Hand Clin 19 (2003) 573584

Casting, splinting, and physical and occupational therapy of hand deformity and dysfunction in cerebral palsy
Judith Wilton, MS, GradDipHthSc, BAppSC, OT
Hand Rehabilitation Specialists, 10 Altona Street, West Perth, WA 6005, Australia

Signicant occupational and physical therapy time and resources are directed to the management of the upper limb in cerebral palsy (CP). The evidence to support therapy interventions for the upper limb is not strong [1]. This in part reects the diculties of research [2] rather than a lack of critical review of practice. Experience and logic underpin many therapeutic applications. This presentation details the available options, the rationale for their use, and the results of treatment. Prerequisites for hand function Ecient performance of the upper limb depends on proximal control and dynamic stability of the trunk and shoulder girdle. From a stable base, distal mobility of the limb enables participation in age-appropriate occupational tasks. Improvement in scapulohumeral and trunk control is a major focus of neurodevelopmental therapy (NDT), one of the most commonly used approaches for treatment of children with CP. NDT techniques attempt to alter muscle tone during movement to facilitate normal movement patterns and postural reactions under the premise that improved postural control improves functional skills [3]. Investigations into this premise in relation to the upper limb determined the eects of NDT on quality of upper limb movements [4] and reaching [5,6]. Although improvements were evident, they were not greater than reach training using principles of motor learning or occupational therapy directed toward functional skills.

For children with more severe motor dysfunction in whom head and trunk control are aected by spasticity and persistent postural reexes, postural control for eective upper limb function is achieved only through adaptive seating. As children get older, the requirements for schooling demand longer periods of time seated. Therapists thus should consider how restrictions imposed by the chair and table in upper limb movement may potentiate deformity and what strategies are needed to address it. Altered sensibility commonly is identied as a contributing factor to impaired hand function in children with CP. Much of the literature has focused on the measurement of sensory decits, with two-point discrimination and stereognosis identied as the most common tests [79]. Recent studies of children with hemiplegia have established a strong relationship between tactile sensibility and dexterity [10] and ngertip force regulation during object manipulation [9,11]. The relationship between sensibility and hemiplegic hand performance in functional bimanual activities, however, was not as strong [10]. The potential to improve hand sensation by systematic sensory education programs, shown to be eective following stroke [1214], has yet to be determined in children with CP. Principles of intervention options Therapeutic modalities specic to hand function essentially fall into two categoriesthose that have an impact on hypertonicity and associated contracture and those that facilitate functional use of the hand related to active motion and dexterity. In the absence of extensive evidence

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under-pinning the therapeutic modalities as applied to typical patterns of deformity of the hand and wrist.

Hypertonicity and contracture When addressing the increased muscle tone in children with CP, it is useful to distinguish between the neural or reexive componentsthe tonic muscle contractionsfrom the non-neural or mechanical components, the viscoelastic properties of muscle and connective tissue associated with contraction and stretch [15,16]. Spasticity, a somewhat imprecise term in clinical practice, refers to the neural component of hypertonicity, that is, the velocity-dependent increase in stretch reex activity [17]. The altered mechanical properties of the muscle and associated tissues occur in response to the abnormal conditions imposed on the muscle by the spasticity. In turn, muscle shortening may participate in the generation and maintenance of spasticity [16,18]. Strategies that address muscle contracture aect the neural and mechanical components of the hypertonicity present. Studies by Nash, Neilson, and ODwyer [19,20] suggest that neural and non-neural components of hypertonicity should be considered as reducing spasticity alone and not altering muscle contracture. Following electromyographic biofeedback training over 10 weeks, subjects were able to reduce spasticity by 50%, but no associated change in muscle contracture was measured, nor improvement in voluntary movement evident. To address contracture and hypertonicity eectively, it is recommended therapists use modalities that prevent or reverse contracture in target muscles for sucient duration each day to promote muscle growth [19]. During growth and in response to changes in posture, the functional length of the muscle is adjusted by altering the number of sarcomeres in series for optimum force generation and power output [21]. When movement does not put the joint through a full range of motion and daily passive range of movement or posturing does not adequately maintain range, adaptation of the muscle results in contracture. This adaptation, a combination of shortening of muscle bers and remodeling of muscle connective tissue [19,22,23], is accompanied by changes in the skin and periarticular tissues [2426]. When safe forces are applied to tissues statically or cyclically, they demonstrate a tran-

sient lengthening depending on the viscoelastic properties of the tissues. This elongation reverses once the force is relaxed. This elastic response is associated with unfolding of tissue and temporary realignment of collagen bers within the connective tissues. The resolution of contracture through the application of low-load prolonged stress to the contracted tissues at the end of their available range ultimately depends on the ability of the cells to sense and transduce the mechanical force into biologic action and to grow [20,23,27]. The response of shortened muscles to stretch, using plaster cast immobilization, has been explored in numerous animal studies. Adult muscle responds to stretching by adding new sarcomeres in series, thereby returning the sarcomeres to their optimum tension-generating length with no change in tendon length. In growing muscles, however, the initial increase in number of sarcomeres up to day ve is followed by a decrease in sarcomere number, thereby decreasing muscle ber length. Muscle tendon length is maintained by lengthening of the tendon [23,28,29]. These ndings suggest that extended casting protocols for young children should consider potential to increase tendon length rather than to inuence muscle ber length. It is stressed also that cast lengthening of muscle contracture should be gradual, because decrease in sarcomere number is greater than decrease in length of muscle connective tissue [23]. Potential exists for muscle ber breakdown from too fast or forceful stretching. Although stretch is essential to muscle growth and in maintenance of functional length once growth has stopped [30], the eectiveness of passive range of motion exercises depends on their frequency. Long-term stretch, applied continuously for periods greater than 6 hours, has been shown to be most eective [31,32]. Casting and splinting are best in applying low-load prolonged stretch to contracted tissues. Experience suggests that, in muscles with hypertonicity, shortening of muscle and connective tissues recur unless stretch is maintained [20,33].

Splinting and casting Published studies in the last 50 years that have addressed the issue of hand splinting in the presence of spasticity have tended to reect the theoretic basis of therapy at the time [3440]. Although direct comparison between studies is not possible, the vast majority identied improvement

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in range of motion associated with splint wearing [4143]. Static splints and casts maintain the joint in one position with the goal of stabilizing it for ecient transfer of muscular forces to distal joints. Serial static splints and casts are designed to lengthen tissues and correct deformity through application of gentle forces sustained for extended periods of time [44]. Splints are remolded and casts replaced at intervals that allowed for tissue response to the lengthened position. Casting has biomechanic and neurophysiologic eects. Biomechanic eects relate to changes in the length of muscle and connective tissues reversing the histologic changes that occur in tissues maintained in a shortened position. The exact neurophysiologic eects of casting on spasticity are undened. It is proposed that inhibition results from decreased sensory input from cutaneous and muscle receptors during the period of immobilization. The eects of neutral warmth and circumferential contact also are believed to contribute to modication of spasticity. Much of the research on upper limb casting in the presence of spasticity is undertaken in a single case study design. Two groups of studies are seenthose using mobilizing principles with a series of circumferential casts worn for 24 hours per day for periods up to 4 weeks [4550] and those in which a single cast is bivalved and worn for periods of 35 hours per day for many months [33,44,51,52]. In the rst group, serial casts applied to elbow and wrist exion contractures for 24 hours per day over several weeks resulted in signicant gains in range of motion. Intermittent static casting of the wrist also demonstrated improvements in range of motion, quality of movements, and functional use of the hand. Biomechanically, bivalved casts achieve wrist immobilization as eectively as a thermoplastic splint. The studies that used static bivalved casts to immobilize the wrist joint for function for extended periods provided no explanation regarding choice of material. Choice may relate to the skills of the therapist in splinting or casting, ease of fabrication, cost, comfort, and aesthetics. Splints to facilitate functional use of the hand include the wrist splints with reex inhibiting components [53,41], a neoprene splint to position the thumb in abduction and the forearm in supination [54], and splints to position the thumb in abduction [55,56]. Studies that investigated splints worn by children with CP reveal trends toward more normal movement patterns and

greater grasp skills [57,58]. No signicant relationship was found between splint type and changes in hand function. Functional gains were associated with splint wear. In practice, splints are designed to meet specic objectives identied by the patient or their caregiver. In many instances splints compensate for functional decits in hand grasping or pointing to secure toys, eating utensils, and writing and computing devices. When a variety of postures of the upper limb are required in the performance of functional tasks, rigid correction of deformity is not always compatible with function. It is probably one of the key issues for noncompliance with rigid splinting and the preference for use of custom made or commercial neoprene and Lycra splints. These splints use a wraparound design with inserts to position the thumb and reinforcement achieved by way of splinting material or metal inserts. Dynamic Lycra splints use the inherent properties of the fabric and design features of the garment to create a low force to resist the spastic muscle action while also facilitating the antagonist action. The mechanical properties of dynamic Lycra arm and hand splints have been established in studies involving normal and hemiplegic subjects [18,59]. More extensive Lycra body splinting in children with CP [60] also showed improved dynamic upper limb function, with reduction in involuntary movement and improved patterns of movement associated with a reduction in muscle tone. Thirteen of fourteen subjects experienced an immediate reduction in involuntary movement, with six maintaining some improvement after removal of the body splint. Although preliminary research suggests Lycra splints have potential to inuence involuntary movement and apply low stretching force to the limb in people with CP without compromising comfort or functional use of the limb, further controlled clinical trials are needed. Functional strength Current understanding is that spasticity is not the primary cause of voluntary movement impairment [20]. The perception of greater strength in the hypertonic muscle, with weakness in its antagonist, is in part caused by the techniques used to determine strength. As skeletal muscle is highly adaptable, its structural characteristics are determined by its conditions of use. Shortened muscles may seem strong at normal length

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because they are tested in their optimal position. Associated changes in passive tension through shortening of the connective tissue elements also may contribute to perceived strength. Weakness in lengthened muscles is the result of remaining in an elongated position beyond the neutral physiologic rest position but not beyond the normal range. Muscles seem weaker because they are not tested at their optimal length. Constant contraction of the muscle when allowed to shorten also may exaggerate the rate and quantity of sarcomere loss, thus weakening the muscle [21]. The hypertonic muscle may be constrained during voluntary movement by the passive mechanical properties of the muscle itself. Lengthening the shortened connective tissue elements in the muscle, together with modication of the functional length with adaptation of sarcomere number, has potential to modify strength of the muscle. Improvement in strength of wrist extensor musculature described following serial progressive casting [50] is in part the consequence of muscle length adaptation. Following the period of immobilization, therapy is required to assist weaker muscles to work against gravity and to perform functional grasp. Splints that oer support to the joint but allow active motion are preferable to rigid immobilization. It is observed that repetitive use of the hand in functional tasks has the potential to further increase strength and endurance. Further investigation is required, however, to validate grip and pinch strength exercise protocols. Manipulation and dexterity Improvement in manipulation and dexterity are aims for children with CP with milder motor diculties [61,62]. Hand intrinsic muscular control is essential to achieve ne motor coordination. Therapy aims to facilitate isolated thumb and nger stability and mobility, accurate patterns of pinch and grip of objects of varying sizes, shapes, and textures, translation and rotation of objects within the hand, bilateral manipulation, and strength and endurance to meet functional demands. The ecacy of occupational therapy programs to address development of ne motor skills in preschool children has been established in several studies by Case Smith [61,63,64]. Although the number of children in these studies with a diagnosis of CP was small, the therapists use of

play and peer interaction inuenced ne motor skills, improving function. Therapists therefore are encouraged to use activities of daily living (ADL), play, and recreational and vocational activities as an integral part of therapy [33,63]. Analysis and treatment of hand dysfunction The wrist and hand present a complex interaction of intrinsic and extrinsic musculature in which hypertonicity dictates the predominant pattern of deformity. Performance of an isolated movement may elicit a dierent pattern from that evident when attempting to use the hand in a functional task. Analysis of patterns of function of the wrist and digits during movement and during function provide the basis for treatment decisions. In addition to the usual tests of passive and active range of motion, information from parents or caregivers about the posture of the limb during sleep often can assist in determining whether contracture is present. In 1981, Zancolli and Zancolli [65] described a surgical classication of spastic hand deformities in the wrist and ngers, whereas House, Gwathmey, and Fidler [66] identied four patterns of deformity in the thumb. Building on these classications, the following model was developed to facilitate analysis of the anatomic and biomechanic components of deformity and dysfunction. Patterns of deformity may evolve over time. Pattern 1: minimal wrist exion in function, thumb adduction Children with this deformity have mild spasticity in exor carpi ulnaris (FCU), which means that reach to grasp, occurs with slight wrist exion and ulnar deviation. The wrist extensor muscles can extend against the resistance of hypertonicity in FCU and there is no evidence of hypertonia in the nger musculature. In a large number of patients, no decit is seen in the thumb, but when present the deformity pattern is adduction at the carpometacarpal (CMC) joint from a combination of contraction and contracture in the adductor pollicis (AP) and rst dorsal interosseous (DI) muscles. Some CMC joint extension and abduction are restricted but with no limitations in motion of the metacarpophalangeal (MCP) and interphalangeal (IP) joints. Full passive range of motion (ROM) is available at all joints of the wrist and ngers with the possibility of reduced ROM of the thumbindex

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nger web space. Imbalance of muscles acting across the joints can contribute to instability. Hyperextension seen at the proximal interphalangeal (PIP) joints results from wrist exion increasing the distance the extensor digitorum communis (EDC) tendons traverse before inserting at the base of the middle phalanx. Great variability exists in the population as to normal mobility of these joints, and unless instability impedes function it need not be addressed. Therapeutic intervention Maintenance of full extensibility of tissues is a primary goal. Function and play activities that incorporate weightbearing are used to provide regular stretch to FCU. In the presence of contracture of the thumb web space, a serial splint worn during nonfunctional times addresses the contracture without compromising function. Designing functional splints to stabilize the thumb in a position for opposition is a signicant challenge. To control the thumb joints, splint components must control the thumb metacarpal against the forces of spasticity. When the web space is shortened by skin contracture, the diculty in directing the abducting force to the metacarpal is increased. Although neoprene or Lycra are more acceptable splinting materials for young children, their elasticity and lack of contour require careful design to ensure appropriate application of forces to the thumb. Combinations of low temperature thermoplastic materials and Lycra or neoprene may better achieve this objective, particularly in older children in whom the tissue forces are greater. It is important to ensure that functional thumb splinting does not impede use of the thumb; no single

splint design has been found that resolves this problem eectively. People with this pattern of deformity have good grasp and release and pinch; however, ne manipulation is impeded by thumb dysfunction. Therapy is focused on activities requiring grasp and pinch of objects of a wide variety of sizes and shapes to encourage thumb opposition and hand manipulation. Placement of objects for manipulation should use a variety of wrist postures, with vertical play one of the ways to promote wrist extension. Pattern 2: moderate wrist exion in function, active wrist extension People with this deformity use a tenodesis-type action, approaching objects with signicant wrist exion with extension of the MCP and PIP joints of the ngers (Fig. 1A). Active exion of the ngers is associated with extension of the wrist. Control of the speed and force of nger exion is a common problem. The hypertonicity is located predominantly in exor digitorum profundus (FDP) and exor digitorum supercialis (FDS), with mild hypertonicity located in FCU and exor carpi radialis (FCR). Strength in the wrist extensor muscles can overcome the resistance in the wrist exors, but EDC cannot extend the ngers with the wrist approaching neutral. EDC is a critical player in this pattern, as it is compromised by its incapacity to generate tension when constantly working in a lengthened position, and by its size and overall smaller capacity to generate tension as compared with FDS and FDP [67]. The thumb metacarpal generally is held in an adducted position by hypertonicity in the AP and rst DI muscles. Extensor pollicis longus (EPL) and extensor pollicis brevis (EPB) act across the

Fig. 1. Pattern 2 with and without dynamic Lycra splint. (A) Approach to grasp is associated with signicant wrist in exion with hyperextension of the MCP joint. (B) Dynamic Lycra splint facilitates a balance between wrist and nger musculature when approaching objects for grasp.

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MCP joint, creating a hyperextension deformity on reach, while not impairing thumb exion. No decits are evident in the passive range of motion of the wrist. Shortening may be demonstrated in FDP and FDS, however, with combined nger and wrist extension. Daily stretching protocols in association with weightbearing on the hand with extension of the wrist and ngers may maintain length without need for splinting or casting. Contracture of the index thumb web space is generally present. Persistent extension of the MCP in combination with adduction of the CMC joint can lead to instability of the MCP joint capsule and ineective force transmission through the thumb during pinch. In people with this deformity, grasping is impaired by reduced thumb web span, limiting the area of the palm of the hand available for object contact. In addition, diminished control of wrist extension in conjunction with exion of the ngers often results in failure to secure the object between the ngers and thumb or the ngers and palm. Successful grip depends on the size and shape of objects in relation to the size of the hand. Transverse volar grip is the most eective because of the tenodesis action in grasping, with eectiveness of lateral and two-point pinch dependent on the size and shape of the object.

nities to use newly acquired movement patterns and consolidate gains. The thumb presents a two-fold challenge. First, the presence of contracture of the thumb index web space, and second, diminished active motion to position the thumb for eective opposition. Resolution of contracture requires serial progressive splinting, preferably at night so as not to impede performance of functional activities. Although thumb mobility is desirable, thumb stability in a position for opposition to the ngers is more important. Achieving this stability is not easy in a situation in which spastic muscles have good moment arms, and splinting levers are small. Splinting materials must have sucient strength to resist the force of AP and extrinsic extensors to stabilize the CMC and MCP joints. Correction of the wrist position and thus reduction of the distance over which the EDC tendons traverse at the wrist resolves much of the hyperextension deformity at the MCP and PIP joints of the ngers. Splinting for the PIP joints is required only if joint instability compromises function, particularly for switching devices or computer access. Small splints that restrict PIP joint extension beyond neutral can be fabricated and worn for specic functional tasks, but compliance with long-term wear is problematic. Pattern 3: wrist exion >20 in function, no active wrist extension In people with this pattern, moderate spasticity is located in FCU and FCR and the FDP, FDS, and palmaris longus. Wrist extensor muscles are weak, constantly working in a position of signicant wrist exion. Mid range exion of the ngers is possible, but active insuciency in FDS and FDP impairs strength of grip. Hyperextension of the PIP joints is present (Fig. 2). This pattern is more common in older children and adults and reects the impact of growth and tissue shortening over time. The signicant feature of this pattern is the decit in extensibility in the wrist exor and extrinsic nger exor musculature, resulting in loss of extension ROM. Shortening also may be present in EDC, limiting full passive nger exion. The predominant posture of the thumb is adduction at the CMC joint and hyperextension of the MCP joint as described in the previous classication. People with this deformity grasp objects between the nger and thumb pads, as it is not

Therapeutic intervention The objective of intervention is to gain better coordination between wrist and nger muscular action. Treatment is designed to combine reeducation of movement patterns in functional tasks that require wrist extensors to work in their mid range of motion, maximize action of EDC for nger extension, and gain control over speed and force of contraction of nger exors during grip. Dynamic Lycra splints (Fig. 1B) can assist in achieving this objective, but rigid splints are incompatible with functional use of the hand. The Lycra fabric allows movement but desires to return to its predetermined resting length. Looking like a glove with inclusion of ngers to prevent migration, the multiple components across the dorsal and volar aspects are designed to provide directional pull and so facilitate movement. The thumb is included with addition of small thermoplastic components if additional stability or positioning is required. Initial splint application should be incorporated into a therapy program directed toward mastery of movement patterns required in specic occupational tasks. Repetition in ADL provides opportu-

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Fig. 2. Examples of pattern 3 deformities. (A) In association with signicant wrist exion tension on EDC contributes to hyperextension in the PIP joints, while AP and contracture inuence the thumb CMC joint and EPL extends the IP joint of the thumb. (B) The right hand illustrates the resting position of the wrist reinforced by gravity and wrist and nger hypertonicity. Greater degrees of extension in the resting position of the left wrist and ngers are the outcome following 18 days of serial casting.

possible to orientate the palm toward the object because of signicant wrist exion. Therapeutic intervention The objective of intervention is to improve hand function, prevent further wrist contracture for ease of management, or address pain in the wrist. As the ngers cannot be exed tightly, there is rarely a risk for breakdown of skin in the palm of the hand. Rigid splinting or casting are directed to decreasing hypertonicity and increasing length in wrist and nger exors. These are best undertaken for extended periods or over night. For patients in whom the contracture of the wrist exceeds a position of 45 of exion, a series of two or three casts over several weeks (Fig. 3) is recommended. With this severe deformity, casting, maintaining the joint for maximum time at end range, has advantages over rigid splints that may be uncomfortable. A dorsal volar splint (Fig. 4) is used when there is less contracture of the wrist and shortening of FDS and FDP. This design is superior to other splint designs because it uses an eective lever system to apply an extension force to the wrist and ngers [68]. Dorsal forearm and volar hand components are remolded as lengthening occurs in shortened tissues. For people with this deformity, functional goals often are determined by the competence of the other hand. For children with hemiplegia, the goal may be to achieve an ecient gross grasp to

use as an assist/stabilizer to the dominant hand. For patients in whom bilateral involvement exists, intervention often is directed at achieving the hand function requirements for a specic task, such as wheelchair control or activating communication devices (Fig. 5). Generally, splinting is

Fig. 3. Three plaster casts illustrate progressive increase in range of passive wrist and nger extension with successive applications.

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Pattern 4: wrist extension with intrinsic hypertonicity Spasticity in this pattern is located primarily in the wrist extensor muscles, extensor carpi radialis longus (ECRL) and extensor carpi radialis brevis (ECRB), and hand intrinsic muscles, with adduction exion at the thumb CMC and MCP, exion and adduction of nger MCP joints, and hyperextension deformities of the nger PIP joints. With exion of the MCP joints the intrinsic pull on the lateral bands of the nger extensor mechanism is facilitated across the dorsal aspect of PIP joint often restricting exion motion at this joint. The thumb metacarpal is held in an adducted position by contraction in the AP and rst DI muscles, with spasticity in the exor pollicis brevis (FPB) contributing to MCP exion and IP extension. Contracture can develop in the ECRL and ECRB musculature, restricting wrist exion. Intrinsic muscle contracture is compounded by decreased extensibility of palmar fascia and skin, and by the fact EDC function is compromised in extremes of wrist extension (Fig. 6A). Failure to manage contracture in the intrinsic muscles and palmar tissues presents problems for skin care and hygiene. The major obstacle to functional use of the hand is the inability to open the hand spontaneously. These patients need to disassociate elbow extension from attempts to grasp, with opening of the hand requiring a neutral wrist position and extension of nger MCP joints. In addition, the thumb must be extended out of the palm of the hand if any grasp is to be eective. In small children with this pattern, the thumb MCP exion contracture often presents the most signicant problem, as the thumb is trapped constantly under the exed ngers.

Fig. 4. The dorsal volar splint has components for dorsal hand and forearm, volar hand and ngers, and the thumb. Each component is molded separately to position joints to address hypertonicity in wrist and nger musculature.

required to assist the wrist in achieving a more neutral position to resolve the biomechanic disadvantage for FDS and FDP in grasp, while not compromising EDC. Functional activities requiring controlled nger opening and closing complement the splinting program. Functional splinting of the wrist may use rigid thermoplastic materials to immobilize the wrist in a position that does not compromise the ability to extend the ngers during reach. Alternatively, materials such as Lycra or neoprene may be used to make circumferential soft splints, reinforced by splinting material or exible boning that restricts wrist motion and opposes the wrist exor spasticity. Lycra or neoprene alone has insucient strength to oppose the strong exion pattern and have no eect on extension decits in the wrist or ngers. Splinting options for the wrist also should incorporate components to address the thumb deformity as described in the previous classication.

Fig. 5. (A) In the absence of active wrist extension in pattern 3 deformity, the wrist exion deformity is reinforced by use of the wheelchair control. (B) A rigid functional thermoplastic splint immobilizes the wrist to achieve a better biomechanic position for nger and thumb musculature. A lining sock is worn under the splint.

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Fig. 6. (A) Pattern 4 deformity results in a posture of the hand with signicant wrist extension and nger exion, with the thumb adducted and exed across the palm. (B,C) A two-piece splint is required to control wrist and thumb positions to allow active nger motion.

Therapeutic intervention Without intervention that has a long-term perspective, this pattern of deformity can lead to signicant contractures of the thumb and nger MCP joints. Treatment is directed toward prevention of intrinsic muscle contracture with maintenance of tissue extensibility and restoration of the biomechanic balance to the wrist. In young children who are highly motivated to use their hand, who can control their elbow position, and who have no contractures, dynamic Lycra splints with design components to facilitate wrist exion and nger MCP extension can assist re-education of extrinsicintrinsic muscle function. Repetitive functional use of the hand is essential for improved muscle strength. Gross voluntary opening and closing of the ngers around objects appropriate to the hand size and simple thumbindex nger pinch are appropriate functional goals. Stretching protocols to prevent contracture must address joint capsular structures, particularly at the MCP joints and muscle tendon unit length of the extrinsic nger musculature. In persons/people for whom tonal patterns are high and contracture is present, however, a greater degree of wrist control is required, necessitating more rigid functional splinting. Materials of choice depend on whether the person can control wrist movement to neutral or slight exion. Designs must incorporate volar and dorsal components (Fig.

6B,C). The volar component is used to position the thumb in abduction and extension for opposition to the ngers and to provide counterforce at the wrist. With appropriate splinting, nger extension to activate switching or computer devices is possible, together with a simple gross grip. Night splinting to address contracture in shortened musculature and soft tissues requires the wrist to be positioned in some degrees of exion, the MCP joints in extension and abduction, the IP joints in some exion, with maintenance of the thumb web space and MCP joint extension. Experience suggests that a reduction in hypertonicity of the wrist and nger musculature also improves elbow function.

Pattern 5: sted hand with wrist exion or wrist extension This is the most severe deformity and reects the hypertonicity and secondary contracture of muscles and associated connective tissues. The ngers and thumb are maintained in a sted position with minimal active motion evident. Skin maceration and nail care are problems. Therapeutic intervention The aim is to maintain sucient motion so the hand can be opened to prevent maceration,

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J. Wilton / Hand Clin 19 (2003) 573584 neurodevelopment therapy plus casting and regular occupational therapy for children with cerebral palsy. Dev Med Child Neurol 1991;33:37987. Fetters L, Kluzik J. The eects of neurodevelopment treatment versus practice on the reaching of children with spastic cerebral palsy. Phys Ther 1996;76:34658. Kluzik J, Fetters L, Coryell J. Quantication of control: a preliminary study of eects of neurodevelopment treatment on the reaching of children with spastic cerebral palsy. Phys Ther 1990;70: 6576. Thibault A, Forget R, Lambert J. Evaluation of cutaneous and proprioceptive sensation in children. A reliability study. Dev Med Child Neurol 1994; 36:796812. Yekutiel M, Jariwala M, Stretch P. Sensory decit in the hands of children with cerebral palsy: a new look at assessment and prevalence. Dev Med Child Neurol 1994;36:61924. Gordon AM, Du SV. Relation between clinical measures and ne manipulative control in children with hemiplegic cerebral palsy. Dev Med Child Neurol 1999;41:58691. Krumlinde-Sundholm L, Eliasson A. Comparing tests of tactile sensibility: aspects relevant to testing children with spastic hemiplegia. Dev Med Child Neurol 2002;44:60412. Eliasson AC, Gordon AM, Forssberg H. Tactile control of isometric ngertip forces during grasping in children with cerebral palsy. Dev Med Child Neurol 1995;37:7284. Carey LM, Matyas TA, Oke LE. Sensory loss in stroke patients: eective training of tactile and proprioceptive discrimination. Arch Phys Med Rehabil 1993;74:6029. Dannenbaum RM, Lones LA. The assessment and treatment of patients who have sensory loss following cortical lesions. J Hand Ther 1993;6:1308. Yekutiel M, Guttman E. A controlled trial of the retraining of the sensory function of the hand in stroke patients. J Neurol Neurosurg Psychiatr 1993;56:2414. Katz RT, Rymer WZ. Spastic hypotonia: mechanisms and management [review]. Arch Phys Med Rehabil 1989;70:14455. ODwyer NJ, Ada L, Neilson PD. Spasticity and muscle contracture following stroke. Brain 1996; 119:173749. Young RR, Wiener AW. Spasticity. Clin Orthop 1987;219:5062. Gracies JM, Marosszeky JE, Renton R, Sandanam J, Gandevia SC, Burke D. Short term eects of dynamic Lycra splints on upper limb in hemiplegic patients. Arch Phys Med Rehabil 2000;81:154755. Nash J, Neilson PD, ODwyer NJ. Reducing spasticity to control muscle contracture of children with cerebral palsy. Dev Med Child Neurology 1989;31:47180.

infection, and breakdown of the skin of the palm and thumb. If opening of the ngers and positioning of the thumb are possible, casting is the preferred option. The gains are maintained by bivalving the nal cast or applying a splint. If casting is not an option, prefabricated palmar protectors and custom made soft rolls can create an interface between tissue layers; however, they do little to resolve contracture. This can be achieved by gradually adding rm components made of splinting material to the soft rolls to hold joints more extended, with the circumference determined by the degree of contracture in the ngers and web space of the thumb. Summary The treatment of hand deformity and associated dysfunction is a major focus of physical and occupational therapy for people with CP, as poor grasp and manipulation has potential to impact on many aspects of daily life. To assist therapists in analyzing patterns of movement of the wrist, nger, and thumb musculature at rest and during functional activities, ve patterns of deformity commonly seen in the hypertonic hand are described. Interventions that impact on hypertonicity and associated contracture and that facilitate functional use of the hand in the presence of these deformities are discussed. The paucity of evidence from clinical trials on intervention strategies reects in part the diversity of people with CP and the highly individual functional problems they encounter. While further research is needed on the many possible interventions and how they contribute to maximizing hand function, there is increasing evidence of the value of therapy that is directed to functional outcomes relevant to the individual.

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