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Splinting and Rheumatoid Arthritis
510 Plays6 months ago
Miranda and Josh talk about splinting for RA.
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Transcript
Introduction and Setup
00:00:06
Speaker
I'm Josh McDonald and I'm random material and we are hand therapy academy.
Understanding RA and Splinting Techniques
00:00:11
Speaker
And so today we're going to be talking about rheumatoid arthritis. Um, we're going to be learning about what do we do in treatment for it? What type of splinting do we use? And so let's just start. I think of course it depends on the severity of the case, but Josh, you have an RA patient that walks in, um, for an evaluation and treatment. They were sent by the hand surgeon. What are you doing first?
00:00:34
Speaker
Um, so I'm looking at how significant the deformity is and trying to set some realistic expectations with them.
Evaluating Patients and Splinting Strategies
00:00:41
Speaker
Um, we'll, we'll focus on splinting this one. Maybe we'll do another one on some of the turbine ideas, but I'm going to focus on. What I can do to help mitigate the collapse shift to deformities that are happening because of RA, we know it's an autoimmune disorder. And so the auto immune system is attacking the synovial fluid. Those joints are breaking down. I can't restore.
00:01:02
Speaker
the mechanics and the anatomy of the joint, but I can hopefully keep it from breaking down further. So one of my starting points is do we need a nighttime resting hand splint? Forearm-based, kind of a standard MCPs in like 15 to 20 degrees of flexion, IPs in gentle flexion.
00:01:20
Speaker
fingers well
Advanced Splinting Techniques
00:01:21
Speaker
spread. And we can talk about how we choose to do that on different splints just to keep that nighttime resting position not in a fist where we get a further ulnar deviation because of radial collateral ligament loss. Yeah, I think that's definitely a concern for these patients. We know that there's common tendon ruptures that occur with them. And so when you're doing the resting hand splint, are you adding in finger spacers? What are some things you're doing to ensure that the
00:01:50
Speaker
How do you keep those fingers from drifting, right? When they're severe, it's like, how do you get those back in neutral alignment? Yeah. So it kind of depends on what materials you have in your clinic. I am a fan of putting finger spreaders in there, not max abduction, but I want a gentle kind of, like we talk about the cascade of the fingers, I want them to be at a gentle rested open position. So I'll often just out of,
00:02:15
Speaker
what's simple and easy is take some of our adhesive back memory
Customizing Splints for Patient Needs
00:02:18
Speaker
foam. We get it in a sheet and I'll just cut little wedge shapes and sticky those down to the splint in between the fingers. So I'll set their hand in it and when I'm forming the splint I'll kind of manually spread their fingers so I get a wide finger pan and then when their hand is in it I just
00:02:34
Speaker
kind of like measure visually or with a tape measure, the size of the little wedge I would need to go in between each finger, cut that, stick it in between their fingers, and then I know it's where it is. Saves me that customization when I can just put it in after I've made the splint and I already have that spread in place. How about you? What do you do to spread fingers?
00:02:54
Speaker
Um, there's a couple of different things I do and it depends on the splint material that I have access to and what we're using. So if I, for some reason choose a perforated one, which in Arizona gets super hot. So sometimes we'll be like, well, let's give her a perforated one. It's the middle of summer. Um, I might use elastomer or otoform and I'll make the splint first and then kind of get an idea of the size of it. And then I will use my own hand in the splint to make the troughs of where I want the fingers to go.
00:03:23
Speaker
And I think it works well with the perforated material because the easy form or the odor form goes down into the perforation. So it sticks in there. And you know, sometimes if it's comfortable and they like it, then I'll go ahead and glue it. And the other thing I've done is taken the Orphe tape with Orphe cast, the wider stuff, I think it's like two inch and then making and troughs. And then, you know, we're taking my heat gun and
00:03:49
Speaker
making sure those edges are really smooth. So I think there's lots of options in whatever supplies you may have, and if one thing doesn't work, then try something different.
00:04:00
Speaker
I've used elastomer otiform a lot of times on burn patients and those kinds of things and you're right, it squishes through those perforations well and then it kind of mushroom it out the other side so it kind of grabs. You mentioned gluing it. I've tried super glue and can't get it to stick. It almost like breaks down the otiform. What glue do you use to get it to stick to our splinting material? Do you remember?
00:04:22
Speaker
I think it was like a gorilla glue that we had in our office for something else. And I like, I think a part of it is, and I'm sure you did this, but getting the sheen off the material so the glue can stick. Um, but you're right. You can't just use super, you know, sometimes we'll have super glue to put hooks on people's fingers and stuff like that. And that doesn't always work. It was like some sort of like adhesive we had for some project we were doing.
00:04:45
Speaker
Another option for spreading them is while I'm making it, if they can hold a pretty decent spread with their fingers, if they're not super far along and they can kind of find that position even if I place them and they can stay there, I will come from underneath and press my fingers up between theirs.
00:05:04
Speaker
And then that shapes the thermoplasts between their fingers. And I do it gently, so I'm not imparting any aggressive lines or changes of direction. But kind of pressing that up, and that will give me the ridge between the valleys of their fingers. So I can do a way to start that. And then if I need something more dramatic, then I can add foam, some of the blue Orphacast tape, that kind of stuff.
00:05:26
Speaker
Yeah, lots of good ideas. I think there's different things, advantages to like hygiene with foam and the elastimier, you know, sometimes you're like, well, we can change this out or give you a couple of different trough options.
00:05:38
Speaker
Yeah, yeah.
Anti-Ulnar Drift Splints and Comfort
00:05:40
Speaker
OK, so another splinting option is the owner anti-owner drift splint. There's different versions of them. Orphacast has one that is a template that they have. They got tons of good videos on it. You can find templates of it. I've made that before. That's more of a sturdy rigid once the material is stabilized. You've got North Coast cells, one that's made out of neoprene, and that's a thicker
00:06:04
Speaker
I would say probably like a three to four millimeter thick material. And then I think they call it comfort preen, which is a thinner material and it's blue on one side and white and grippy on the backside. Much thinner, lighter weight. Have you used any of those? What do you think about those? Yeah, I actually really like those. I think they're comfortable and they give gentle support.
00:06:25
Speaker
Um, I think you and I were talking one point about, well, if you're putting so much pressure on getting the alignment, you know, getting the pulled back over into a neutral position or all that radial drift and you put more pressure on the wrist. I think, um, you had mentioned that. Um, so I do think, yes, that might be the case, but if it's not that aggressive or if they have a, like a lot of our patients have wrist fusions too, right? They might have.
00:06:48
Speaker
or some procedure done where we might not really be influencing the risk kinematics as much as we would have as someone that didn't have it done. But I think it's a case by case basis. I really like those, especially the light ones. How about you?
00:07:04
Speaker
Yeah, the article you're talking about was an article by Janine Beasley. She's at Grand Valley. It's actually my alma mater, so I love every time I see her name on something. And it was, I think, 2008, something like that. And she talked about how if you're correcting too much, because it's a zigzag deformity, if you're correcting the middle of the zigzag, you may cause problems down at the CMC joint of the wrist.
00:07:21
Speaker
Like we talked about earlier, I'm not looking to reverse things. I'm looking to prevent further decline. And so my idea is not using that strap to wrench things into place and pull them back to neutral. It's just a little light support that makes things maybe a little less painful when they come into flexion and too much tension and it's too hard to flex the fingers.
00:07:42
Speaker
If I'm putting that thicker neoprene material, it can add a lot of bulk. So on patients who are bigger, stronger, I'll go ahead and use the thicker material or if they like that neutral warmth. On our slider patients or smaller, I'll use the thinner comfort preen from North Coast. I do have to be careful though because the white, like a rubbery, grippy backing can be tough on skin integrity if there's like a lateral shift there. So that can kind of, some of our patients, very thin skin can be an issue.
00:08:09
Speaker
Yeah, definitely. And I think that's why it's a case by case. Sometimes we have like samples once in our clinic, we just have a box of sample ones and we say, Hey, try these on. Does it feel good? You know, you can wear this for 20 minutes, you know, do some tasks while you're sitting here.
Final Recommendations for RA Splinting
00:08:22
Speaker
feel it intuitively. I think if things feel good for people, then they're one, they're going to wear it and it's probably good for their joint. If it's hurting them, then you're probably, you know, hurting their joints more than anything because especially with RA, right? Their joints are already pretty fragile. We don't want to be forcing them to do things that are not natural or, you know, putting them in a position that they can't tolerate.
00:08:45
Speaker
Yeah. And any, with all these patients like visit one, I say, if there's anything that hurts, if there's anything I give you that doesn't feel helpful, nevermind doesn't hurt. If it doesn't feel like it's taking us the right direction, you tell me and we'll stop because last thing I want to do is add layers that are going to add discomfort or challenge onto a structure that's already compromised. Yeah, definitely.
00:09:06
Speaker
So we're fans of nighttime resting, like forearm-based resting hand splint with a neutral resting flexion position, even like making it over like a ball sometimes. If I have a large enough ball and they can't find that pattern with their hand, I'll just set their hand in the soft splinting material on that ball shoot to get that. So that general resting position, possibly anti-only dress splints if it's the right fit without too much aggression. But that's kind of our go-tos for splinting for RA.
00:09:34
Speaker
Perfect. So for more information, you can email us info at hand therapy academy or check out our website, which is hand therapy academy.com.