Visual System

Of people over age 65, researchers found that 17.2% have some type of visual impairment related to developing functional limitations [Dunlop et al. 2002]. Decreased vision can also play a role in noncompliance of splint wear. For example, some older adults may be unable to apply their splints because of poor figure/ground discrimination. Older adults may also have difficulty seeing straps and Velcro as well as inspecting their skin. Using colored thermoplastic splinting material and contrasting colored straps may assist the older adult who has poor visual discrimination. Bright colors may prevent the splint from being easily lost or mistakenly sent to the laundry.

When receiving splint instructions by demonstration, older adults who have correctable vision should wear their glasses. The older adult demonstrates to the therapist proper splint application and removal. The therapist provides simple large-print instructions. A high contrast of the ink and paper is helpful. The use of magnification devices can also help with reading instructions and with performing skin inspection.

For older adults who have macular degeneration (e.g., blurred or loss of central vision), the therapist encourages the use of compensatory techniques during application and removal of the splint and during skin inspections. Compensatory techniques include eye scanning, head turning, and placement of the splint or hand into the field of vision.

Auditory System

Approximately 25% of older adults between 65 and 74 years of age, 50% of older adults age 75 or older, and 65% of those age 85 and older describe difficulty with hearing [American Federation for Aging Research 2004]. Hearing impairment influences verbal explanations and statements. Sometimes hearing problems can be detected during the initial interview or during splint fabrication. Therapists should not rely solely on printed information to relay instructions because some older adults may be unable to read or have visual impairments that make reading difficult or impossible. The therapist may need to use more tactile cues when positioning the person for splinting. When talking to a person who is hearing impaired, the therapist should use the guidelines outlined inBox 15-2.

Touch

Somatosensory research has demonstrated a decline in two-point discrimination with age [Stevens and Patterson 1995]. Because the decline is gradual over the life span, older adults may not be aware of their diminished sensibility. Because vision is the primary sense used to compensate for decreased tactile sensation, when both sensory functions have declined the older adult is at greater risk for compromised skin integrity.

Tactile sensation may become impaired secondary to poor positioning of older adults with limited mobility. Decreased sensation may contribute to compression neuropathies of the median or ulnar nerves. Cubital tunnel syndrome, a compression of the ulnar nerve at the elbow level, may result from constant pressure on flexed elbows while sitting in a wheelchair or from prolonged bed confinement. A well-padded elbow splint with the elbow flexed 30 to 60 degrees prevents further pressure to the nerve [Clark et al. 1998, Blackmore 2002].

Prefabricated soft elbow pads are another option. Compression of the median nerve at the wrist may be due to prolonged wrist flexion posturing or secondary to an associated medical condition, such as rheumatoid arthritis (RA) or diabetes. A prefabricated wrist splint with D-ring straps is easier to don and can be used to prevent nerve compression (Figure 15-1; and see Chapter 13 for further discussion of these conditions).

Pain

Perception of pain is variable among individuals regardless of age. A visual analog scale and careful history (including assessment of location and particular activities that increase or decrease pain) should be part of the initial evaluation.

Skeletal System

One of the most impacted body systems affected by age is the skeletal system. Osteoporosis and osteoarthritis (OA) are common diagnoses that often require splinting as part of the intervention process. Osteoporosis is a gradual loss of bone density that begins as young as age 35 [Boughton 1999]. After menopause, the rate of bone loss for women increases [Barzel 2001], and the distal radius is especially vulnerable to fractures [Bostrom 2001]. A common fracture of the distal radius is called a Colles’ fracture, which often occurs because of accidental falls [Nordell et al. 2003].

Although wrist fractures are usually treated in an outpatient setting, older individuals may at the same time fall and sustain a hip fracture, which initially requires inpatient therapy. Sustaining a Colles’ fracture can be associated with functional declines in physical performance in hand strength and walking speed [Nordell et al. 2003]. A volar wrist splint is generally indicated after removal of an arm cast or external fixator for immobilization (see Chapter 7). As the fracture heals, the splint goal may change to one of mobilization (which can be achieved by serial adjustments to improve wrist extension). It is also important to determine if there are other etiologies causing upper extremity impairments. For example, a thorough evaluation for a client referred with a wrist injury may reveal preexisting sensory loss in the digits due to compression of cervical nerve roots caused by OA. The sensory loss might otherwise have only been associated with the wrist fracture.

Another condition that affects the skeletal system is OA. Women are more frequently affected, and the initial onset typically occurs between ages 50 and 60 [Melvin 1989, Rozmaryn 1993, Hellman and Stone 2004]. Primary OA results from idiopathic or known causes. Secondary OA results from congenital joint abnormalities; genetics; infections; and metabolic, endocrine, or neurological disorders [Beers and Berkow 1999]. Most older adults have evidence of some cartilage damage [Bland et al. 2000]. Hand joints are more frequently affected by primary OA [Rozmaryn 1993, Bozentka 2002], which is characterized by enlarged distal interphalangeal (DIP) joints (Heberden’s nodes) and enlarged proximal interphalangeal (PIP) joints (Bouchard’s nodes). The nodes typically cause more discomfort in the index finger because of the demands placed on the joints during activities that require pinch. An immobilization splint for the DIP joint is a conservative measure to decrease pain (Figure 15-2). Surgical fusion may be warranted for more advanced cases.

OA of the thumb at the CMC joint is another common reason for a splint referral. Initial conservative management usually requires a hand-based thumb immobilization splint (see Chapter 8). Individuals with this condition must be educated in joint protection techniques and instructed with methods to balance activities throughout the day to break the pain cycle. As discussed in Chapter 8, there are different approaches to splinting arthritic hands. The most prevalent approach is to fabricate a removable hand-based splint to immobilize only the CMC joint.

Researchers evaluated the effectiveness of a short opponens splint (only the CMC is immobilized) compared to a long opponens splint (the wrist, CMC, and thumb metacarpophalangeal (MP) are immobilized). Researchers found that 42% of the subjects who wore the short opponens splint reported performance of ADL to be easier. Fifty-one percent of the subjects reported performance of ADL to be the same when wearing the short opponens splint. Some subjects (7%) found ADL performance more difficult while using the short opponens splint. Only 16% of subjects who wore the long splint found activities easier to perform [Weiss et al. 2000]. The researchers concluded that splinting is effective for pain reduction and helps to reduce subluxation in the early stages of OA.

Chronic flexion of the thumb MP joint, or an adduction contracture, can lead to a hyperextended interphalangeal (IP) joint. This can be conservatively treated with a figure-of-eight splint to improve stability and function of the thumb (Figure 15-3). If the older adult needs to use a walker and has thumb pain or a weak grip, a prefabricated walker splint can be used to decrease stress to the thumb (Figure 15-4).

OA may also affect the cervical spine and result in sensorimotor deficits in the hand. The therapist checks the older adult’s medical history for cervical involvement in order to distinguish peripheral nerve from cervical nerve root compression. In older adults who have multiple medical conditions, the source of decreased sensorimotor function in the hand requires careful medical evaluation.

Deformities that result from RA may be seen in older adults. However, the most common onset of this systemic condition is in women typically between the ages of 40 and 50 [Pincus 1996]. Mitt splints lined with Plastazote can be helpful for older adults who have residual painful deformities and fragile skin (Figure 15-5). Additional examples of splints for RA are included in the chapters on wrist, hand immobilization, thumb, and mobilization splints.

General Mobility

Many older people become sedentary, which decreases aerobic capacity, muscle strength, ROM, and coordination [Lavizzo-Mourey et al. 1989, Evans 1999]. The therapist should be cautious that splints do not result in unnecessary immobility or loss of engagement in activity. Among persons over age 65 living in the community, 30% fall each year [Gillespie et al. 2004]. Associated injuries include lacerations and bruising; scalds and burns; arm, wrist, hand, and hip fractures; and concussions [Lavizzo-Mourey et al. 1989, Daleiden 1990, Potempa et al. 1990, Carter et al. 2000].

The percentage of falls in institutions is even higher [Gillespie et al. 2004]. The risk for falls increases with age, with one out of two older adults over age 80 experiencing a fall every year [Crane 2002]. If a splint is out of reach, the older adult may not be able to reapply it because of difficulty with ambulation and reach. Maintaining a consistent storage location within reach and easy walking distance is important.

The splint design should be simple. The older adult may be unable to manipulate multiple straps to apply a splint by using one hand. Riveting one end of the strap to the splint or using adhesive straps prevents their removal and loss. Attached straps reduce the risk of the older adult falling while attempting to retrieve a dropped strap.

Digestive System

Dehydration, alcohol abuse, chronic disease, or poor diet in older adults may cause nutritional deficiencies. Sensory testing is carefully completed with individuals who have digestive disorders and nutritional deficiencies, including pernicious anemia, because they may also present with impaired nerve function. Poor wound healing may be the result of a poor nutritional status. The condition of the skin and nails is observed to determine appropriate materials and splint care.

Endocrine System

Diabetes mellitus (DM), a disorder of the endocrine system, is a common secondary diagnosis affecting up to 15.1% of older adults [DHHS 2003]. There are two types of diabetes. Type 1 is insulin-dependent diabetes mellitus (IDDM), with onset before age 30. Type 2 is non-insulin-dependent diabetes mellitus (NIDDM), with onset more typically after age 30 [Beers and Berkow 1999]. Individuals with long-standing diabetes have an increased incidence of other conditions that must be considered before a splint is made.

A careful sensory evaluation will help determine whether there are peripheral neuropathies in the fingers or toes. If sensation is diminished, pressure caused by a splint may not be perceived by the older adult and may lead to skin breakdown. Straps must never cause constriction, especially if there is associated peripheral vascular disease. These considerations are particularly important when someone with diabetes is referred for a foot-drop splint, a knee extension splint after a below-the-knee amputation, or a finger flexion contracture secondary to a CVA.

Individuals with diabetes are at greater risk of associated conditions [Cagliero et al. 2002] that may require splints for the upper extremity [Chammas et al. 1995]. There is an increased incidence of carpal tunnel syndrome in persons who are diabetic. Conservative management includes a wrist immobilization splint with the wrist positioned in neutral. This splint is worn at night. Stenosing tenosynovitis may occur at the first dorsal extensor compartment on the radial aspect of the wrist. This is called de Quervain’s tenosynovitis, which is managed with a thumb immobilization splint on the wrist and thumb (see Chapter 8).

Trigger finger is another form of stenosing tenosynovitis that occurs during middle age and that has an increased incidence associated with diabetes. Conservative management may include a splint to restrict MP flexion [Fess et al. 2005] to decrease inflammation in the distal region of the palm near the involved digit. The therapist may decide to (1) custom fabricate a splint (Figure 15-7A), (2) take measurements for the purchase of a custom-manufactured silver ring splint (Figure 15-7B), or (3) order a prefabricated splint (Figure 15-7C). Considerations for this decision include the availability of materials, reimbursement source, and client input.

Related posts:

Clinical Reasoning for Splint Fabrication Foundations of Splinting Splinting for the Fingers Antispasticity Splinting Splinting for Nerve Injuries Thumb Immobilization Splints

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