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Enhancing function after radial nerve injury with a high-profile orthosis and a bio-occupational orthotic framework
Journal of Hand Therapy xxx (2018) 1e5
Contents lists available at ScienceDirect
Journal of Hand Therapy journal homepage: www.jhandtherapy.org
Case Report
Enhancing function after radial nerve injury with a high-profile orthosis and a bio-occupational orthotic framework Flávia Pessoni F.M. Ricci PT, MSc, PhD a, *, Pat McKee BSc(OT), MSc, OT(C) b, Ana Carolina Zampar BScPT a, Ana Carolina Grillo Semedo PT, MSc a, Paulo Roberto Pereira Santiago PhD c, Marisa de Cássia Registro Fonseca PT, PhD a a
Department of Health Sciences, Rehabilitation and Functional Performance Postgraduate Program, School of Medicine of Ribeirão Preto, University of São Paulo, Ribeirao Preto, São Paulo, Brazil b Department of Occupational Science and Occupational Therapy, University of Toronto, Toronto, Ontario, Canada c Laboratory of Biomechanics and Motor Control, School of Physical Education and Sport of Ribeirao Preto, University of São Paulo, São Paulo, Brazil
a r t i c l e i n f o
a b s t r a c t
Article history: Received 26 June 2017 Received in revised form 7 August 2018 Accepted 7 September 2018 Available online xxx
Study Design: Case report. Introduction: Radial nerve injury can cause severe functional impairment due to paralysis of wrist and digit extensors. Various orthotic designs have been described, including static, dynamic, and tenodesis. All provide wrist stabilization or extension assistance. Some, but not all, also provide extension assistance to the wrist, thumb, and fingers. Purpose and Methods: This article tells the story of Max, a 27-year-old male university student, who sustained a radial nerve injury after a left humeral shaft fracture. He was treated at a Brazilian tertiary hospital, where the choice of thermoplastics and dynamic components resulted in limited options for orthotic fabrication. Max was provided with custom-molded static wrist orthosis and a bulky, older style, high-profile dynamic forearm-based wrist-finger-thumb assistive-extension orthosis. Results and Discussion: Grip strength and functional status improved, and Max was completely satisfied because with the dynamic orthosis, he could play the guitar again, which was his favorite activity. Conclusion: Max’s story illustrates that a convenient functionally oriented orthotic intervention can be performed even in resource-limited environments by following the client-centered bio-occupational orthotic framework proposed by McKee and Rivard. This framework addresses the client’s biological needs (addressing paralyzed muscles and maintaining length of soft tissues) and occupational/functional needs. Ó 2018 Hanley & Belfus, an imprint of Elsevier Inc. All rights reserved.
Keywords: Radial nerve injury Orthotic intervention Splinting Bio-Occupational Orthotic Framework
Introduction Radial nerve injury causes paralysis of the wrist and finger extensors, resulting in functional impairment, partly due to the inability to synergistically use the wrist extensors during power grip.1 A variety of orthotic designs have been described, and objectives include wrist stabilization; extension assistance to the wrist, thumb, and fingers; maintaining optimal length of muscle/ tendon units and joint capsule/ligaments; and enhancing function.2 Static orthoses simply stabilize the wrist in a fixed amount of extension without providing assistance to the digits. Most dynamic orthoses have an outrigger that either provides the structure to
* Corresponding author. Department of Health Sciences, Rehabilitation and Functional Performance Postgraduate Program, School of Medicine of Ribeirão Preto, University of São Paulo, 3900, Bandeirantes Avenue, Ribeirao Preto, São Paulo 14049-900, Brazil. Tel.: þ55 1633154769; fax: þ55 1633154413. E-mail address: fl[email protected] (FláviaP.F.M. Ricci).
which elastics are attached (high-profile design) or acts as a pulley to redirect the dynamic components. The latter design results in a low-profile orthosis that is less cumbersome and less obvious. Many dynamic designs hold the wrist in extension and apply dynamic forces to the digits. The orthosis described by McKee and Nguyen2,3 provides dynamic extension power to the wrist, fingers, and thumb by elastic cords and thin flexible thermoplastic, without the need of an attached outrigger, achieving a no profile orthosis. Tenodesis designs allow motion of the fingers and wrist, but all finger metacarpophalangeal (MCP) joints move together, not independently. Active wrist flexion causes reciprocal passive finger MCP extension, whereas active finger MCP flexion causes reciprocal wrist extension.5 Optimal enhancement of function is likely achieved when all involved joints of the wrist, thumb, and fingers are allowed to move independently.2-6 However, it is not always possible to provide an ideal design due to limitations in knowledge of the therapist and/or financial resources to purchase optimal thermoplastics and attachments.
0894-1130/$ e see front matter Ó 2018 Hanley & Belfus, an imprint of Elsevier Inc. All rights reserved. https://doi.org/10.1016/j.jht.2018.09.003
2
F.P.F.M. Ricci et al. / Journal of Hand Therapy xxx (2018) 1e5
This article discusses a high-profile dynamic orthotic design, which met the client’s functional goals, made in a Brazilian tertiary public hospital. It shows that a convenient, functionally-oriented intervention can be performed even in resource-limited environments by following the client-centered Bio-Occupational Orthotic Framework proposed by McKee and Rivard.7 This framework addresses the client’s biological needs (addressing paralyzed muscles and maintaining length of soft tissues) and occupational/functional needs. Max’s story Max, a 27-year-old male university student, was involved in a motorcycle accident causing a compound (open) fracture of his left (nondominant) humeral shaft, which was initially treated with external fixation in a public hospital. A week later, Max underwent open reduction with internal plate fixation. At 7 months postinjury, he was referred to a specialized tertiary hospital and underwent bone grafting and radial nerve exploration and repair. Nine months postinjury, he started hand therapy at a tertiary rehabilitation center. Although elbow extension was unimpaired, there was a lack of active wrist, finger, and thumb extension, resulting in a typical dropped wrist posture (Fig. 1). Due to the delayed initiation of hand therapy, Max decided that he needed to do something to enable guitar-playing, which was his favorite hobby. He made himself a dynamic orthosis using rubber bands, metal nails, adhesive tape, and fabric strips. However, the orthosis did not achieve his intended goal due to the poor mechanical design (Fig. 2). When Max came to hand therapy and showed his therapist a photo of the orthosis he had made, she replaced it with a volar static wrist orthosis, which stabilized the wrist in moderate extension (Fig. 3) and a dorsal forearm-based high-profile dynamic finger-thumb MCP-extension orthosis to better enable guitarplaying (Figs. 4 and 5).
Fig. 2. Max’s self-made orthosis. Photo provided by Max.
Rationale for this dynamic orthotic design The tertiary public hospital, where Max’s orthoses were made, had financial challenges that caused budget restrictions. In the hand therapy department, this was reflected as a small labor pool and restricted material choices, which contributed to limited orthotic design options. The hand therapists were allowed to order and stock only 1 inexpensive thermoplastic, which was 1/8 inch (3.2 mm) thick,
Fig. 1. Max’s dropped wrist posture. Photo shows joint markers, which were applied to collect data for a different concurrent study.
Fig. 3. Volar forearm-based static wrist orthosis made by therapist. (A) ulnar view, (B) radial view, and (C) volar view. Photos show joint markers, which were applied to collect data for a different concurrent study.
F.P.F.M. Ricci et al. / Journal of Hand Therapy xxx (2018) 1e5
3
Fig. 4. Dorsal forearm-based high-profile dynamic finger-thumb metacarpophalangeal extension orthosis made by therapist. (A) radial view; (B) dorsal view.
thus preventing the utilization of the design by McKee and Nguyen, which uses 1/12 or 3/32 inch (2 or 2.4 mm) thermoplastic. Due to Max’s goal to play guitar, a tenodesis design was not suitable due to the inability to individually move the finger MCP joints. Thus, a dynamic orthosis was made using the only thermoplastic available and premade metal outriggersda large one for the fingers and a small one for thumbdthat were manufactured at a local orthopedic factory. These same limitations had existed for many years, so the therapists continued to fabricate a relatively old-style dynamic orthotic design for individuals with radial nerve injury. As shown in Figure 4, the outriggers were secured to the dorsal base with scraps of thermoplastic. Ordinary rubber bands and soft straps provided the passive dynamic forces to the MCP joints. Results Grip strength was measured with a Jamar Grip Dynamometer (JLW Instruments; handle position 2) (Fig. 6). The mean values of grip strength were stronger with the dynamic orthosis compared with the static wrist orthosis, and both were notably lower than the unaffected hand (Table 1). From a biological perspective, the orthoses helped to prevent contracture of the volar muscles and joint tissues while preventing overstretching of the paralyzed dorsal muscles and joint tissues. From an occupational/functional perspective, the static volar wrist orthosis allowed Max to accomplish activities such as lifting weights. Although there are relatively few activities that are performed with the forearm fully supinated, when playing the guitar, fingers of the nondominant hand press the strings while the forearm is supinated. The dynamic orthosis held Max’s wrist in static extension, and the elastic bands provided individual passive finger extension assist to lift the fingers off the strings while allowing
Fig. 5. Max playing guitar while wearing the high-profile dynamic orthosis. Photo provided by Max.
active finger flexion to press the strings. Due to the dorsal-based design, there was relatively little thermoplastic on the volar side of the hand, thus facilitating grasp of neck of the guitar. As a result, the dorsal dynamic design enabled a valued occupation for Max in a way that the static wrist orthosis could not. When asked about how he felt about the orthoses, Max said that they made him feel useful again because he “gained functionality of movements with a reasonable degree of utility” (translated from Portuguese to English). He also reported that, in addition to enabling him to play the guitar, the dynamic orthosis helped him with various daily activities. “The main goal was to play the guitar, but while wearing it, I could perform other activities, for example holding a glass, working out and making my bed” (translated from Portuguese to English). Max used the therapist-made dynamic orthosis for 4 months until he had tendon transfer surgery (pronator teres to extensor carpi radialis brevis, palmaris longus to extensor pollicis brevis, and flexor carpi radialis to extensor digitorum communis). Discussion Meeting both the biological and occupational/functional needs of a client within a resource-limited environment can be
4
F.P.F.M. Ricci et al. / Journal of Hand Therapy xxx (2018) 1e5
Fig. 6. Grip strength testing of affected hand with Jamar Grip Dynamometer, handle position 2. (A) Without orthosisdunable to properly grasp the dynamometer. (B) Wearing static volar wrist orthosis. (C) Wearing dorsal forearm-based high-profile dynamic finger-thumb metacarpophalangeal extension orthosis. (D) Nonaffected side. Photos show joint markers and electromyography sensors, which were applied to collect data for a different concurrent study.
challenging. However, it is possible to help a client even when the optimal orthotic materials are unavailable and optimal orthotic designs are not provided.
Table 1 Grip strength (mean of 3 trials SD) for each orthotic condition Orthotic design
No orthosis Static orthosis Dynamic orthosis
Grip strength (kg) Injured side
Unaffected dominant side
00 16 2 21.3 1.1
61.3 11 NA NA
SD ¼ standard deviation; NA ¼ not available.
The high-profile dynamic orthosis presented in this article addressed and accomplished Max’s most important needs and goalsdplaying the guitar, working out, and holding a glass. For this reason, although it was a bulky older design and the wrist was held in static extension, the orthosis worked for him. Client satisfaction is relevant to orthotic intervention because it can highly influence client adherence to the device.8-10 Alsancak9 found that clients who wore dynamic orthoses for radial nerve injury were content with function and support but unhappy with the appearance of the orthosis. In contrast, Max did not complain about the cumbersome appearance, likely because his orthosis enabled guitar playing, which was his favorite hobby. He was not able to play at all after the injury, despite his own efforts to make
F.P.F.M. Ricci et al. / Journal of Hand Therapy xxx (2018) 1e5
himself a dynamic orthosis. However, when he could play again with the therapist-made orthosis, he described the feeling as “poetic happiness”. When asked about the amount of time that he wore each one of the orthoses, Max answered that he used the dynamic orthosis for longer periods than the static one. Hannah and Hudak10 conducted a single-subject experiment in which the client preferred to wear the static volar wrist cock-up orthosis because, although it did not statistically improve her hand function, it was supportive, easy to apply, and less noticeable. She was an 83year-old woman, whereas Max is a 27-year-old male university student. Such differences in the preference for different orthotic designs highlight the importance of a client-centered approach because individuals in different contexts will have distinct and very individual needs. By using the client-centered Bio-Occupational Orthotic Framework by McKee and Rivard, the therapist addressed Max’s biological needs (paralyzed muscles and maintaining length of soft tissues) and occupational/functional needs (desire to play guitar and work out) by providing usable well-engineered orthoses. A holistic, client-centered, and professional practice process was used, giving consideration to Max’s unique social and physical environmental contexts. The ultimate goal, to enable participation in activities that were important and meaningful for Max, was achieved despite using a bulky old-fashioned orthotic design.
5
Acknowledgments The authors thank Max for his kind permission to share part of his rehabilitation journey.
References 1. Ricci FPF, Barbosa RI, Elui VMC, Barbieri CH, Mazzer N, Fonseca MCR. Radial nerve injury associated with humeral shaft fracture: a retrospective study. Acta Ortop Bras. 2015;23(1):19e21. 2. McKee P, Nguyen C. Customized dynamic splinting: orthoses that promote optimal function and recovery after radial nerve injury: a case report. J Hand Ther. 2007;20(1):73e87. 3. McKee P, Nguyen C. Low-profile dorsal dynamic wrist-finger-thumb assistiveextension orthosis for high radial nerve injurydfabrication instructions. J Hand Ther. 2007;20(1):70e72. 4. McKee P, Morgan L. Orthotics in Rehabilitation: Splinting the Hand and Body. Philadelphia, PA: F.A. Davis; 1998:112e114. 5. Szekeres M. Tenodesis extension splinting for radial nerve palsy. Tech Hand Up Extrem Surg. 2006;10(3):162e165. 6. Peck J, Ollason J. Low profile radial nerve palsy orthosis with radial and ulnar deviation. J Hand Ther. 2015;28(4):421e423. 7. McKee P, Rivard A. Foundations of orthotic intervention. In: Skirven TM, Osterman L, Fedorczyk J, Amadio PC, eds. Rehabilitation of the Hand and Upper Extremity. 6th ed. Philadelphia, PA: Elsevier; 2011:1565e1580. 8. McKee PR, Rivard A. Biopsychosocial approach to orthotic intervention. J Hand Ther. 2011;24(2):155e161. 9. Alsancak S. Splint satisfaction in the treatment of traumatic radial nerve injuries. Prosthet Orthot Int. 2003;27:139e145. 10. Hannah SD, Hudak PL. Splinting and radial nerve palsy: a single-subject experiment. J Hand Ther. 2001;14:195e201.
Contents lists available at ScienceDirect
Journal of Hand Therapy journal homepage: www.jhandtherapy.org
Case Report
Enhancing function after radial nerve injury with a high-profile orthosis and a bio-occupational orthotic framework Flávia Pessoni F.M. Ricci PT, MSc, PhD a, *, Pat McKee BSc(OT), MSc, OT(C) b, Ana Carolina Zampar BScPT a, Ana Carolina Grillo Semedo PT, MSc a, Paulo Roberto Pereira Santiago PhD c, Marisa de Cássia Registro Fonseca PT, PhD a a
Department of Health Sciences, Rehabilitation and Functional Performance Postgraduate Program, School of Medicine of Ribeirão Preto, University of São Paulo, Ribeirao Preto, São Paulo, Brazil b Department of Occupational Science and Occupational Therapy, University of Toronto, Toronto, Ontario, Canada c Laboratory of Biomechanics and Motor Control, School of Physical Education and Sport of Ribeirao Preto, University of São Paulo, São Paulo, Brazil
a r t i c l e i n f o
a b s t r a c t
Article history: Received 26 June 2017 Received in revised form 7 August 2018 Accepted 7 September 2018 Available online xxx
Study Design: Case report. Introduction: Radial nerve injury can cause severe functional impairment due to paralysis of wrist and digit extensors. Various orthotic designs have been described, including static, dynamic, and tenodesis. All provide wrist stabilization or extension assistance. Some, but not all, also provide extension assistance to the wrist, thumb, and fingers. Purpose and Methods: This article tells the story of Max, a 27-year-old male university student, who sustained a radial nerve injury after a left humeral shaft fracture. He was treated at a Brazilian tertiary hospital, where the choice of thermoplastics and dynamic components resulted in limited options for orthotic fabrication. Max was provided with custom-molded static wrist orthosis and a bulky, older style, high-profile dynamic forearm-based wrist-finger-thumb assistive-extension orthosis. Results and Discussion: Grip strength and functional status improved, and Max was completely satisfied because with the dynamic orthosis, he could play the guitar again, which was his favorite activity. Conclusion: Max’s story illustrates that a convenient functionally oriented orthotic intervention can be performed even in resource-limited environments by following the client-centered bio-occupational orthotic framework proposed by McKee and Rivard. This framework addresses the client’s biological needs (addressing paralyzed muscles and maintaining length of soft tissues) and occupational/functional needs. Ó 2018 Hanley & Belfus, an imprint of Elsevier Inc. All rights reserved.
Keywords: Radial nerve injury Orthotic intervention Splinting Bio-Occupational Orthotic Framework
Introduction Radial nerve injury causes paralysis of the wrist and finger extensors, resulting in functional impairment, partly due to the inability to synergistically use the wrist extensors during power grip.1 A variety of orthotic designs have been described, and objectives include wrist stabilization; extension assistance to the wrist, thumb, and fingers; maintaining optimal length of muscle/ tendon units and joint capsule/ligaments; and enhancing function.2 Static orthoses simply stabilize the wrist in a fixed amount of extension without providing assistance to the digits. Most dynamic orthoses have an outrigger that either provides the structure to
* Corresponding author. Department of Health Sciences, Rehabilitation and Functional Performance Postgraduate Program, School of Medicine of Ribeirão Preto, University of São Paulo, 3900, Bandeirantes Avenue, Ribeirao Preto, São Paulo 14049-900, Brazil. Tel.: þ55 1633154769; fax: þ55 1633154413. E-mail address: fl[email protected] (FláviaP.F.M. Ricci).
which elastics are attached (high-profile design) or acts as a pulley to redirect the dynamic components. The latter design results in a low-profile orthosis that is less cumbersome and less obvious. Many dynamic designs hold the wrist in extension and apply dynamic forces to the digits. The orthosis described by McKee and Nguyen2,3 provides dynamic extension power to the wrist, fingers, and thumb by elastic cords and thin flexible thermoplastic, without the need of an attached outrigger, achieving a no profile orthosis. Tenodesis designs allow motion of the fingers and wrist, but all finger metacarpophalangeal (MCP) joints move together, not independently. Active wrist flexion causes reciprocal passive finger MCP extension, whereas active finger MCP flexion causes reciprocal wrist extension.5 Optimal enhancement of function is likely achieved when all involved joints of the wrist, thumb, and fingers are allowed to move independently.2-6 However, it is not always possible to provide an ideal design due to limitations in knowledge of the therapist and/or financial resources to purchase optimal thermoplastics and attachments.
0894-1130/$ e see front matter Ó 2018 Hanley & Belfus, an imprint of Elsevier Inc. All rights reserved. https://doi.org/10.1016/j.jht.2018.09.003
2
F.P.F.M. Ricci et al. / Journal of Hand Therapy xxx (2018) 1e5
This article discusses a high-profile dynamic orthotic design, which met the client’s functional goals, made in a Brazilian tertiary public hospital. It shows that a convenient, functionally-oriented intervention can be performed even in resource-limited environments by following the client-centered Bio-Occupational Orthotic Framework proposed by McKee and Rivard.7 This framework addresses the client’s biological needs (addressing paralyzed muscles and maintaining length of soft tissues) and occupational/functional needs. Max’s story Max, a 27-year-old male university student, was involved in a motorcycle accident causing a compound (open) fracture of his left (nondominant) humeral shaft, which was initially treated with external fixation in a public hospital. A week later, Max underwent open reduction with internal plate fixation. At 7 months postinjury, he was referred to a specialized tertiary hospital and underwent bone grafting and radial nerve exploration and repair. Nine months postinjury, he started hand therapy at a tertiary rehabilitation center. Although elbow extension was unimpaired, there was a lack of active wrist, finger, and thumb extension, resulting in a typical dropped wrist posture (Fig. 1). Due to the delayed initiation of hand therapy, Max decided that he needed to do something to enable guitar-playing, which was his favorite hobby. He made himself a dynamic orthosis using rubber bands, metal nails, adhesive tape, and fabric strips. However, the orthosis did not achieve his intended goal due to the poor mechanical design (Fig. 2). When Max came to hand therapy and showed his therapist a photo of the orthosis he had made, she replaced it with a volar static wrist orthosis, which stabilized the wrist in moderate extension (Fig. 3) and a dorsal forearm-based high-profile dynamic finger-thumb MCP-extension orthosis to better enable guitarplaying (Figs. 4 and 5).
Fig. 2. Max’s self-made orthosis. Photo provided by Max.
Rationale for this dynamic orthotic design The tertiary public hospital, where Max’s orthoses were made, had financial challenges that caused budget restrictions. In the hand therapy department, this was reflected as a small labor pool and restricted material choices, which contributed to limited orthotic design options. The hand therapists were allowed to order and stock only 1 inexpensive thermoplastic, which was 1/8 inch (3.2 mm) thick,
Fig. 1. Max’s dropped wrist posture. Photo shows joint markers, which were applied to collect data for a different concurrent study.
Fig. 3. Volar forearm-based static wrist orthosis made by therapist. (A) ulnar view, (B) radial view, and (C) volar view. Photos show joint markers, which were applied to collect data for a different concurrent study.
F.P.F.M. Ricci et al. / Journal of Hand Therapy xxx (2018) 1e5
3
Fig. 4. Dorsal forearm-based high-profile dynamic finger-thumb metacarpophalangeal extension orthosis made by therapist. (A) radial view; (B) dorsal view.
thus preventing the utilization of the design by McKee and Nguyen, which uses 1/12 or 3/32 inch (2 or 2.4 mm) thermoplastic. Due to Max’s goal to play guitar, a tenodesis design was not suitable due to the inability to individually move the finger MCP joints. Thus, a dynamic orthosis was made using the only thermoplastic available and premade metal outriggersda large one for the fingers and a small one for thumbdthat were manufactured at a local orthopedic factory. These same limitations had existed for many years, so the therapists continued to fabricate a relatively old-style dynamic orthotic design for individuals with radial nerve injury. As shown in Figure 4, the outriggers were secured to the dorsal base with scraps of thermoplastic. Ordinary rubber bands and soft straps provided the passive dynamic forces to the MCP joints. Results Grip strength was measured with a Jamar Grip Dynamometer (JLW Instruments; handle position 2) (Fig. 6). The mean values of grip strength were stronger with the dynamic orthosis compared with the static wrist orthosis, and both were notably lower than the unaffected hand (Table 1). From a biological perspective, the orthoses helped to prevent contracture of the volar muscles and joint tissues while preventing overstretching of the paralyzed dorsal muscles and joint tissues. From an occupational/functional perspective, the static volar wrist orthosis allowed Max to accomplish activities such as lifting weights. Although there are relatively few activities that are performed with the forearm fully supinated, when playing the guitar, fingers of the nondominant hand press the strings while the forearm is supinated. The dynamic orthosis held Max’s wrist in static extension, and the elastic bands provided individual passive finger extension assist to lift the fingers off the strings while allowing
Fig. 5. Max playing guitar while wearing the high-profile dynamic orthosis. Photo provided by Max.
active finger flexion to press the strings. Due to the dorsal-based design, there was relatively little thermoplastic on the volar side of the hand, thus facilitating grasp of neck of the guitar. As a result, the dorsal dynamic design enabled a valued occupation for Max in a way that the static wrist orthosis could not. When asked about how he felt about the orthoses, Max said that they made him feel useful again because he “gained functionality of movements with a reasonable degree of utility” (translated from Portuguese to English). He also reported that, in addition to enabling him to play the guitar, the dynamic orthosis helped him with various daily activities. “The main goal was to play the guitar, but while wearing it, I could perform other activities, for example holding a glass, working out and making my bed” (translated from Portuguese to English). Max used the therapist-made dynamic orthosis for 4 months until he had tendon transfer surgery (pronator teres to extensor carpi radialis brevis, palmaris longus to extensor pollicis brevis, and flexor carpi radialis to extensor digitorum communis). Discussion Meeting both the biological and occupational/functional needs of a client within a resource-limited environment can be
4
F.P.F.M. Ricci et al. / Journal of Hand Therapy xxx (2018) 1e5
Fig. 6. Grip strength testing of affected hand with Jamar Grip Dynamometer, handle position 2. (A) Without orthosisdunable to properly grasp the dynamometer. (B) Wearing static volar wrist orthosis. (C) Wearing dorsal forearm-based high-profile dynamic finger-thumb metacarpophalangeal extension orthosis. (D) Nonaffected side. Photos show joint markers and electromyography sensors, which were applied to collect data for a different concurrent study.
challenging. However, it is possible to help a client even when the optimal orthotic materials are unavailable and optimal orthotic designs are not provided.
Table 1 Grip strength (mean of 3 trials SD) for each orthotic condition Orthotic design
No orthosis Static orthosis Dynamic orthosis
Grip strength (kg) Injured side
Unaffected dominant side
00 16 2 21.3 1.1
61.3 11 NA NA
SD ¼ standard deviation; NA ¼ not available.
The high-profile dynamic orthosis presented in this article addressed and accomplished Max’s most important needs and goalsdplaying the guitar, working out, and holding a glass. For this reason, although it was a bulky older design and the wrist was held in static extension, the orthosis worked for him. Client satisfaction is relevant to orthotic intervention because it can highly influence client adherence to the device.8-10 Alsancak9 found that clients who wore dynamic orthoses for radial nerve injury were content with function and support but unhappy with the appearance of the orthosis. In contrast, Max did not complain about the cumbersome appearance, likely because his orthosis enabled guitar playing, which was his favorite hobby. He was not able to play at all after the injury, despite his own efforts to make
F.P.F.M. Ricci et al. / Journal of Hand Therapy xxx (2018) 1e5
himself a dynamic orthosis. However, when he could play again with the therapist-made orthosis, he described the feeling as “poetic happiness”. When asked about the amount of time that he wore each one of the orthoses, Max answered that he used the dynamic orthosis for longer periods than the static one. Hannah and Hudak10 conducted a single-subject experiment in which the client preferred to wear the static volar wrist cock-up orthosis because, although it did not statistically improve her hand function, it was supportive, easy to apply, and less noticeable. She was an 83year-old woman, whereas Max is a 27-year-old male university student. Such differences in the preference for different orthotic designs highlight the importance of a client-centered approach because individuals in different contexts will have distinct and very individual needs. By using the client-centered Bio-Occupational Orthotic Framework by McKee and Rivard, the therapist addressed Max’s biological needs (paralyzed muscles and maintaining length of soft tissues) and occupational/functional needs (desire to play guitar and work out) by providing usable well-engineered orthoses. A holistic, client-centered, and professional practice process was used, giving consideration to Max’s unique social and physical environmental contexts. The ultimate goal, to enable participation in activities that were important and meaningful for Max, was achieved despite using a bulky old-fashioned orthotic design.
5
Acknowledgments The authors thank Max for his kind permission to share part of his rehabilitation journey.
References 1. Ricci FPF, Barbosa RI, Elui VMC, Barbieri CH, Mazzer N, Fonseca MCR. Radial nerve injury associated with humeral shaft fracture: a retrospective study. Acta Ortop Bras. 2015;23(1):19e21. 2. McKee P, Nguyen C. Customized dynamic splinting: orthoses that promote optimal function and recovery after radial nerve injury: a case report. J Hand Ther. 2007;20(1):73e87. 3. McKee P, Nguyen C. Low-profile dorsal dynamic wrist-finger-thumb assistiveextension orthosis for high radial nerve injurydfabrication instructions. J Hand Ther. 2007;20(1):70e72. 4. McKee P, Morgan L. Orthotics in Rehabilitation: Splinting the Hand and Body. Philadelphia, PA: F.A. Davis; 1998:112e114. 5. Szekeres M. Tenodesis extension splinting for radial nerve palsy. Tech Hand Up Extrem Surg. 2006;10(3):162e165. 6. Peck J, Ollason J. Low profile radial nerve palsy orthosis with radial and ulnar deviation. J Hand Ther. 2015;28(4):421e423. 7. McKee P, Rivard A. Foundations of orthotic intervention. In: Skirven TM, Osterman L, Fedorczyk J, Amadio PC, eds. Rehabilitation of the Hand and Upper Extremity. 6th ed. Philadelphia, PA: Elsevier; 2011:1565e1580. 8. McKee PR, Rivard A. Biopsychosocial approach to orthotic intervention. J Hand Ther. 2011;24(2):155e161. 9. Alsancak S. Splint satisfaction in the treatment of traumatic radial nerve injuries. Prosthet Orthot Int. 2003;27:139e145. 10. Hannah SD, Hudak PL. Splinting and radial nerve palsy: a single-subject experiment. J Hand Ther. 2001;14:195e201.