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What is your opinion on splinting to help with foot-drop and for a hand with hemiplegia that has a lot of tone?

My partner’s therapists won’t splint because they say the tone and movement in his hand could cause joint damage or pressure sores if splinted. He can only move one foot and this foot is now dropping and is also slightly on its side. He’s had Botox but they won't splint. He was in the hospital recently and they are annoyed that the therapists at his rehab center won’t splint as they’ve seen his hand and foot have gotten worse since joining rehab 6 months ago. What is your stance on splinting?

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Senior physical therapist

Answer transcribed from Brightway's interview with Dr. Cristen Gordon (pt.2):


I don't want to go against my fellow therapist. However, I am a big fan of splinting and bracing. In fact, there's a whole lot of research that shows that especially after botox, you should be getting therapy, splinting, stretching, and bracing within seven days. It takes a special type of splint or a special type of brace to prevent joint breakdown. It also takes education on how to manage the skin and check the skin and make sure that's not happening. They have what’s called static braces and then dynamic braces. You’ll hear me use brace and splint interchangeably in this conversation, but there is one company in particular called Ultraflex that makes a splint which is a dynamic stretching splint. What that means is you put the patient into their comfortable range of motion and you can add a little bit of resistance, which passively stretches the muscle. You can make it very gentle or a little more aggressive. We try not to make it aggressive especially with spasticity because that triggers the tone. Those braces in conjunction with spasticity management work amazingly. 


That being said, not everybody can tolerate that passive stretch because you are to wear it for about four to six hours. You can use static splints and static bracing to either maintain range of motion or stretch range of motion. I mentioned spasticity before, which is just the brain telling the muscle to turn on and never telling it to turn off. In this case, if we're talking about the calf muscle or the gastric muscle, its job is to point your toes. If you are continuously pointing your toes, your muscles will start to adapt and stay in that position. They will get so tight in the calf muscle that you can't stretch it and the muscles in the front of the leg will get very weak and there's nothing then counterbalancing your toes pointing down. Braces and splints are there to prevent that from happening. There's a lot of merit and validity to using bracing and splinting so I'm a little bit surprised at the hesitancy to use it when there are just so many options to do that. 


In fact, that just made me think about another one which is called serial casting. What you do with serial casting is you actually put the joint in a cast. You make the cast what we call bifurcated, so it's split in half so that you can take the cast off when you need to. Every week or even more frequently depending on your body, the therapist that made the serial cast for you can change the angle of the cast. Therefore, every week they’d adjust the amount of stretch you're getting. You may start with it on Monday, and let's say it'll feel tight on Monday, but you wear it at the recommended time your therapist gives you how many hours to wear it per day by the end of the week, that cast is not going to feel tight anymore. Then the next week, they come back and make another one. They crank up the angle a little bit so you're getting more range of motion. The same thing happens, you wear the recommended time for that week by the end of the week, that one is now feeling easier to tolerate.


There are a lot of options for bracing and splinting. I am an advocate for if you are working with a healthcare professional that you don't feel is doing what needs to be done, reach out for a second opinion. Talk to another therapist, and it's always your prerogative as the patient to ask for somebody else to take a look and get that second opinion. As healthcare providers, I always like to think that we're going to advocate for patients the best we can but sometimes, we all get stuck in our way of doing things as being the right way. So if we're not doing our job and advocating for you, make sure that you're advocating for yourself and say okay well, I want to maybe go see another therapist and see what happens.