Cherry Kilbride and colleagues offer a summary of a guideline on splinting to prevent and correct contractures in adults with neurological dysfunction.
The full guideline was published earlier this year.
The first joint practice guideline for both occupational therapists and physiotherapists on splinting to prevent and correct contractures in adults with a neurological condition was published in January. In compiling it, the College of Occupational Therapists (COT) and the Association of Chartered Physiotherapists in Neurology (ACPIN) used a process that has been accredited by the National Institute of Health and Care Excellence.
The guideline draws together theoretical underpinnings, available evidence, service users’ perspectives, and 19 recommendations for practice. It should be used alongside therapists’ expertise in applying the evidence to practice and the context of the specific circumstances, environment and the needs of service users. The guideline does not replace the need for clinical reasoning and skills’ development.
Why do we need a new practice guideline?
Previous guidance in this area was physiotherapy-specific, out-dated, and has been withdrawn from circulation (ACPIN 1998). The need for the new guideline was supported by a national online survey of occupational therapists and physiotherapists working in neurology. Splinting for contracture management was the most commonly cited reason for both professions (Kilbride et al. 2013).
The new guideline promotes clarity of terminology in practice. Splinting is defined as the process of applying a prolonged stretch through the application of a range of devices, most commonly a splint or a cast. Specificity of terms is essential when evaluating this intervention in the future. The new guideline promotes a more in-depth consideration of muscle physiology, biomechanical and neurological factors underpinning the rationale of splinting (section 3 of the guideline).
Why is contracture management important?
- Contracture is a common secondary complication of weakness and paralysis following nervous system damage, and is defined as a limitation in passive range of joint movement. The presence of features like spasticity can also play a role in the loss of range of movement. Contracture formation is complex and multi-factorial and who gets affected and why is not yet understood.
- Decreased range of movement can lead to a loss of function, both active and passive. Active function is the performance of a functional task by the active movement of the individual’s affected limb, such as using a fork to eat. Passive function (also referred to as ‘ease of care’) is when a task is carried out by the individual using their unaffected (or less affected) limb or by someone else, such as a carer (or by a carer and affected person working together).
- Contractures are costly to the individual and society. It is estimated that inpatient treatment and surgery for a single contracture costs about £18,000 (http://bit.ly/1Nw2GNP). Conservative approaches to preventing and managing contractures are needed, including splinting where appropriate.
- Occupational therapists and physiotherapists, as members of the wider health and social care team, play a key role in managing long-term neurological conditions. As part of a comprehensive, goal-directed rehabilitation or management programme, splinting can be a useful tool in preventing and correcting contractures.
- Functions, active or passive, share a common aim to contribute towards the achievement of an individual’s wider participation in society.
- To achieve this goal, change and/or maintenance is required at the level of the body structure and function in order to reverse, prevent or minimise the risk of contracture. fl
- Dr Kilbride led the guideline core development group, whose members were Dr Stephen Ashford, Tess Baird, Dr Karen Hoffman and Joanne Tuckey
- To find out more about the CSP professional network titled the Association of Chartered Physiotherapists in Neurology (ACPIN), visit www.acpin.net
- For a quick reference version of the guideline, visit http://bit.ly/1jLmlQx
- Splinting for the prevention and correction of contractures in adults with neurological dysfunction: Practice guideline for occupational and physiotherapists, from the College of Occupational Therapists and ACPIN http://bit.ly/1OQUqv5
Resources freely available
Obtaining guidance evidence is essential; dissemination and implementation resources are freely available from www.acpin.net and www.cot.co.uk
- A PDF copy of the splinting guideline document.
- A quick reference guide lists the recommendations and indicates their strength and the quality of the evidence leading to their development.
- A continuing professional development session including ready made PowerPoint slides.
- An audit form provides a template for individual therapists or services to audit and review their current interventions against the splinting process.
Further templates and guidance available for planning treatment and management, which are free to download, include:
- Key steps for consideration when splinting adults with contracture: a 7-stage review to assist with clinical reasoning.
- Identified factors for caution when splinting.
- Factors to take into consideration when splinting would not be advisable.
- Section on outcome measures for active and passive function.
- A patient information sheet.
- A splint and cast wearing and monitoring timetable.
AuthorDr Cherry Kilbride, senior lecturer, department of clinical sciences, Brunel University London
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