually heal in 3 to 7 days and
they rarely result in scarring. Superficial partial-thickness
burns (superficial second degree) compromise the epider­
mis and upper dermis. These burns are very painful, very
red, and often have blisters or weeping wounds. Superficial
partial-thickness burns usually heal in 14 to 21 days and
rarely develop scar. In deep partial-thickness burns (deep
second degree), deeper layers of the dermis are damaged.
The wound may or may not be painful, it may be cherry red
or pale, and the skin is still pliable. Deep partial-­thickness
burns require more than 21 days to heal spontaneously
and will scar. In full-thickness burns (third degree) all lay­
ers of the skin are destroyed. The wound generally has a tan
or brown appearance and exhibits a leathery texture. Full-
thickness wounds are painless and need several weeks to heal
without surgical intervention. Deep partial-thickness burns
are often managed by skin grafting; full-thickness injuries
require skin grafting. A deeper burn generally correlates
with an increased severity of injury.
Surgical Management of Burns
Small burn wounds may be excised and primarily closed;
however, most burn wounds require excision of the burn
followed by coverage of the site with a skin graft.18 Excision
of the burn wound is ordinarily performed tangentially;
that is, thin layers of the burn are removed until viable tis­
sue is reached.19 Autografts (split-thickness grafts) are har­
vested from undamaged areas of the body for coverage of the
excised wound.19 Skin grafts placed on tangentially excised
wounds ­demonstrate good long-term functional results.20
Full-thickness skin grafts can also be used. Interestingly, split-
thickness grafts scar more than full-thickness grafts.20
Progress has been made in the use of skin substitutes
and cultured skin for the coverage of the excised burn.21–23
Areas treated in this fashion tend to be fragile and suscep­
tible to breakdown.24 Wounds treated with cultured epithe­
lium do not aggressively scar; however, little information is
available about the rehabilitative ramifications of this treat­
ment approach.25
Burn Size
Burn wound size is reported as a percentage of the TBSA that
is injured. Lund and Browder26 describe a method for esti­
mating percent TBSA. Variations in body part ratios during
development and diversified proportions of individual ana­
tomical parts are considered in the estimation (Figure 15-2).
The “rule of nines” is another technique for estimating sur­
face area by dividing the body into 11 different areas equal
to 9% each; the genitalia make up the remaining 1% of the
total 100% estimate.27 A burn injury increases in severity as
the percentage of TBSA burn increases. Large burns usually
require longer convalescence, which in turn increases the
rehabilitative needs of the patient.
Location of the Burn
Burns of the face, perineum, hands, and feet create special
problems.6 Burns of the face are distressing because there
may be cosmetic disfigurement, visual impairment, or com­
promised nutrition (intake of food). Injuries of the face are
often accompanied by inhalation injuries. Hands and feet
First
Superficial second
(most of basal layer is intact)
Second
Deep second
(basal layer present only in the
lining of spared skin appendages)
Third
Classification
by degree
Classification
by thickness
Superficial
Superficial
partial thickness
(most of the basal layer is intact)
Deep
Partial thickness
(basal layer present only in the
lining of spared skin appendages)
Partial thickness
Full thickness
Epidermis
Dermis
Adipose
FIGURE 15-1  The depths of burn injury, referencing both the contemporary thickness classification
with the more traditional degree terminology. (From Ward RS. The rehabilitation of burn patients.
CRC Crit Rev Phys Med Rehabil 1991;2[3]:121-138.)

414
Section II  Orthoses in Rehabilitation
have broad functional importance that can be substantially
compromised after burn injury. Severity of injury is signifi­
cantly magnified as the total surface area of the hand or foot
encompassed by the burn increases. Any burn that crosses a
joint increases the risk for functional compromise and creates
challenges in rehabilitation.
WOUND CARE
The time it takes to heal a burn wound is directly related to
depth of the injury. The more superficial a wound, the faster
it heals. Surgical intervention, such as skin grafting, is often
used to reduce healing time for deep wounds. Wound infec­
tion can significantly delay healing and lead to increased scar
formation.28
Topical Agents and Wound Dressing
The outermost layer of epidermis (stratum corneum) in intact
skin is too dry to support microbial growth and serves as an
effective barrier to microbial penetration. As a result, skin
infections seldom occur unless the skin is opened.29 Because
this protective barrier is compromised or destroyed in burn
injury, the risk for infection is greatly increased. Personal
protective equipment, particularly gloves, gowns, and masks,
must be worn when caring for patients with burn wounds.30
Topical agents may be applied to these open wounds after
each cleansing and debridement to prevent or manage infec­
tions. Topical agents are particularly important for ischemic
wounds in which systemic delivery of natural substrates to
fight infection is compromised.29,31 A well-applied dressing
minimizes discomfort and allows mobility.
Mild lotions help relieve dryness and itching in matur­
ing healed wounds.29 The use of moisturizers helps prevent
healed wounds from cracking or splitting. Because alcohol is
a desiccant to the skin and exacerbates dryness, lotions that
contain alcohol should be avoided. Fragrance-free moistur­
izers are recommended; most hypersensitivity reactions are
triggered by perfumes. Moisturizers can also be beneficial
when applying a splint, orthotic, or prosthetic device to a
patient with healed burns or scar because they help protect
the skin from desiccation and shear.
Rehabilitative personnel often take an active role in the
wound care of a patient with burns. Involvement in wound
care provides a better understanding of the reasons for dis­
comfort. Familiarity with wound care procedures is often
necessary for outpatient therapy sessions.32,33 Adjustments
in the treatment plan are often necessary as the wound heals
and tolerance of certain rehabilitative procedures changes.
Consideration of the effects of pressure, shear, and friction
on a healing wound or newly healed, fragile skin is especially
important when splints, orthotics, prosthetics, or other exter­
nal devices are being used.
PSYCHOLOGY OF BURN INJURY
An acute burn injury creates emotional distress. Treatment of
the burns is often traumatic as well; stress and anxiety con­
tinue during the period of recovery. The psychological con­
sequences of burn trauma in the adult include depression,
posttraumatic stress disorder, despair, fear, anxiety, and sur­
vivor's guilt.34–37 Children often feel guilt and manifest loss
of interest in play, unpredictable sadness, avoidance, and
regression.38–40
Psychological adaptation in early phases after burn injury
includes denial (often manifest by a feeling of calmness),
and concern about prognosis, pain, personal issues, and
dependence on medical staff (depression).39,41 Individuals
who become actively involved in the process of rehabilita­
tion and self-care often are more encouraged and optimistic
about the future.38,41
Relative Percentages of Areas Affected by Growth
Area
Age
0
1
5
A = 1/2 of head
B = 1/2 of one thigh
C = 1/2 of one leg
9 1/2
2 3/4
2 1/2
8 1/2
3 1/4
2 1/2
6 1/2
4
2 3/4
Area
A = 1/2 of head
B = 1/2 of one thigh
C = 1/2 of one leg
Age
10
15
Adult
5 1/2
4 1/4
3
4 1/2
4 1/2
3 1/4
3 1/2
3 1/2
4 3/4
A
A
A
A
B
B
B
B
B
B
B
B
C
C
C
C
C
C
C
C
13
13
13
13
1
1
1
1
2
2
2
2
2
2
2
2
1
1
11/4
11/4
11/4
11/4
11/4
11/4
11/4
11/4
11/2
11/2
11/2
11/2
11/2
11/2
11/2
11/2
13/4
13/4
13/4
13/4
13/4 13/4
21/2
21/2
21/2
21/2
13/4
13/4
FIGURE 15-2  The original Lund and Browder chart outlines the accepted method for determin­
ing the TBSA of a burn injury. (From Lund CC, Browder NC. The estimation of areas of burns. Surg
Gynecol Obstet 1944;79:352-358.)

Chapter 15  Splinting, Orthoses, and Prostheses in the Management of Burns
415
Rehabilitation professionals can facilitate psychologi­
cal function and recovery of patients with burns in several
ways. Encouraging independence by allowing individuals as
much control over medical procedures as possible helps them
focus on recovery and empowers them to a certain degree.41,42
Patients feel more comfortable with caregivers if they have the
opportunity to get to know one another outside painful treat­
ment settings.38,42 Support and understanding demonstrate a
caring attitude. Tactful but honest answers to questions about
prognosis, cosmesis, and functional outcome help establish
trust.38 Ongoing education about the recovery process helps
the patient develop realistic expectations about recovery.
REHABILITATION INTERVENTION
Early surgical intervention, availability of nutritional support,
and pharmaceutical advances have improved survival after
burn injury and the American Burn Association has reported
a survival rate of 94.8% from 2000 to 2009.3 As a result of
improvement in care, treatment, and survival of burned
patients, more physical therapists will become responsible for
treating these patients for a significant portion of their reha­
bilitation in settings other than a hospital burn center (e.g.,
outpatient clinics, community hospitals).
This improvement, in turn, has increased the emphasis on
and need for rehabilitation of patients with burns. Physical
therapists and occupational therapists are important mem­
bers of the burn care team.
After examination and evaluation, the team establishes
goals and designs and implements an appropriate plan of care.
Important rehabilitation goals for patients with burns might
include the following as put forward in The Guide to Physical
Therapist Practice: (1) wound and soft tissue healing is enhanced;
(2) risk of infection and complications is reduced; (3) risk of sec­
ondary impairments is reduced; (4) maximal ROM is achieved;
(5) preinjury level of cardiovascular endurance is restored; (6)
good to normal strength is achieved; (7) independent ambula­
tion is achieved; (8) independent function in activities of daily
living (ADLs) is increased; (9) scar formation is minimized; (10)
patient, family, and caregivers understanding of expectations
and goals and outcomes is increased; (11) aerobic capacity is
increased; and (12) self-management of symptoms is improved.43
Burn rehabilitation interventions emphasize patient indepen­
dence through achievement of maximal functional recovery.44
Wound Healing and Scar Formation
Unhealed burn wounds can create challenges during reha­
bilitation. Most problems in burn rehabilitation are caused
by the ceaseless contraction and hypertrophy of immature
burn scars.45 Scar contracture can lead to visible cosmetic
deformity of involved body parts, particularly of the face and
hands. Functional limitations are common when the scar
crosses a joint. The contraction of scar has been classically
associated with a type of fibroblast called myofibroblasts,
which have contractile properties.46–48
Burn wound healing encompasses three phases: the inflam­
matory phase, the proliferative phase, and the maturation, or
remodeling, phase.49 The inflammatory phase is character­
ized by the formation of new blood vessels, an initial defense
against infection, and migration of fibroblast and epithelial
cells into the injured area. Treatment focuses on proper wound
care to encourage vascular regrowth and retard contamina­
tion of the site. The proliferative phase is marked by continued
revascularization, rebuilding, and strengthening of the wound
site as a result of vigorous synthesis of collagen by fibroblasts,
and reepithelialization.50 Treatment is directed toward pro­
moting epithelialization and encouraging proper alignment of
newly deposited collagen fibers. During the maturation phase,
the wound site is further strengthened by protracted deposi­
tion of collagen fibers by active fibroblasts. Treatment during
maturation stresses lengthening the scar, reconditioning the
patient, and returning the patient to preburn functional lev­
els. Activity and rehabilitation interventions aimed at oppos­
ing wound and scar tightness and education about the process
of recovery are critical in all phases of healing.
While fibroblasts deposit collagen during the proliferative
phase, macrophages and endothelial cells release enzymes that
degrade collagen. The severity of scar formation is determined
by the balance between collagen synthesis and lysis: the more that
collagen deposition exceeds its breakdown, the more likely a sig­
nificant scar will form.51,52 A hypertrophic scar is raised above the
normal surface of skin (Figure 15-3).53–55 A keloid occurs when
the scar extends beyond the initial boundaries of the wound.53–55
FIGURE 15-3  The dorsum of this patient's hand exhibits hypertro­
phic scarring. (From Ward RS. Pressure therapy for the control of
hypertrophic scar formation after burn injury: a history and review.
J Burn Care Rehabil 1991;12[3]:257-262.)

416
Section II  Orthoses in Rehabilitation
An immature scar is raised, red, leathery, and stiff.
As the scar matures, it becomes pale, relatively soft and flat­
tened, and more yielding.56–58 The process of scar maturation
requires 6 to 18 months after wound closure; scars actively
contract during maturation.56,57,59 Contraction is most vigor­
ous in the early months of maturation but continues through­
out this period of remodeling.
Superficial and partial-thickness burns usually do not scar;
full-thickness burns almost always do. Full-thickness wounds
closed by a skin graft scar significantly less than a similar
wound allowed to heal spontaneously. Very dark-skinned or
very fair-skinned individuals and those with familial history of
susceptibility to scarring are more likely to form hypertrophic
scar.60–63 The larger the burn, the greater the likelihood of scar
formation.62–64 A contracture occurs when a portion or distor­
tion of the shortening scar becomes fixed or semifixed.65 The
axilla, elbow, hand knee, face, and neck are common and most
problematic sites of scar contracture formation.61,63,65 One of the
most important goals of burn rehabilitation is to prevent, coun­
teract, and minimize the adverse effects of scar contraction.65
Operative Scar Management
Surgery is used to correct scar contractures that have created
specific functional deficits or deformities.66 Surgical techniques
used to release scar contracture include split-thickness or full-
thickness skin grafts, skin flaps, Z-plasties, and tissue expan­
sion.66,67 Most surgeries are deferred until at least 6 months after
the burn or until the scar is sufficiently mature.66,67 Although
surgery alleviates contracture-related problems, it also creates
a new wound with its own subsequent scar maturation process.
Rehabilitation is necessary after a majority of reconstructive
surgeries to again avert the affects of contraction.
Nonoperative Scar Management
The nonoperative control of hypertrophic scarring most
commonly involves pressure therapy and the application of
silicone gel sheeting. The use of continuous pressure for the
treatment of burn scars was described in 1971.68 Pressure has
also been shown to relieve other aggravating discomforts of
the healing burn wound, such as itching and blistering.69–72
ROM is not significantly impeded with pressure garments
despite the restriction felt by patients (particularly initially)
when fit with pressure garments.73
Pressure therapy is indicated when healing requires more
than 14 days or if skin grafting has been performed. There
are several strategies to assess burn scar condition. The
Vancouver Scar Scale developed by Sullivan and colleagues
describes severity of the scar by rating pigmentation, vascu­
larity, pliability, and height of the scar tissue (Box 15-1).74
Early pressure therapy is used to control edema in a wound
even if there is no ensuing scar formation. Some of the most
common elastic materials used on newly healing, still frag­
ile wounds include elastic bandages, Coban self-adherent
wrap (3M Medical, St. Paul, Minn.), or elasticized cotton
tubular bandages such as Tubigrip (SePro Healthcare, Inc.,
Montgomeryville, Pa.).75–77 These materials are useful while
the patient is waiting for the arrival of custom-fit, antiburn
scar supports.75–77
Individuals with scars are commonly fitted with
­custom-fit pressure garments for the duration of the
maturation phase of healing. Custom-fit, antiburn scar
supports are available from manufacturers such as Bio-
Concepts (Phoenix, Ariz.), Barton-Carey Medical Products
(Perrysburg, Ohio), Gottfried Medical (Toledo, Ohio), and
Medical Z (San Antonio, Texas). Although the measur­
ing procedure varies by manufacturer, most require mea­
surements approximately every 1 to 1.5 inches along each
extremity, with special guidelines for the torso, face, and
hands. Burn scar supports can be fabricated to fit almost any
body part, including the face, torso, upper extremity, hand,
and lower extremity. Some burn centers fabricate rigid or
semirigid face masks (essentially orthotics) in an attempt to
gain a better match with facial contours.78
Pressure garments and devices are worn through the entire
process of scar maturation, to be discontinued only when the
scar has completely matured.1 Fit of pressure garments is
Modified from Sullivan T, Smith J, Kernoda J, et al. Rating the burn scar. J Burn Care Rehabil 1990;11(3):256-260.
PIGMENTATION
0 = Normal (scar color closely resembles that of the rest
of the body)
1 = Hypopigmentation
2 = Hyperpigmentation
PLIABILITY
0 = Normal
1 = Supple (flexible with minimum resistance)
2 = Yielding (gives way to pressure)
3 = Firm (inflexible, not easily moved, resistant to man­
ual pressure)
4 = Banding (ropelike tissue that blanches with extension
on the scar)
5 = Contracture (permanent shortening of scar, produc­
ing deformity or distortion)
VASCULARITY
0 = Normal (scar color closely resembles that of the rest
of the body)
1 = Pink
2 = Red
3 = Purple
HEIGHT
0 = Normal (flat)
1 = Raised less than 2 mm
2 = Raised less than 5 mm
3 = Raised more than 5 mm
BOX 15-1  Vancouver Scar Scale Ratings for Assessing Burn Scar

Chapter 15  Splinting, Orthoses, and Prostheses in the Management of Burns
417
regularly reassessed to ensure the desired therapeutic effect.
Regular follow-up provides an opportunity for the patient to
discuss other ongoing rehabilitative problems associated with
the burn.
Silicone gel sheets or pads can be put right on a maturing
scar. Silicone gel sheeting is generally applied over small areas
or on scar where it is otherwise difficult to provide sufficient
pressure. The mechanism of action for the effect of silicone
gel on scar is not known.79,80
BURN REHABILITATION INTERVENTIONS
Many different types of rehabilitation interventions are
appropriate in the care of patients with burns. Although
many interventions are briefly described in the following
section, the emphasis is on the use of splints, orthoses, and
prosthetic devices.
Therapeutic Exercise
Exercise helps minimize outcomes of burn injury and burn
scar formation by improving mobility and function.81 As
important and effective as exercise is in burn rehabilita­
tion, some individuals may be reluctant to exercise (and
some therapists may be reluctant to encourage them)
because of the anticipation of increased pain or anxiety
about damaging newly healing tissue. Exercise programs
for patients with burns are principally directed at the pre­
vention of burn scar contractures and the side effects of
inactivity and disuse. Additional consequences of immo­
bilization in these patients can include progressive con­
tracture of the joint capsule and pericapsular structures,
atrophy and contracture of muscle, deleterious effects on
articular cartilage, and possible decrease in bone strength.
Exercise is a significant health promotion and disability
prevention component in the rehabilitation of patients
with burns.
Assessment of location and depth of burn injury identifies
those areas most at risk of burn scar contracture. This assess­
ment also guides design of an exercise program to improve
mobility, strength, and functional status. Past and present
medical conditions influence rehabilitative expectations; a
previous orthopedic injury may have already reduced ROM
of a particular joint whereas a concomitant inhalation injury
may limit exercise tolerance.
Active Exercise
After a burn, exercise may be difficult because of edema, pain
(particularly over areas of partial-thickness burns), the loss
of skin elasticity in the burned tissue, and wound contrac­
tion.44,82 Early on, edema is a major contributor to stiffness of
joints; active exercise is valuable in reducing the edema.32,83
Positioning and compressive wraps or devices are used for
edema control in addition to exercise. Pain tolerance varies
widely among individuals. The therapist is challenged to help
the patient understand the importance of activity despite the
pain involved. Many individuals have relief of their pain and
stiffness after exercise periods, which may encourage them to
participate in the subsequent therapy sessions. Persons who
understand the advantages of exercise may be asked to confer
with, and encourage, newly injured individuals or those hav­
ing difficulty with their exercises.
General stiffness from the loss of skin elasticity and wound
contracture is a short-term problem but often persists during
the process of scar maturation, especially for those who form
a hypertrophic scar. Exercise targeting those areas most vul­
nerable to scar formation identified in the initial evaluation
must begin as early as possible after admission.44,84 Early pre­
sentation of an exercise routine aids edema control, relieves
stiffness, and prevents loss of strength and ROM. The early
introduction of active exercise reinforces the importance of
exercise to the individual, who will incorporate daily exer­
cise as a important contributor to overall recovery. Because of
the wide scope of benefits derived from active exercises, they
are the preferred form of ROM exercises for patients with
burns. A survey of physical and occupational therapists, 96%
reported instituting active ROM exercises within 24 hours of
acute burn center admission.85
Patients are also encouraged to perform independent
activities of daily living.44,83 Self-reliance is important after
burn injury, and independence can increase the patient's
self-confidence.44,83 It is likely that the more patients can do,
particularly in directing their exercise programs, the more
compliant they will become.84 Independence in an exercise
program is therefore an important goal for those recovering
from burn injury.
The primary goals of active exercise for patients with
acute burns are opposition of tissue contraction and
strengthening. For an individual with a burn crossing the
antecubital fossa and weakness of the biceps brachii, exer­
cise is focused on preservation of elbow-extension ROM
and functional strength of the muscle. If a patient with a
burn encompassing the lower leg and ankle also has weak­
ness and atrophy of the triceps surae, appropriate strength­
ening exercises may be performed, but certainly not at the
sacrifice of active ankle ROM.
Conditioning exercises can be incorporated to improve
the cardiovascular status of the patient.86 Occupation-specific
training programs may be a part of the long-term rehabilita­
tion plan as patients plan to return to their jobs. This type of
activity may be directed at one or a few specific functions or
may incorporate a traditional work-hardening program.
Gait Training
The functional nature of ambulation makes it an important
exercise for burned lower extremities.87 Ambulation assists
with edema control, ROM, and strengthening in all lower
extremity joints. Ambulation also helps with the function
of other physiological systems such as the cardiovascular,
gastrointestinal, and renal systems. Individuals with lower
extremity burns exhibit gait deviations related to compro­
mised joint function, such as incomplete hip and knee flexion
in initial swing and incomplete knee extension in terminal
swing. Initial contact may be made with the entire foot (foot
flat) instead of the heel, and loading response may be com­
promised by lack of plantar flexion ROM or an unwillingness
to perform the controlled knee flexion necessary for shock

418
Section II  Orthoses in Rehabilitation
absorption. Excessive knee flexion in midstance, poor or
absent heel-off and weight shift in terminal stance, and inade­
quate knee flexion in preswing are often present.33 Differences
in individual gait deviations in gait phases are generally based
on variations in the location, size, and depth of the burn
injury and levels of pain. Any gait deviation caused by the
burn may accentuate the need for vigilant gait training of a
patient with burns who also has a lower extremity prosthesis.
Exercise is an important adjunct to gait training because it
can address specific movement limitations of the lower limbs.
Passive Exercise and Stretching
Passive exercise is included in therapy regimens when patients
are unable to move on their own or cannot actively complete
normal ROM. Passive ROM and slow, gentle stretching exer­
cises that elongate healing soft tissues are used to preserve
and improve joint ROM.88 Eighty-four percent of physical
and occupational therapists reported initiating passive ROM
stretching exercises within the first 24 hours after burn cen­
ter admission.85 Blanching of the scar indicates an appropri­
ate amount of stretch. Although the scar should be stretched
to the point of tolerance, joint movement should not be
forced because of possible tissue damage and the potential for
­heterotopic ossification.89–91
Positioning or splints are used after a stretching session
to maintain the achieved ROM. Suitable stretching positions
must also consider scars that cross multiple joints and there­
fore affect a broad kinematic chain.
Most of the exercise equipment typically found in reha­
bilitation settings is appropriate for patients with burns. The
therapist must decide when certain equipment will be most
beneficial and incorporate the use of this resource into the
plan of care. The use of latex rubber tubing for strengthening
and overhead reciprocal pulleys for increasing ROM are a few
examples of simple equipment that have been described in
the literature.92–94 Bicycle ergometers for either the upper or
lower extremities assist with motion, provide resistance, and
allow for some cardiovascular workout.
Physical Agents
Because of the variety of treatment goals important for burn
rehabilitation, many different types of modalities may be used
for appropriate intervention. Hydrotherapy, functional electrical
stimulation (neuromuscular electrical stimulation), transcuta­
neous electrical nerve stimulation, ultrasound, continuous pas­
sive motion (CPM), and paraffin are physical agents that have
been reported to be used in burn care. Hydrotherapy is most
often used for wound care but may also be used for dressing
removal and exercise.95 If hydrotherapy is chosen as a thermal
modality, precautions similar to those used for any open wound
care are necessary to reduce the chance of cross-contamination.
Functional electrical stimulation has been successfully
used to treat hands that have responded poorly to typical
treatment.96 Burn pain has been altered by transcutaneous
electrical stimulation in some cases.97 Ultrasound has been
used to treat pain and ROM impairments in patients with
burns; however, the efficacy of ultrasound in either decreasing
pain or improving motion is still a matter of some debate.98–100
Successful use of CPM has been specifically reported for hand
burns and lower extremity burns at the knee.101 The gentle
heat provided by paraffin, as well as the potential skin soften­
ing from the mineral oil in the paraffin, may be reasons for
the use of this modality in burn care.102
Healing skin and recently healed skin are often very sen­
sitive. Scar tissue has varying levels of sensory deficit.103,104
Accordingly, heat, cold, coupling agents, and electrode adhe­
sives may lead to skin breakdown. Caution must be exercised
when applying any modality; thorough pretreatment and
posttreatment inspection of the site is warranted.
Positioning
Positioning is an important component of any burn reha­
bilitation program. Positioning is used for acute burn and
postsurgical edema control and to prevent or treat scar con­
tractures.105 The initial burn therapy evaluation identifies
sites at risk for contracture formation; appropriate counterac­
tive positions become part of the therapy plan. Contracture
prevention is more successful when a program of positioning
and activity is instituted as soon after burn as possible.44,63
Postexercise positioning extends the effects of activity;
positioning is also fundamental for individuals who cannot
move or exercise. Manufactured positioning devices, such as
arm boards that attach to the side of the bed, are available to
assist in proper positioning of extremities. Positioning need
not be expensive or require intricate equipment. Avoiding the
use of a pillow behind the head is a simple way of decreasing
neck flexion and facilitating a neutral alignment of the head
and neck. A pillow or several folded blankets placed under
the arms can effectively elevate the burned limb while keep­
ing the elbows extended and supporting the hands. At least
some horizontal flexion of the shoulders is indicated to mini­
mize prolonged stretch of the brachial plexus.106,107 A wash­
cloth, towel, or gauze roll placed in the palm helps hold the
hand in a functional position. Pillows, high-top tennis shoes,
towels, blankets, and foot boards help position the foot with
a neutral ankle.44 Positions of choice for a patient with burns
are shown in Box 15-2 (see next page).
SPLINTS AND ORTHOSES
Hippocrates described burn scars as “tetanus,” and Wilhelm
Fabry illustrated a splint to treat a hand for hyperextension
scar contractures.16 In the early to mid-1900s, patients with
burns were placed in splints immediately on admission
to the hospital in an effort to prevent contraction; splints
were removed for brief periods to permit wound care. Most
burns were not covered by skin graft until at least 5 weeks
after injury. The advent of surgical excision and grafting in
the mid-1900s decreased the time required for a burn to
heal. As a result, prophylactic splinting became a less com­
mon procedure, and in the late 1970s and early 1980s active
exercise became the primary treatment method used by
physical therapists working with burn patients.44 The use
of splints has, however, become a critical adjunct to active

Chapter 15  Splinting, Orthoses, and Prostheses in the Management of Burns
419
exercise and positioning of individuals with burns. The
term splint is used in burn care more often than orthosis,
even though the terms and the devices they represent are
nearly synonymous.
Splints may have a multiplicity of purposes.108 Splinting is
often used to protect fragile wounds or newly grafted burn
wounds. Splints are also used to position joints to maintain
achieved ROM or as dynamic devices to apply gentle pro­
longed stretch to increase ROM. Splints cannot replace active
exercise; contractures will form even in desirable positions
if a patient is constantly splinted in a particular position.
Static splints are designed to maintain a position of choice by
immobilizing the joint.109,110 Dynamic splints are designed to
exercise or mobilize a joint.110–113 A splint may also enhance
the pressure applied to a scar by a pressure support. If unusual
pain (other than from gentle tissue elongation or stretch),
sensory impairment, or wound maceration occurs at the site
of the splint, it must be removed and the fit adjusted.114
A splint should be fabricated with a proper, secure fit to
minimize friction injuries or skin breakdown at pressure
points. Pressure points over bony prominences are particu­
larly vulnerable in this regard. Large, broad surface contact
areas better distribute forces and reduce the likelihood of
pressure-related tissue injury. The splint is worn only when
it will not impede the functional activities or requisite exer­
cises of the patient; splints are often donned during rest peri­
ods and at night when the patient is sleeping. The corners
and edges of the splint are rounded and sometimes padded
to avoid shear stresses. The design of the splint may also need
to be adapted for orthopedic hardware such as surgical pins
or for intravenous line sites. The splint design should, when­
ever possible, allow for ease of application and removal to
enhance compliance among staff and family members who
otherwise might struggle while maneuvering the splint.
Careful consideration should be given as to the rationale for
the application of a splint in any clinical case.115
Material used in fabricating splints include thermoplastics,
plaster, and elastomer compounds. Thermoplastics resource
companies include Orthoplast (Johnson and Johnson,
New Brunswick, NJ), Orfit (Orfit Industries, Jericho, NY),
Supracor (Supracor Inc., San Jose, Calif.), and Hexalite
(Reebok International, Canton, Mass.), among others.
Hexalite and plaster are most often used to make temporary
splints. Thermoplastic material, which can be remolded to
adjust fit, make it an ideal splinting material for patients with
burns. The amount of material to be used is determined by
measuring the area to be splinted and the design of the splint.
The splint is then molded to the individual. When the splint­
ing material is set, or hardened, the splint should be inspected
for correct fit to avoid pressure- and shear-related problems.
Splints are often padded with gauze or any of the numerous
cushion or foam materials available. For areas where frag­
ile skin is problematic, foam is a soft alternative splinting
material; however, it does not provide the same resistance to
force that more rigid materials do. The advantages and dis­
advantages, as well as indications and contraindications of
­therapist-fabricated splinting and burn care, are summarized
in Box 15-3. Although a number of appropriate splint designs
for each anatomical site are possible, some are chosen more
commonly than others and the choices are based on clinical
indications and are not ­generally evidence based.115
Neck
Extension, no rotation
Shoulder
Abduction (90°)
External rotation
Horizontal flexion (10°)
Elbow and forearm
Extension with supination
Wrist
Neutral or slight extension
Hand
Functional position (dorsal burn)
Finger and thumb extension
(palmar burn)
Trunk
Straight postural alignment
Hip
Neutral extension/flexion
Neutral rotation
Slight abduction
Knee
Extension
Ankle

Neutral or slight dorsiflexion
No inversion
Neutral toe extension/flexion
BOX 15-2  Preferred Positions for Patients
with Burns
ADVANTAGES
Maintains or increases (serial or dynamic) joint position
Can be used during any phase of healing
Custom formed for each individual
Adjustable
May protect tissue (e.g., exposed tissues such as tendon
or joint capsule, or skin from pressure)
DISADVANTAGES
Potential for skin breakdown
Shearing may occur if not properly fit or fixed over a joint
May be difficult for nontherapist to apply
INDICATIONS
Need for positioning specific joints
Wound or scar contraction
Decreased joint range of motion
Need for safeguarding anatomical structures
Need for conforming scar tissue
Uncommunicative or nonresponsive patient
CONTRAINDICATIONS
Direct application onto fragile tissue
Constrictive fixation strapping or wraps
BOX 15-3  Advantages, Disadvantages,
Indications, and Contraindications
of Therapist-Fabricated Splints in
Burn Care

420
Section II  Orthoses in Rehabilitation
Neck
The possible consequences of anterior neck burns include flex­
ion contracture, facial disfiguration, loss of cosmetic contours
of the neck, and difficulty with mastication.114,116 A molded
neck conformer splint helps prevent neck flexion contracture
and provides compression on the forming scar. A rectangular
piece of low-temperature thermoplastic splinting material is cut
to span the distance from ear to ear along the jaw line and from
below the lower lip to the sternoclavicular notch. After heating,
the splint is molded directly on the patient's neck. Padding is
added to protect vulnerable areas, and a hook-and-loop mate­
rial strap is attached over the back of the neck to secure the
splint.114 Because this type of splint is occlusive and covers many
bony prominences, the splint must be frequently removed to
inspect the skin for any areas of irritation or breakdown.
For wounds that do not involve much of the chin, soft
cervical collars have also been successful in providing posi­
tioning, pressure, and contour.114,116 Although soft collars are
more comfortable to wear, they do not extend over the chin
for increased moment arm resistance. Commercially avail­
able Philadelphia collars may be an alternative. Watusi splints
can also be designed to assist with conforming neck scarring
and maintaining neck position.117
Axilla and Shoulder
Burns involving the axilla and shoulder may lead to adduc­
tion contracture and webbing of the axillary folds. This type of
deformity contributes to difficulty in reaching and ­overhead
use of the arm, components of many functional ­activities.
A custom-fit conforming splint is often used to inhibit devel­
opment of such contracture and webbing. Conforming splints
for axillary burns support the entire arm, from the wrist
through the axilla, and extend down the trunk to at least waist
level.118 The splint wraps around the trunk from umbilicus to
spine, one third of the circumference of the chest, at the axilla
around both folds, and one half of the circumference of the arm
at the brachium, elbow, and wrist.114,119,120 The splint is molded
directly to the patient (flaring at the iliac crest may be neces­
sary) and appropriate padding is applied. Hook-and-loop
material ­strapping or other wraps around the trunk, shoulder,
arm, and wrist secure the splint. A more traditional airplane
splint may also be used to counteract the problems at the shoul­
der (Figure 15-4). Clavicle straps or soft foam may also be used
to help conform the axillae.
Elbow and Forearm
The most common deformities caused by burns involving
the elbow and forearm are elbow flexion and pronation con­
tractures. The elbow joint is most often fit with a conformer
splint designed as either an anterior or posterior gutter or
trough (Figure 15-5).114,116,119 The splint is fit to the arm from
the proximal third of the brachium to the distal third of the
forearm. Partial circumference measurements are taken at the
proximal and distal sites and the elbow. The splint is molded
directly on the patient, with padding added. The splint should
be flared or “bubbled” at the bony prominences of the elbow.
The splint is held in place by hook-and-loop material straps
or by circular gauze or elastic wrapping. Commercially avail­
able three-point extension or air splints may also be used.
Wrist and Hand
Burns of the wrist may lead to contractures in extension or
flexion or ulnar or radial deviation, depending on the location
of the burn. The prevention of flexion or extension contrac­
tures of the hand and fingers is important, as is maintenance
of the web space of the thumb. Many different designs of
wrists and hand splints exist; the best option for a particular
individual is based on the anticontracture position of the joint
or joint complex that is involved.
The most common splint used at the wrist and the
hand is the Antideformity Splint.114,116,119,121,123 This splint is
designed to position the wrist and hand in the functional
position. A modification of this splint, the pan splint, posi­
tions all finger joints in extension (Figure 15-6). Splints that
conform to the thumb, thumb web space, and the index fin­
ger can help preserve the thumb web space.114,116,119 Dorsal-
or palmar-resting extension splints, used when the wrist has
been burned but the hand is not damaged, may be custom
molded or are commercially available. Finger gutter or trough
splints are used to treat individual fingers, on the basis of the
same principles used in elbow conformer splints.
FIGURE  15-4  An example of a thermoplastic airplane splint
designed to reduce the likelihood of development of an axillary
contracture during burn healing. (Courtesy Shriners Hospitals for
Children, Cincinnati Burn Hospital, Cincinnati, Ohio.)
FIGURE 15-5  A thermoplastic anterior elbow gutter splint being
custom fit for a patient with burns of the antecubital fossa.

Chapter 15  Splinting, Orthoses, and Prostheses in the Management of Burns
421
Another easily fabricated splint that is useful to minimize
formation of either flexion or extension contractures when
multiple joints of the fingers have been burned is the sand­
wich splint.116,122 Foam padding is attached to two pieces of
splinting material that have been cut large enough to cover
the hand. The burned hand is “sandwiched” between these
two padded supports, which are held in place with a circum­
ferential wrap (Figure 15-7).124
Trunk and Pelvis
Patients with burns involving the anterior trunk are at risk
for developing kyphosis. Clavicular straps in a figure-of-eight
design have been used to position the shoulders in retrac­
tion and counteract the flexion forces in healing upper trunk
burns.114,116 Commercially available corsets or thoracolumbar
spinal orthotics may be prescribed to help maintain posture
for individuals with burns of the mid and lower trunk if it is
being compromised by scar contracture.
For burns of the pelvis, groin, and hip, the problem is the
likelihood of hip flexion and adduction contractures. Hip
abduction splints reinforced with a spreader bar or an ante­
rior hip spica splint may be necessary for some patients.116
Lower Extremity
At the knee, flexion contracture is an important concern.
Splinting of the knee is similar to that of the elbow, adjusted
to fit the longer segments of the lower extremity.114,116,119,125
Although knee conformer splints are most often chosen for
patients with burns involving the knee, three-point exten­
sion splints or air splints have also been used to reduce risk of
­flexion contracture as the burn scar matures.
Because of the complexity of structure and arthrokine­
matics, burns of the ankles and feet often present challenges
for splinting similar to those of the wrist and hand. The loca­
tion of the burn dictates whether the patient is at risk for con­
tracture in either a plantar flexion or dorsiflexion direction
(or both). Posterior foot drop splints, or anterior or poste­
rior ankle conformers, are the most commonly fabricated
ankle splints.114,116,119 The distance from toes to calf is mea­
sured, and limb half-circumferences determine the width of
the splint. After the desired splint pattern is cut from thermo­
plastic material, the splint is molded directly on the patient.
Necessary padding is applied and the splint is flared at the
malleoli and often on the posterior heel. Successful treatment
of burns to the dorsum of feet can be difficult.
Another important consideration is the extrapolation of
splint designs for other anatomical areas to a seemingly unre­
lated location. In 2001, Guild126 reported an application of
the designs from various splints for dorsal hand burns to a
splint for the treatment of burns of the dorsal foot. The splint
has a base and a dorsal thermoplastic piece that fits over the
toes and is secured with a hook-and-loop material strap. This
splint is intended to minimize or prevent contractures of the
dorsal foot during scar maturation. “Bunny boots” and other
commercial foot drop splints can also be used for position­
ing ankles that have been burned.114 Molded leather shoes can
be useful in positioning both the ankles and toes of involved
feet.116 High-top gym shoes provide a less expensive but simi­
lar option for foot splinting.38,116 Toe conformer splints can
be fabricated for the dorsal surface of the foot to prevent toe
extension contracture.
Face and Mouth
Burns of the face can affect the eyes and eyelids, the con­
tours of the face, and the soft tissue around the mouth.127–130
Contracture of the mouth (microstomia) is particularly
FIGURE 15-6  A thermoplastic pan splint that been molded to sup­
port the wrist in a functional position, with fingers in full extension.
A
B
FIGURE 15-7  A, Materials used for a sandwich splint include ther­
moplastic splinting material, foam, and a compression wrap. B, A
sandwich splint applied to the hand with burns. (From Ward RS,
Schnebly WA, Kravitz M, et al. Have you tried the sandwich splint?
A method of preventing hand deformities in children. J Burn Care
Rehabil 1989;10[1]:83-85.)

422
Section II  Orthoses in Rehabilitation
troublesome because it interferes with feeding (and sub­
sequently nutrition), speaking, and dental care.131 Splints
designed to support the functional contours of specific
areas of the face are often fabricated (Figure  15-8). This
type of splint helps decrease scar hypertrophy and mini­
mize or prevent ectropion (eversion) deformity of the lower
eyelids and the lips.
Microstomia prevention splints, designed to apply pressure
or stretch to commissures and fibrotic oral muscles, are com­
mercially available or may be custom made (Figure 15-9).132–134
This type of splint or appliance is worn at all times when the
patient is not eating or receiving oral care or is speaking.134 In
cases in which contracture affects the actual opening of the
mouth, cone-shaped splints of thermoplastic material can be
used to increase the opening of the mouth progressively. The
cone is placed between the teeth after the mouth is opened.
As the mouth is able to open wider, the narrower portions of
the cone are cut off and the patient progresses to a wider part
of the splint to widen the opening of the mouth.
Additional Considerations
Simple materials such as tongue depressors secured with gauze
wrapping at various joints have been described as “splints.”135
Elastic wraps have also been used to increase ROM much like
dynamic splints.136,137 These methods may be useful as tempo­
rary devices but are not effective substitutes for more stable
splinting materials.136
For patients with existing contractures, a serial splint­
ing protocol is often used to assist in stretching the defor­
mity. Plaster casts, thermoplastic materials, and Dynasplints
(Dynasplint Systems Inc., Severna Park, Md.) have been suc­
cessfully used in this manner.138,139 Individually fabricated
dynamic splints are also helpful for individuals with contrac­
ture after burns.
Any splint worn over an open wound may be a transfer
agent for microorganisms from the burn.140 In fact, organ­
isms can be cultured from splint surfaces 50% of the time.141
Effective strategies for cleaning burn splints are imperative.
Simple washing and drying of the splint is not always effective
in eliminating all organisms. The use of quaternary ammonia
(1 oz per gallon of water) has been found to be 100% effective
as a cleaning agent and is the recommended splint-cleaning
strategy.141
Occasionally, special rehabilitative complications arise
after burn injury, especially in patients who have sustained
deep thermal wounds or an electrical injury. The most com­
monly encountered complications are exposed tendons
and peripheral neuropathy with motor or sensory deficit.
Splints can be useful in protecting or supporting these areas.
Exposed tendons must be kept moist with an ointment-based
A
B
FIGURE  15-8  A, This elastomer mold of the patient's nose and
cheeks will be reinforced with rigid thermoplastic material. B, When
worn under a compression garment, the insert will deliver pressure
more effectively to areas of the face than the compression garment
alone. Splint inserts may help minimize ectropion (eversion) of the
lower eyelids. Both would be worn during the maturation phase of
healing to prevent excessive contracture and hypertrophic scarring.
(From Ward RS. The rehabilitation of burn patients. CRC Crit Rev
Phys Med Rehabil 1991;2[3]:121-138.)
FIGURE 15-9  A microstomia prevention appliance is used to pre­
serve the oral opening.

Chapter 15  Splinting, Orthoses, and Prostheses in the Management of Burns
423
gauze or biological dressing. The limb is splinted in a position
where the tendon is slack, and exercise is avoided.88 Idiopathic
neuropathy occurs most often in patients with 20% or more
TBSA burn involvement.1 Secondary neuropathies may be
caused by overelongation or compression of a peripheral
nerve; such problems can be prevented by careful systematic
monitoring of a patient's position, tightness of dressings, and
the fit of splints and may be more common following deeper
burn ­injury.88,142,143 Splints may also be fit to overcome a tem­
porary or long-term neurological deficit such as a drop foot.
AMPUTATION AND PROSTHESES IN BURN
REHABILITATION
Electrical burn injuries are more likely to lead to amputation
than any other types of burns. Significant damage occurs as
electrical current passes through nerve tissue, vascular tissue,
and other deep structures. The current can cause destruction
of cells, coagulation of tissues, thrombosis of blood vessels,
neuropathies, and tissue necrosis. Other types of burn inju­
ries and frostbite injuries may necessitate amputation if the
wound is very deep or has associated tissue trauma. Some
amputations, however, can be the consequence of an unre­
lenting infection.
Patients with burns who require limb amputation may
have complications that delay prosthetic fitting and train­
ing as a result of multiple wound or scar sites, skin graft­
ing on the residual limb, repeated surgical procedures (not
necessarily associated with the residual limb), and burn-
induced catabolic atrophy. Individuals with burns are also
susceptible to the same postoperative complications faced
by any patient with a new amputation: edema, phantom
pain, and formation of neuroma or bone spur. Patients with
amputation as a result of electrical injury may be suscep­
tible to the formation of bone spurs.144 Otherwise, hetero­
topic bone formation does not appear to be more prevalent
in a burn population. Edema after burn injury is generally
a short-term problem and seldom creates long-term delays
in prosthetic training. There are no reports that suggest
individuals with burns with amputations are more likely
to develop phantom limb pain than other patients with
amputation.145
CASE EXAMPLE 1
A Patient with Burns of Both Upper Extremities
M. J. is a 17-year-old girl who was injured in a house fire
3 weeks ago and sustained 11% TBSA burns to her face and
both upper extremities. Facial burns were partial thick­
ness in depth and spontaneously healed within 2 weeks.
The burn injuries affecting both arms from midbrachium
down each forearm and the dorsum of each hand were full
thickness and required skin grafting for wound closure.
Skin grafting procedures were completed during the first
2 weeks of hospitalization in a series of three surgeries.
Questions to Consider
• What tests and measures would be most appropriate to
document and track changes in M. J.'s ROM, strength,
endurance, and functional status? How might they
need to be modified or adapted because of the severity
of her burns?
• How will the medical care of her healing partial-­thickness
facial burns and her full-thickness, grafted upper extrem­
ity burns be similar or different in terms of pain control,
likelihood of scarring, and wound care? What factors
might influence maturation of burn scars in this young
woman?
• At this point in time, what are the primary rehabili­
tation goals for this young woman? How do rehabili­
tation goals change over the stages of wound healing
(inflammatory, proliferative, and maturation)?
• What joints are most at risk for developing contracture
in the early phases of healing? What positions would be
optimal to reduce risk of contracture development? What
type of orthosis might you recommend at this time?
What other interventions would be important to consider
as she progresses through the stages of wound healing?
• What passive and active exercise strategies might you
recommend to enhance ROM, flexibility of healing tis­
sues, strength, and endurance?
• What education and supportive strategies might be
necessary?
• How long would you expect M. J. to be involved in
rehabilitation activities? How will you assess whether
your interventions are accomplishing the rehabilita­
tion goals?
Interventions and Outcomes
When M. J. is not immobilized after surgery, she is
involved in a treatment program that includes upper
extremity mobility exercises and strengthening exercises
and an aerobic conditioning exercise program. Early ROM
is generally mildly limited because of edema and wound
contraction. After the skin-grafting procedures, ROM at all
affected joints is improving, with the exception of declines
in left elbow extension and left hand metacarpophalangeal
flexion (digits 2 through 5). An anterior elbow-conforming
splint is fabricated for the left arm and a functional position
splint with approximately 40 degrees of metacarpopha­
langeal flexion is made for the left hand. Both splints are
made of thermoplastic material and secured with hook-
and-loop material strapping. These splints are applied
during rest periods, naps, and during the night to prevent
further loss of ROM. When awake, M. J. participates in
therapy sessions and a home program of passive stretching
and active exercise of all the affected joints, with empha­
sis on the troublesome left elbow and hand. Use of the
splints is discontinued after 2 weeks because the ROM has
improved to normal.

424
Section II  Orthoses in Rehabilitation
Any of these complications may intensify discomfort or
the amount of work and time required for prosthetic train­
ing, which can be reasons for limited use or rejection of the
prosthesis. Despite these concerns, patients with burn-related
amputations are successfully rehabilitated with standard
protocols.146–148
Skin Condition
For individuals with skin graft sites on the residual limb,
fragility of skin (its tolerance of pressure and shear forces)
is an important concern. Blisters or small open wounds may
appear where a skin graft or a fragile scar breaks down as a
result of forces on the residual limb during gait. Wearing of
the prosthesis is often discontinued until the new wound is
adequately healed. Wounds or skin grafts on areas associ­
ated with the prosthesis use, such as the shoulder or scapula
under an upper extremity prosthetic harness, may demon­
strate these same initial problems with wound breakdown.
Even though the presence of a skin graft or fragile scar may
delay or prolong prosthetic training, most patients with
burn-related amputation are eventually successful in using
their prostheses on skin-grafted limbs.146–150 New “­antishear”
prosthetic socket suspension and lining ­materials may
be especially helpful for individuals with burn-related
amputation.
Contracture
The typical postamputation contracture in patients with
burns is a result of muscle and soft tissue shortening related
to a decreased moment arm of the affected extremity. When
there is a maturing burn scar or graft site over the joint of the
residual limb, the risk of contracture significantly increases
(Figure  15-10). Such contractures may form more rapidly
with the additional shortening force of the contracting scar
tissue (Figure  15-11). The prevention of joint contracture
after amputation requires vigilant positioning and stretching,
which may be augmented by knee extension splints for indi­
viduals with transtibial amputation.
Delayed Fitting
For patients with large TBSA burns, repeated surgical
skin-grafting procedures are often necessary to cover the
burn wound adequately. Repeated surgical procedures
often delay prosthetic fitting and training. Individuals
may be placed on postoperative bed rest for up to 7 days
to ensure initial healing of the grafted area. To protect
the new graft site and promote healing, the limb may be
temporarily positioned in a less than optimal position for
prosthetic use. Continued monitoring by the therapist,
along with conscientious wrapping of the residual limb,
can help overcome some of the problems caused by suc­
cessive surgeries.
Stabilization of Body Weight
It is common for patients with burns to lose weight because of
hypermetabolism. A large burn can nearly double the body's
metabolic requirements. Although individuals with signifi­
cant burns receive nutritional supplementation, this often
slows but does not prevent catabolic weight loss. Most indi­
viduals regain the weight lost in the catabolic process; this
may require a series of revisions or refabrications of tempo­
rary sockets until weight stabilizes enough to fit a permanent
prosthesis.
FIGURE  15-10  This patient with burn-related transfemoral
amputation has increased risk of flexion contracture caused by scar­
ring of the graft sites over the anterior surface of the hip. (From Ward RS,
Hayes-Lundy C, Schnebly WS, et  al. Rehabilitation of burn
patients with concomitant limb amputation: case reports. Burns
1990;16[5]:390-392.)
FIGURE  15-11  This patient has sustained bilateral transtibial
amputation as a result of severe burn injury. She is at risk of signifi­
cant knee flexion contracture because of the positioning required
for her burn care and the inevitable contraction and scarring of her
extensive graft sites. The areas of skin graft in her distal residual
limbs may not initially tolerate the pressure and shear forces asso­
ciated with prosthetic use, leading to delays in prosthetic fit and
training.

Chapter 15  Splinting, Orthoses, and Prostheses in the Management of Burns
425
EDUCATION
The patient with burns is the most important member of the
rehabilitative burn care team. Family members and any others
who will be caregivers outside the hospital must be included
as early as possible to learn about the process of burn recovery
and rehabilitation. Effectiveness of education is reflected by
CASE EXAMPLE 2
A Patient with Amputation After Electrical Burns
C. T. is a 32-year-old man who was injured when a
metal ladder he was using to trim tree branches made
contact with overhead electrical wires. He sustained
35% TBSA burns to his face, trunk, both upper extremi­
ties (including the right axilla), and his right lower leg.
A right transhumeral amputation and a right transtibial
amputation were required because of significant tissue
damage from the electrical current. The amputations
were performed on the third day after the burn; both
residual limbs required several revisions of the ampu­
tation sites. Both residual limbs were successfully cov­
ered with a skin graft by the sixth day after the initial
amputation.
Questions to Consider
• What tests and measures would be most appropriate to
document and track changes in C. T.'s ROM, strength,
endurance, and functional status? How might they
need to be modified or adapted because of the severity
of his burns?
• Given the cause of his burns, what are the possible
issues related to wound healing, contracture formation,
and preprosthetic care that will influence your clinical
decision making? What are the most pressing rehabili­
tation goals considering both his burns and his ampu­
tations in this early period of rehabilitation? In the
months ahead?
• What will pain management and wound healing be like
for someone like C. T., who has undergone amputation
after electrocution, compared with someone with ther­
mal burns who has had skin grafting?
• What factors will influence C. T.'s readiness for pros­
thetic fitting for this transtibial limb? For his trans­
humeral limb? What is C. T.'s prognosis for prosthetic
use at both transtibial and transhumeral levels? How
might the presence of skin grafts influence the prosthe­
tist's recommendation for socket type and suspension
of the prostheses? How will maturation of the residual
limb and likely changes in body weight over time influ­
ence prosthetic fit and function?
• What are the key components in your preprosthetic
plan of care for C. T.'s residual limbs? How might tissue
healing influence his progression through prosthetic
training? What passive and active exercise strategies
might you recommend to enhance ROM, flexibility of
healing tissues, strength, and endurance?
• What education and supportive strategies might be
necessary for this young man with serious burns and
amputation?
• How long would you expect C. T. to be involved in
rehabilitation activities? How will you assess whether
your interventions are accomplishing the rehabilita­
tion goals?
Interventions and Outcomes
Although C. T. was fitted with a transtibial prosthesis within
3 weeks of skin grafting, the fitting of C. T.'s initial upper
extremity prosthesis must be postponed because of the time
required to obtain closure of the remaining burn wounds
on the right upper extremity (6 weeks). Given the extent of
his burns, signal sites for a myoelectric (externally powered)
prosthesis are difficult to identify; thus, C. T. is fit with a
conventional body-powered transhumeral prosthesis with a
hook as a terminal device. (See Chapters 30 and 31 for more
information about prosthetic options and rehabilitation for
individuals with upper extremity amputation.) Deep burns
on both shoulders and the left trunk further delay (10 weeks)
this fitting because of intolerance of the newly healed skin to
the prosthetic harness.
C. T. quickly becomes functional with his transtibial
prosthesis although susceptibility to pressure requires a
special antishear, pressure-distributing liner. (See Chapters
23 and 26 for more information on prosthetic options and
rehabilitation for patients with transtibial amputation.)
During the fitting and training delays for his transhumeral
prosthesis, an aggressive treatment program, including
mobility exercises and strengthening exercises, is directed
at the right upper extremity. The residual limb is also
shaped with compression wraps and stockinet. C. T. also
participates in similar mobility and strengthening exer­
cises for other affected areas as well as an aerobic exercise
program aimed at improving his endurance.
Twelve weeks after injury, C. T. is fit for and begins
­formal training with his prosthesis (dual-control cable sys­
tem). There is one incident of skin breakdown under the
harness over the left scapula. This area is dressed and pad­
ded with dense foam. There are no further incidences of
skin breakdown. C. T. is discharged from physical therapy
associated with the amputation 15 weeks after injury.
During his episode of care for rehabilitation and
­prosthetic training, C.T. endured several delays in man­
agement of his amputations as a result of the care related to
other burn injuries, particularly those in strategic anatom­
ical regions. It was important to maintain focus on prep­
aration of the transtibial residual limb for containment
within and functional use of the prosthesis and to prepare
his transhumeral residual limb and opposite arms for the
figure-of-eight harness and control system. Much of C.T.'s
rehabilitation care concentrated on mobility ROM, and
strength (especially of his upper extremities and the shoul­
der girdle) and endurance training.

426
Section II  Orthoses in Rehabilitation
the individual's and caregiver's ability to demonstrate knowl­
edge and understanding of the rehabilitation program.151 Skin
care, exercise programs, use of pressure supports, position­
ing techniques, and splint protocols are the obvious items
that need to be taught to the patient.152,153 Reinforcement, rea­
soning, and reassurance are key words to remember when
designing an educational process.
SUMMARY
Optimal care of individuals recovering from burn injury taps
the knowledge and skills of many different health care pro­
viders. Rehabilitation professionals are actively involved in
many facets of postburn care, such as wound care and sur­
gical grafting procedures; education about the burn reha­
bilitation process; and preventive care to minimize risk of
hypertrophic scarring, contractures, deformity, and subse­
quent disability. Postburn rehabilitation care requires knowl­
edge of and expertise in splint design and fabrication, exercise
prescription (stretching and flexibility, strengthening, endur­
ance), adaptive and assistive devices for gait and activities of
daily living, and often prosthetic prescription and training.
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101. Covey MH, Dutcher K, Marvin JA, et al. Efficacy of continuous
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102. Head M, Helm P. Paraffin and sustained stretching in treat­
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104. Ward RS, Tuckett RP. Quantitative threshold changes in cuta­
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430
16
Adaptive Seating in the Management of Neuromuscular
and Musculoskeletal Impairment
Barbara Crane
Neuromuscular and musculoskeletal impairments often
limit a person's functional gait potential. When this occurs,
adaptive seating support and wheeled mobility interven­
tions are essential in returning a person to a maximal level
of independent function. Individuals use their wheeled
mobility device for many hours each day. People who use
wheeled mobility devices (wheelchairs or scooters) for
some or all of their mobility often require adaptive seat­
ing support. Additionally, individuals who use wheeled
mobility devices often require assistance for other activities
of daily living and may require postural support and bal­
ance in a seated position. Individuals with neuromuscular
impairments typically require specialized seating support
to attain a maximal level of independent function, comfort,
safety, and quality of life. Individuals with musculoskele­
tal impairment in the absence of neurological deficits may
also require postural support because of the amount of time
they spend in a seated posture or, in some cases, because of
the inability to either stand or walk.
Individuals who use wheelchairs and adaptive seating sys­
tems are of all age groups and races. They use their wheel­
chairs in many different environments and for many different
reasons. Some are full-time wheelchair users because they
cannot stand or walk. Others spend part of their day in the
wheelchair to augment their mobility over long distances or
on uneven surfaces. Some use wheelchairs for short-term
conditions that resolve within weeks or months, such as lower
extremity fractures or joint replacement surgeries. Others
use wheelchairs long-term because of permanent disabling
conditions.
There are approximately 1.7 million community-dwelling
people in the United States who use wheelchairs or powered
scooters to assist them with mobility.1 Of these, approximately
1.5 million use manual wheelchairs, 155,000 use electric-
powered wheelchairs, and 142,000 use electric-powered
scooters.2 In addition to these permanent users, there are
likely to be several million part-time or temporary wheeled
mobility device users at any given time in the United States,
not including individuals residing in institutional settings.
The National Medical Expenditure Survey conducted in 1987
indicated there were 2.5 million individuals residing in long-
term care facilities, and of these, more than 50% use wheel­
chairs for mobility.3,4 Individuals who use wheelchairs range
from very young children who never attain the ability to walk
to very old adults who have lost this ability because of various
disabling conditions and processes.
Among all age groups, the leading condition associated
with wheelchair use is cerebrovascular disease. Among indi­
viduals ages 18 to 64 years, the leading condition associated
with wheelchair use is multiple sclerosis.1 Other conditions
commonly associated with wheelchair use include osteo­
arthritis and rheumatoid arthritis, congenital absence or
amputation of lower extremities, tetraplegia and paraplegia,
cardiopulmonary diseases and disorders (e.g., emphysema)
that limit endurance, cerebral palsy, diabetes, and orthopedic
impairment of the lower extremities.1
Individuals who use adaptive seating and wheeled mobil­
ity live in many different environments. Many live in the
16
LEARNING OBJECTIVES
On completion of this chapter, the reader will be able to do
the following:
1. Describe the population of individuals who use wheel­
chairs and adaptive seating.
2. Identify the elements of a basic wheelchair and seating
evaluation.
3. List potential outcomes for adaptive seating and mobility
intervention.
4. Summarize biomechanical principles related to adaptive
seating and wheeled mobility.
5. Rank the major types of wheelchair technologies in order
from lowest technical sophistication to highest technical
sophistication.
6. Explain various factors related to development of pressure
ulcers for wheelchair users with a spinal cord injury.
7. Specify which of the current technologies for postural con­
trol in seating would be most effective in the management
of severe spasticity in a patient with cerebral palsy.
8. Recommend an appropriate wheeled mobility base and
adaptive seating system for a patient after a cerebrovascu­
lar accident.

Chapter 16  Adaptive Seating in the Management of Neuromuscular and Musculoskeletal Impairment
431
­community independently or with assistance or support.
Others live in long-term care settings or in assisted-living
environments. Individuals use wheelchairs at home, school,
work, and outdoors. People rely on their wheeled mobility
devices to allow them to work, learn, play, care for them­
selves, and meet their personal goals. Therefore the assess­
ment for and recommendation of a wheeled mobility
device and seating support system is an important respon­
sibility, which is typically undertaken by a team of trained
individuals.
WHAT IS A WHEELCHAIR?
A wheelchair, or wheeled mobility device, is a complex piece
of assistive technology. In addition to providing a means for
mobility, this device provides the foundation for all other
function, that is, activities of daily living such as bathing
and dressing, work activities, and recreation. To do this, sev­
eral interrelated components of the wheeled mobility device
must work together to meet the needs of the individual
user. The three major components of a wheelchair are the
seating system (the postural support component), the wheel­
chair frame (the supporting structure), and the propelling
structure (Figure 16-1).5 All three components provide dif­
ferent functions but must form an integrated unit for efficient
and safe wheeled mobility. Successful integration is critical to
the function of the wheelchair user.
Seating System
The seating system, or adaptive seating component, of the
wheeled mobility device is primarily responsible for support
and positioning of the wheelchair user or wheelchair rider.
This component can be thought of as an orthotic intervention
in wheeled mobility prescription.
Adaptive seating is used to promote postural support and
positioning so that the user may function optimally.6 To do
this, it must accomplish the following five goals:
1. Provide effective postural support and positioning for
the pelvis, trunk, lower body, and sometimes extremi­
ties and head
2. Provide optimal soft-tissue loading by pressure redis­
tribution to minimize the risk of pressure ulcer
development
3. Provide optimal comfort so that the seating system may
be tolerated for long periods
4. Facilitate distal extremity function by providing a stable
base of support for the user
5. Permit optimal access to the mobility interface compo­
nent (e.g., the wheel rims of a manual chair or the power
controller of a powered wheelchair) of the wheelchair
Although all these goals are critical to the optimal function
of any wheeled mobility device, goals must be prioritized on
the basis of personal needs of each user. For example, a wheeled
mobility device user with a spinal cord injury who has good
overall posture but lacks sensory function requires greater empha­
sis on pressure management goals than on postural support.
The seating system is often divided into several compo­
nents, each with responsibility for supporting different body
segments. Table  16-1 summarizes the indications for each
type of seating component.
Support Frame and Mobility Components
The support frame is integrated with the seating component
and is closely linked with the propelling structure. The main
purpose of the support frame is to provide a smooth inte­
gration or connection of the seating support system and the
mobility component of the wheeled mobility device. Many
styles of frames are available; some provide specialty pur­
poses, such as tilt, recline, or standing frames, but the major­
ity are configured to allow attachment of adaptive seating
systems and facilitate access to the mobility structures of the
device by the user.
The mobility base, or propelling structure, of the wheel­
chair is composed of the drive wheels, caster wheels, tires, and
some type of user interface component. Goals for the mobil­
ity base focus on the facilitation of mobility within the user's
environment and can include the following:
1. Independent mobility in all environments encountered
by the individual
2. Safe access to mobility and the prevention of injuries,
such as overuse or secondary injuries
3. Maximum efficiency in mobility
4. Facilitation of overall function within the person's
environment
In Cook and Hussey's Human Activity Assistive Tech­
nology model, wheeled mobility devices and seating systems
are defined as “extrinsic enablers.”5 These devices facilitate or
allow the user to perform many functions. A seating support
system is referred to as a “general-purpose extrinsic enabler”5
A
B
C
FIGURE 16-1  The three components of a wheelchair include the
postural support (A), the supporting structure (B), and the propel­
ling structure (C).

432
Section II  Orthoses in Rehabilitation
because it facilitates many different functions for the user,
such as self-care, recreation, or mobility. The wheeled mobility
device is a “specific purpose extrinsic enabler,” meaning it spe­
cifically allows users to be mobile within their environment.
SEATING AND MOBILITY ASSESSMENT
Seating and mobility assessment is a highly complex process
involving multiple component evaluations and tests.7 Seating
and mobility assessments have many similarities to physical
therapy and occupational therapy assessments but are more
specific to the seating and wheeled mobility needs of the
patient. The major difference in the outcome between more
traditional therapy assessment and seating and mobility assess­
ment is the intervention. The intervention plan in a seating
and mobility assessment involves recommending a particular
wheeled mobility device and adaptive seating system. As with
any therapeutic intervention, the first step is an examination
of the patient.8 This examination allows the therapist to collect
all appropriate information to evaluate the patient's needs and
determine the most appropriate intervention plan.
Members of the Assessment Team
Specially trained clinicians, organized in a team structure,
are usually responsible for performing seating and mobility
assessments (Figure 16-2). This team may consist of physi­
cal or occupational therapists with specialized training in
wheelchair seating and mobility, physicians, rehabilitation
technology suppliers, orthotists, and other health care pro­
fessionals. The rehabilitation technology supplier is the
team member who is ultimately responsible for providing
the equipment to the patient. The rehabilitation technology
supplier participates in the assessment process, compiles an
equipment quotation and cost estimate, orders the equip­
ment from the manufacturer, submits the justification and
billing information to the equipment funding source(s), and
then assembles the components in preparation for delivery
of the wheeled mobility system. When an individual with
seating or mobility problem is referred to the team, a multi­
step process of assessment, prescription, and training begins
(Figure 16-3). The team must carefully document its find­
ings and recommendations.
History
As with most therapeutic examinations, a detailed history is
an essential component of a seating and mobility assessment.
This history typically includes information related to diag­
nosis, nature of the disabling condition, related health prob­
lems, current and past assistive technology use, description of
the home environment and other environments in which the
equipment will be used, transportation needs of the patient,
and funding source information for the equipment. All these
elements are critical to the selection of an appropriate seating
and wheeled mobility device.
TABLE 16-1  Postural Support Components and Indications for Use
Postural Support Component
Indications for Use
Seat cushion
Wheelchair use for any amount of time (see Table 16-6 for detailed descriptions of types of seat cushions)
Solid seat support
Wheelchair use for any amount of time, particularly a folding wheelchair with sling seat upholstery
Solid back support
Wheelchair use of 4 hours or more per day
Impaired sitting balance or trunk control
Scoliosis or any need for lateral and posterior spinal support
Lateral thoracic supports
Impaired sitting balance or trunk control
Flexible or fixed spinal scoliosis
Need for additional lateral support for safe or efficient activities of daily living (e.g., driving)
Lateral pelvic supports
Impaired pelvic and lower trunk control
Flexible or fixed scoliosis
Medial knee supports
Lower extremity adduction while sitting
Hypertonicity (spasticity) of lower extremities
Windswept deformities of lower extremities
Knee blocks
Impaired anterior stability of pelvis in wheelchair
If the patient slides out of wheelchair on a regular basis
Severe extensor spasticity in lower extremities
Head support
Impaired head control from weakness or abnormal muscle tone
Anterior pelvic support
Anterior/posterior instability of pelvis while sitting (e.g., falling into posterior pelvic tilt or excessive
anterior tilt, sliding out of chair)
Anterior trunk support

Anterior trunk instability
If additional support is needed for safe and efficient functional activities (e.g., wheelchair propulsion,
mobility over rough terrain, driving activities, or transportation needs)

Chapter 16  Adaptive Seating in the Management of Neuromuscular and Musculoskeletal Impairment
433
The diagnosis of the patient is a critical component of the
history—particularly diagnoses related to why years requires
a wheeled mobility device. If a patient has a gait disability,
the cause of the disability must be described both to evaluate
the most effective intervention and to justify the need for the
equipment to the funding source. Important questions to ask
include the following:
1. When was the onset of the disability?
2. Was it sudden or slow?
3. Is the disability progressive or nonprogressive?
In addition to the major diagnosis, information about
associated health problems is also important. Related health
problems may include breathing problems, cardiovascular or
circulatory problems, seizure disorders, bowel and bladder
continence problems, nutrition and digestion, medications
the individual takes, surgeries in the past or planned surger­
ies, orthopedic concerns such as subluxation or dislocation of
the hip or shoulder, osteoporosis, other orthotic interventions
(including any leg or foot orthoses or trunk orthoses), skin
condition problems or concerns, sensation, pain problems,
visual deficits, hearing deficits, and cognitive and behavioral
problems.9 Diagnostic information and related health con­
cerns have a direct impact on the selection of appropriate
equipment.
The history must also include elements related to the
patient's equipment use and the environmental demands.
Gathering information about current and past assistive tech­
nology use is important. Knowing what the individual has
tried and the outcomes of these interventions helps avoid
the repetition of mistakes. Also, knowledge of previously
used assistive technology is important for interfacing any
new devices with already existing devices, such as alterna­
tive communication systems. Also, knowledge of the mode of
transportation (e.g., car, adapted van, public transportation,
school-provided transportation) is critical because equip­
ment must be chosen to meet these transportation needs.
The demands of the patient's home environment or other
environments in which the equipment will be used must be
understood, including school or workplace environment and
recreational activities.7 Last, but certainly not least, the funding
source or sources for the equipment must be discerned.
Different funding sources have different requirements for evi­
dence documented in support of patient needs and benefits
of selected devices and for medical necessity to justify reim­
bursement for the equipment.
Systems Review
Once this detailed history is gathered, the therapist may move
on to a systems review.8 A systems review includes a limited
examination of the major systems affecting the selection of
the assistive device (Table 16-2), including the cardiovascular
and pulmonary system, the integumentary system, the mus­
culoskeletal system, the neuromuscular system, and the com­
munication and cognitive abilities of the individual.8 During
the systems review, additional questions may arise related to
the history of the patient, particularly related to past equip­
ment use; these questions should be incorporated into the
remainder of the examination and the responses integrated
with the history already recorded.
If an individual is already using a wheeled mobility
device, the systems review must include an assessment of the
patient's use of the current equipment. The make and model
Referral
Training
Education
Delivery
Funding
Final
goal
setting
Equipment
selection
Tests and
measures
Systems
review
Consumer
goal
setting
The
interview
and
history
Letter of
medical
justification
Seating
or mobility
problem
FIGURE 16-3  When a patient is referred to the team, the first steps
in the process involve collecting relevant information and examina­
tion, including specific tests and measures. The team uses this infor­
mation to select appropriate components on the basis of prognosis and
the patient's functional needs. Once ordered and delivered, the team
works with the patient on mobility, safety, and maintenance issues.
Physical
Therapist
Rehabilitation
Engineer
Physician
Assistive
Technology
Practitioner
Rehabilitation
Technology
Supplier
Vocational
Rehabilitation
Counselor
Family
members
Occupational
Therapist
FIGURE  16-2  The interdisciplinary seating and mobility assess­
ment team is most successful if it is consumer focused.

434
Section II  Orthoses in Rehabilitation
of any devices currently used should be recorded, along with
the sizes of all items and their present condition. In addi­
tion to the condition of the equipment, the patient's posture
and function while using this equipment should be noted.
Determining why the person needs an assessment for new
equipment is extremely important. Questions to ask include
the following:
• Did the patient outgrow the equipment or did the
equipment exceed its expected lifespan?
• Did the patient's needs change because of a change in
medical condition or functional status?
Specific details of how the current equipment is used
and whether such use is appropriate and effective help with
­setting goals and determining the most effective equipment
intervention for the future.
The reason for the seating and wheeled mobility assess­
ment often translates into the justification for the recom­
mended equipment, so this information is critical to ascertain
during the examination. If the patient has not used any device
in the past, why is one needed now? What change has trig­
gered the referral for an evaluation? During this review, the
specific, patient-centered, functional goals related to wheeled
mobility device use also should be determined. These goals
are incorporated into the intervention after all the data are
collected and the evaluation is made.
Cardiovascular and pulmonary assessment, including
blood pressure, heart rate, pulse oximetry, respiratory rate,
and edema, are also important. Skin condition must be
assessed, particularly overall seating contact areas. Gross
musculoskeletal status should be assessed and the patient's
height and weight recorded. General assessments of function
and movement ability in the current wheeled mobility sys­
tem and the patient's communication skills and abilities and
cognition should also be performed.
Tests and Measures Used in Seating and
Mobility Assessment
The systems review helps determine which areas require a
more comprehensive assessment in the form of specific tests
and measures, including seated and supine mat evaluation,
seating simulation, equipment simulation, and pressure map­
ping (Table 16-3). If a patient has a cardiovascular condition,
such as postural hypotension, then more extensive testing
of different seated positions and interventions along with
detailed tracking of changes in blood pressure are necessary
during the mat evaluation and the seating simulation. Many
tests and measures are used during the seating and wheeled
mobility examination process. Some are necessary for all
patients requiring adaptive seating, and some are used only in
particular instances. Tests and measures for adaptive seating
and mobility intervention can be classified according to pos­
tural and technical or instrumentation requirements, such as
mat table or seat simulator.
Mat Evaluation
Many of the tests and measures used are incorporated into
the mat evaluation, which consists of an evaluation with the
patient in both seated and supine postures.7 During a seated
mat evaluation, the therapist measures or determines a
person's unsupported seated posture, postural asymme­
tries, sitting balance, joint flexibility (particularly of the
spine and pelvis) and functional abilities in terms of trans­
fers and seated function, such as reaching ability. A supine
mat evaluation is essential for measuring specific joint range
of motion, strength, coordination, and abnormal muscle tone
and reflexes. Particular attention must be paid to true hip
joint mobility, orthopedic deformities such as pelvic asym­
metries, hip joint subluxations or dislocations, and flexibility
of spinal postures.7 The supine mat evaluation is critical in
determining the flexibility of postural deformities because of
TABLE 16-2  Components of the Systems Review for
Seating and Wheelchair Assessment
Systems
Issues to Assess
Musculoskeletal
Range of motion
Strength of all muscles
Postural asymmetry
  Pelvic obliquity
  Pelvic rotation
  Pelvic tilt (anterior/posterior)
  Scoliosis
  Excessive kyphosis
  Lordosis
Flexibility of any noted asymmetries
Integumentary
History of skin breakdown
Surgeries performed
Skin inspection to identify current problems
Performance of active pressure reliefs
Condition of pressure management
equipment
Success/failure of technologies in the past
Neurological
Motor control
Abnormal muscle tone
Abnormal primitive reflexes
Cardiovascular
Heart rate
Blood pressure (at rest and with activity)
Edema
Pulmonary
Respiratory rate
Shortness of breath (dyspnea)
Blood oxygenation (pulse oximetry)
Change in pulmonary status with activity
Change in pulmonary status with position
Communication
Verbal and nonverbal
Use of alternative or augmentative systems
Effectiveness of communication
  With family or familiar individuals
  With unknown or unfamiliar individuals
Cognitive status




Type of cognitive impairments present
Developmental delay
Progressive dementia
Overall mental health and judgment
Ability to learn
Understanding of wheeled mobility function

Chapter 16  Adaptive Seating in the Management of Neuromuscular and Musculoskeletal Impairment
435
the change in the effects of the gravitational pull on the body.
If a postural deformity is present during the sitting assess­
ment and then disappears during the supine mat evaluation,
that deformity is “flexible” in nature and may be correctible in
the adaptive seating system. If, on the other hand, the postural
asymmetry is present in both seated and supine postures, in
spite of any attempt at repositioning, then this asymmetry is
described as a “fixed” posture.
SIMULATION TECHNIQUES AND EQUIPMENT
The other tests and measures of a seating and mobility assess­
ment are performed by using simulation techniques or equip­
ment. Three primary simulation techniques are used: hand
simulation, simulation with a commercial seated simulator,
and simulation with commercial seating and mobility prod­
ucts similar to those likely to be selected.9,10
Hand simulation is often performed with the patient
seated on the mat. During this simulation the therapist uses
his or her hands to simulate or mimic forces applied by vari­
ous components of an adaptive seating system. In this man­
ner, the therapist can determine if external supports are
capable of providing the desired effect on the patient's pos­
ture and how much force is required or what is the optimal
application point on the body.7
After hand simulation, a seating simulator may be used to
verify the manual data. A seating simulator is a highly adjust­
able wheelchair frame with many interchangeable components.10
This device is first preset to provide the desired supports; then
the patient sits in it so the therapist can determine if the settings
actually produce the desired postural or functional outcomes.
The third simulation method involves assembling actual
commercial products into a system similar to that being rec­
ommended to assess its effect. This may be done if a com­
mercial simulator is not available as an additional component
after performing the other types of simulation. This final sim­
ulation provides evidence of the effectiveness of actual prod­
ucts in meeting the desired goals of the seating and mobility
assessment and may be an excellent way of providing the
funding source with information regarding why specific
equipment is being recommended.
Other tests and measures used for seating and mobility
assessment include pressure mapping (Figure 16-4),11 custom
contour seat simulation, pulse oximetry during simulation,
specific circulatory assessments during simulation, and func­
tional wheelchair propulsion testing.12 These specific mea­
sures may not be used in all seating and mobility assessments
but can be mixed and matched according to the needs of
the patient. All these tests and measures provide the thera­
pist with necessary information required for evaluation and
determination of final equipment selections.
Plan of Care and Equipment Prescription
The evaluation of all this information will lead to a diag­
nosis related to the patient's level of function and a plan to
address specific adaptive seating and wheeled mobility device
needs that have been identified (Table 16-4). The clinician
TABLE 16-3  Tests and Measures Used in Seating and
Wheelchair Assessment
Component of Evaluation
Measures or Task Analysis
Seated mat
evaluation
Unsupported seated posture
Sitting balance
Postural flexibility
Functional abilities
  Transfers
  Reaching
Activities of daily living
simulation
Supine mat evaluation
Seating angles
  Thigh-to-trunk angle
  True hip flexion range of motion
  Thigh-to-lower leg angle
  Hamstring tightness
  Lower leg-to-foot angle
Pelvic flexibility
Abnormal muscle tone
Mobility skills and abilities
Supine to/from sitting transition
Mat (hand) simulation
Position of supports required
Amount of force required
Ability to reduce flexible
asymmetries
Seated simulation
testing
Desired seating dimensions
Desired seating angles
  Seat tilt or orientation
  Seat to back angle support
  Need for biangular back support
Other simulated supports and
effects
  Lateral pelvic supports
  Lateral trunk supports
  Arm supports
  Leg and foot supports
  Head support
Equipment simulation
What equipment was used
Results of mobility assessment in
mock-up
Consumer comfort
Ability to meet goals with simulated
system
Photos to include with justification
documents
Pressure mapping
Note cushions used during testing
Results of cushions tested
  Pressure distribution patterns
Consumer education
Importance of proper seat
cushion use
  Optimal pressure relief methods
Other



Custom molding simulation
Pulse oximetry
Circulatory testing
Functional wheelchair propulsion
testing

436
Section II  Orthoses in Rehabilitation
and patient also set specific goals for use of the equipment
within various environments. The actual intervention process
in seating and wheeled mobility is often called the equipment
recommendation or equipment prescription. During this
process a specific mobility base is selected and adaptive seat­
ing equipment is specified.
Other major components of adaptive seating and mobil­
ity intervention involve coordination, communication, and
documentation. The physical or occupational therapist typ­
ically has the primary responsibility of coordinating the
seating team and assuring that all team members are work­
ing together to assist in the attainment of the patient's goals.
Communication with all team members is essential during
this process. All team members must be made aware of the
results of the examination and the ultimate goals involved.
Each team member may have some responsibilities in this
process; the rehabilitation technology supplier, for example,
has a primary responsibility to provide specific manufac­
turer's specifications for the equipment needed. These spec­
ifications will then be used to prepare the letter of medical
justification. In addition to all the typical documentation of
the history and physical assessment, the therapist also has a
primary responsibility, in the case of adaptive seating inter­
vention, to prepare the letter of medical justification. The
letter is critical because it is the primary means of communi­
cation with all funding sources involved to obtain necessary
funding for the seating and wheeled mobility system.
Documentation: The Letter of Medical Justification
The intention of the letter of medical justification is to provide
the funding source with a clear picture of the patient with a dis­
ability and the equipment being recommended, with a focus
on why the specific equipment being prescribed is required.
This letter must contain several elements. The introductory
paragraph should describe the person with a disability. This
description includes the diagnoses, onset dates, prognosis, and
a summary of the history and the systems review.
Next, detailed information is provided about the specific
tests and measures used during the examination and out­
comes of the evaluation. These include, but are not limited to,
the individual's functional status, strength, range of motion,
orthopedic deformities, motor coordination, abnormal tone
or reflex findings, and the results of the equipment simula­
tion. This information can be organized and reported on a
standardized form or in a narrative style.
Specific measurable, functional goals for the adaptive seating
and wheeled mobility system should be clearly stated. All the
specifications of the selected equipment must be included, and
the reason for each item must be effectively justified as to why
the person requires this specific piece of equipment (Box 16-1).
The funding source sometimes also requires a description of
other possible lower cost options and an explanation of why
these options are not effective for the patient. Finally, a sum­
mary of the patient information and contact information for
the primary therapist and the prescribing physician should be
provided so that the funding source may contact these individ­
uals if any questions arise during the review process.
200
180
160
140
120
100
80
60
40
20
0 mmHg
Sensors included 140
Validation coefficient 124.7%
Standard deviation 33.8
Average pressure 29.4
Maximum pressure 200
Center of pressure 7.9,5.5
A
B
C
D
E
F
G
H
I
J
K
L
M
N
O
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
A
B
C
FIGURE 16-4  An example of a pressure measurement system. The
pressure-sensitive mat that the patient sits on is connected to a com­
puter (A). The computer generates a two-dimensional (B) or three-
dimensional (C) display of seating pressures. (From Cook AM,
Hussey SM [eds]. Assistive Technologies: Principles and Practice, vol 1,
2nd ed. St. Louis: Mosby, 2002. p. 196.)
TABLE 16-4  Components Included in Final
Recommendations
Category
Details
Wheelchair propulsion
ability
Distance
Speed
Safety
In recommended wheelchair
In less expensive options
Final equipment
selection
Mobility base
  Access method
  Postural support components
Goals of the seating
system
Based on consumer's stated goals
Objective
Measurable
Related to recommended equipment
Wheelchair and
seating fitting and
delivery needs
Is preliminary fitting required?
How many visits will be necessary?
Estimated time to delivery
Training and
education plans
When will the training begin?
Who will carry out the training?
  Referral for additional training?
Written materials to be provided
  Product manuals
  Care and maintenance instructions
  Safety recommendations and concerns
  Guidelines for proper and effective use
Plan for follow-up
care
When will follow-up occur?
  Scheduled visits or as needed?
Frequency of reevaluation?

Chapter 16  Adaptive Seating in the Management of Neuromuscular and Musculoskeletal Impairment
437
EXAMPLE 1
Reason for referral:
Frequent falls in the home
Evaluation finding:
Only able to ambulate for 20 feet and unsteady; high risk of falling
Goals:
Safe and independent mobility for functional distances, at least 200 feet for indoor environments
Equipment feature:
Manual, power assist, or power wheeled mobility device
Justification:
Patient able to safely and independently propel the selected wheeled mobility device for functional
distances in his or her environment
EXAMPLE 2
Reason for referral:
Having problems sitting upright in wheelchair; falls to the left and has difficulty propelling
chair
Evaluation findings:
Impaired sitting balance noted during mat evaluation, poor trunk muscle strength resulting in
poor trunk control, no ability to react to sitting balance challenges
Goals:
Able to maintain upright sitting posture and perform all functional activities without falling, such
as wheelchair propulsion, activities of daily living
Equipment feature:
Solid seat cushion and back support, possible lateral trunk supports, seat tilt posterior or open
seat to back angle if simulation shows increased stability in these postures without compromis­
ing function
Justification:
Patient able to sit upright with adequate support for pelvis and spine to allow maximal func­
tion of upper body for activities of daily living or other functional activities (e.g., access to
propulsion)
EXAMPLE 3
Reason for referral:
Impaired endurance; fatigues easily and cannot go into community
Evaluation findings:
Unable to tolerate wheelchair propulsion farther than 100 feet and becomes quite short of breath
with indoor manual propulsion, even in lightweight wheelchair
Goals:
Ability to tolerate mobility for functional distances in all desired environments, in home and
community
Equipment feature:
Powered wheelchair or powered scooter
Justification:
Patient independent for all mobility with selected device for functional distances for the patient's
home environment
EXAMPLE 4
Reason for referral:
Pressure ulcer under the left ischial tuberosity
Evaluative findings:
Stage 2 pressure ulcer under left ischial tuberosity observed during mat evaluation skin inspec­
tion; pelvic obliquity noted in sitting, disappears in supine (flexible)
Goals:
Improve pressure distribution and correct pelvic obliquity to minimize pressure under left
ischial tuberosity; provide equipment and training for active pressure relief while seated in
wheelchair
Equipment features:
Skin protection and positioning seat cushion that redistributes pressure, minimizing pressure
under the ischial tuberosities, and supports pelvis in a neutral position; may also require
increased trunk support, possibly lateral supports for correcting pelvic obliquity posture
Justification:
Equipment will provide safe seating for up to 4-hour intervals without worsening of pressure ulcer
and will facilitate healing of current ulcer over time; seating will correct pelvic obliquity and
minimize weight bearing under left ischial tuberosity, to be verified with pressure mapping
EXAMPLE 5
Reason for referral:
Right shoulder pain and weakness; difficulty with transfers and manual wheelchair propulsion
Evaluative findings:
Right shoulder rotator cuff tear with resulting pain and muscle weakness
Goals:
Maximize functional abilities while minimizing pain and decreasing stress on right shoulder
Equipment features:
Powered wheelchair with access method that minimizes stress on right shoulder; sliding board
and training for transfers that minimize stress on right shoulder
Justification:
Patient will function independently with minimal pain in right upper extremity and will be
independent for all mobility and transfer activities
BOX 16-1  Examples of Adaptive Seating and Wheeled Mobility Interventions and Goals

438
Section II  Orthoses in Rehabilitation
Meticulous preparation of the letter of medical justifica­
tion may mean the difference between efficient funding of
the seating and mobility system and a long, drawn-out review
process that may delay the delivery of equipment by several
months.
When the Seating and Mobility System Is Delivered
After approval by the funding source and after the adaptive
seating equipment is ordered and obtained, the rehabilitation
technology supplier notifies the therapist that the seating and
mobility system is ready for delivery. The patient then returns
to the seating clinic and the adaptive seating and mobil­
ity device is delivered and adjusted to ensure proper fit and
efficient function. Delivery of the wheelchair or seating sys­
tem is a critical element in the intervention process and
directly affects the outcomes related to use of the equipment.
Delivery of equipment typically occurs several months
after the examination and prescription process. The therapist
is responsible for ensuring that the status and needs of the
patient have not changed since the initial seating and mobil­
ity assessment. If the needs have changed, then recommended
modifications to the equipment must be specified at this time.
The equipment must then be verified to ensure it meets all the
recommended specifications. Finally, the equipment must be
adjusted for proper fit and the patient must be trained in its
safe use, adjustment, maintenance, and care.
The patient should have the opportunity to function in
and use the equipment during the initial delivery to ensure
that the goals set during the examination can be effectively
attained. This may require a period of training and further
rehabilitation intervention as an outpatient or in the patient's
living environment. In addition, the patient and caregivers are
instructed in routine maintenance and cleaning of the equip­
ment, by verbal instruction, demonstration, and in written
format, such as review of the owner's manuals provided by
the equipment manufacturers. The patient and caregivers also
need to learn when they should return to the clinic for adjust­
ment or modification of the equipment.
Assessment of Seating and Mobility Outcomes
The final critical component of an adaptive seating eval­
uation is reexamination, or followup and follow-along.
Adaptive seating equipment needs are fluid over time. Fixed
orthopedic deformities may change or progress, and func­
tional abilities often change. Equipment needs must be
reevaluated when the patient's needs are no longer met by
the equipment. This may happen as equipment ages and falls
into disrepair, or as the patient's functional or physical sta­
tus changes over time. Most adaptive seating equipment has
a usable life span of 3 to 5 years. If a person is particularly
active or if the equipment is used in harsh and demanding
environments, the equipment may have a shorter functional
life span. Periodic reexamination of equipment and patient
needs is essential to maintain optimal function. Although
planning reexamination appointments is important, the
patient needs to understand when and why contact­
ing the therapist and requesting a reexamination between
scheduled visits might be necessary. The patient is the most
knowledgeable person regarding the adequacy of the equip­
ment and whether goals are being met.
BIOMECHANICAL PRINCIPLES IN SEATING
AND MOBILITY
Adaptive seating for persons who use wheelchairs involves
the strategic application of forces to provide postural support
and stability for optimal function. All applications of forces in
this context are governed by the laws of physics and described
in the field of biomechanics, the study of body position and
movement.5 All adaptive seating components exert forces or
torques on the body that ultimately affect changes in posture
and static or dynamic equilibrium. Improperly applied forces
or improper fit of components can lead to a variety of seat­
ing and mobility problems. Table 16-5 summarizes the most
commonly encountered problems.
Propulsion of a wheeled mobility device, particularly man­
ual propulsion, depends on the forces and torques applied
by the user. These forces must be understood because of
their possible long-term effects on the body; wheelchair
users are at risk of repetitive motion and overuse inju­
ries.13 Understanding basic biomechanical principles and
how they affect the design of adaptive seating and wheeled
mobility is critical to the strategic application of forces to
maximize function and minimize risk of injury for the
wheeled mobility device user.
No single strategy, or even a small set of strategies, works
for every wheelchair user. Each wheelchair user is unique,
with a unique set of problems and goals, and each therefore
requires an individualized approach to adaptive seating.14
Many biomechanical and ergonomic principles govern the
application of forces in adaptive seating, but all center on
basic principles, as outlined by Engstrom.14 These principles
include the following:
1. Providing a stable base of support for the pelvis
2. Providing adequate pressure distribution
3. Allowing an individual to move into an active position
(e.g., to lean forward)
4. Allowing variations in positions
5. Providing support for the back
6. Allowing free movement of the feet and legs if possible
7. Providing the user with a feeling of safety, security, and
comfort
Providing adaptive seating that meets all these require­
ments is often quite challenging.
Stability of the Pelvis
A basic challenge inherent in seated posture is achieving
pelvic stability. Although the base of support is larger and the
body's center of gravity is lower when sitting than standing,15
the pelvis is actually more unstable when seated. In standing,
ligamentous tension and balanced muscle activity contribute
to stability of the pelvis. When sitting, many of the ligaments
become slack, and the flexed hip position alters the line of
pull and efficiency of muscles around the hip. If, in addition,

Chapter 16  Adaptive Seating in the Management of Neuromuscular and Musculoskeletal Impairment
439
the patient who is sitting demonstrates a lack of flexibility
(shortening or tightness) in the hamstring muscles, the pelvis
rotates posteriorly and the spine adopts a more flexed pos­
ture than in standing (Figure 16-5).15 This flexed posture has
been implicated in muscle fatigue and abnormally high disk
pressures, both of which contribute to discomfort and pain in
prolonged sitting.
Forces exerted in an adaptive seating system must over­
come these natural tendencies as well as any postural asym­
metries caused by abnormally high muscle tone or other
disability-related impairments. To do this, forces to the body
must be applied as strategically as possible by considering
both the lever arm and the surface area through which the
force will be applied.
When a torque is applied to control or influence the posi­
tion of a body part, the force necessary is inversely related to
the lever arm, the distance from the axis of rotation of the body
part, and the point of application of the force. As the distance
away from the point of rotation increases, the force required
to achieved the desired outcome decreases.5 This principle is
very important for adaptive seating, because in dealing with
application of forces on the surface of the body, decreasing the
force necessary is critical to a person being able to tolerate that
force. One way to accomplish this is to apply the force as far
from the part to be controlled as reasonably possible.
Pressure is directly related to the force applied but inversely
related to the area over which the force is distributed. This
means that, if high forces are necessary to achieve the desired
outcome, providing a larger area of contact will decrease the
pressure exerted on the body.5 Applying forces over as large
an area as possible is critical to avoiding pressure-related skin
ulcers as well as increasing comfort and tolerance for the
wheelchair user.
Understanding and applying these two biomechanical
principles assists the clinician in designing adaptive seating
systems that accomplish the goals of postural support and
positioning for function while being comfortable and well
tolerated by the patient.
One of the main forces that adaptive seating systems must
balance is the force of gravity (Figure 16-6). Gravity is a con­
stant force exerted on the body that must be counteracted for
an individual to remain in an upright-seated posture. The
adaptive seating components must provide enough external
support so that, combined with the internal muscular forces
generated by the wheelchair user, an individual can sit in a
desired position for long periods of time and perform all
TABLE 16-5  Potential Problems Resulting from Improper Biomechanics in Support or Propulsion
Support or Access Problem
Possible Resultant Biomechanical Problem
Potential Equipment Solutions
Seat too long
Posterior pelvic tilt
Sliding out of wheelchair
Shorten seat or provide additional back support
(effectively shortening seat)
Seat too short
Pressure ulcer, lack of support under femurs
Sliding out of seat
Increase seat depth of wheelchair or add longer
seat cushion with solid support underneath
Seat too wide
Lateral shift of pelvis in chair
Pelvic obliquity
Trunk scoliosis
Feeling of instability
Narrow wheelchair seat or add lateral pelvic
supports to properly center pelvis in wheelchair
Seat too narrow
Pressure ulcers over greater trochanters
Difficulty transferring in and out of wheelchair
Widen wheelchair seat
Back too wide
Flexible scoliosis
Lateral trunk leaning
Pelvic obliquity
Feeling of instability
Narrower back support
Lateral thoracic supports
Lateral pelvic supports
Back too narrow
Lack of movement needed for function
Skin breakdown on lateral trunk
Discomfort caused by inability to move
Widen wheelchair back support
Back too low
Upper trunk instability; limited function
Excessive thoracic kyphosis
Posterior pelvic tilt
Higher back support
Solid back support (if current back is sling)
Back too high
Falling forward in wheelchair
Inability to propel wheelchair optimally
Lower back height
Narrower upper back support to allow increased
scapular excursion
Rear wheels too far back
Shoulder pain; impingement
Inability to optimally propel wheelchair
Move rear wheels forward
Rear wheels too far forward
Wheelchair tipping backwards; user unable
to control
Move rear wheels back on frame

440
Section II  Orthoses in Rehabilitation
desired functional activities. This can be quite challenging,
depending on the ability of the wheelchair user to generate mus­
cular forces that work in opposition to the force of gravity. Body
positions should allow gravity to facilitate desired postures or
functions if an individual has severe weakness or muscle fatigue.
This is often a main reason for using tilt or recline seating sys­
tems. These systems allow the person's body to be reoriented in
space, allowing the force of gravity to facilitate desired postures
or functions rather than requiring the user to generate muscular
forces to counteract the force of gravity at all times.
Propulsion
Biomechanical principles are also extremely important in the
propulsion of manual wheelchairs.13 Manual wheelchair users
have many problems associated with shoulder and wrist pain
and injuries.16 Understanding wheelchair propulsion biome­
chanics and the importance of wheelchair configuration and
wheelchair propulsion training is critical to minimizing or pre­
venting these overuse injuries. The weight of the wheelchair
user should be distributed rearward (with the seat moved back
in relation to the rear wheels) to decrease rolling resistance
and make the wheelchair easier to propel.17 This will also make
the wheelchair easier to tip backward, so the skill of the user in
controlling this tipping must be carefully considered.
The seat surface should be low enough to allow a 100- to
120-degree bend in the elbow when the user's hand is placed
at the top of the wheel rim (Figure 16-7). This position tends
to minimize impact on the shoulders and maximize effi­
ciency in propulsion.17,18
Individuals who self-propel manual wheelchairs must mas­
ter and consistently use proper propulsion techniques.19 Long,
smooth strokes limit excessive forces on upper extremity joints
and soft tissue and decrease the rate of loading on the push
rims. In contrast, short, choppy pushes are associated with
higher energy expenditure and the development of repetitive
use syndromes. Allowing the hands to drop below the rims
during the “recovery,” or nonpropulsion part of the stroke, aids
in smooth motion and protects the shoulders from injury.17
SEATING CLASSIFICATION AND MATERIALS
Many new wheeled mobility and adaptive seating technolo­
gies have been developed over the last 20 years.7 Technological
development has helped meet the challenges involved in
two major wheelchair seating objectives: postural support
and pressure management. Individuals with neuromuscular
A
B
FIGURE 16-5  A, In the presence of hamstring tightness, if knees are relatively extended, the pelvis
falls into a position of posterior rotation, with a decrease in lumbar lordosis, an increase in thoracic
kyphosis, and cervical lordosis. B, One strategy to achieve optimal alignment of pelvis and spine in
the presence of hamstring tightness is to reduce seat depth and position slightly under the seat.
F upper back
F lower back
F lower leg
W leg
W thigh
W HAT
FIGURE  16-6  Each body segment has its own center of mass
(W HAT, W thigh, W leg). These downward forces must be coun­
terbalanced by opposing forces from support surfaces (seat, upper
back, sacral, foot). W, weight = gravity acting on center of mass; F,
opposition forces.