Transcript
josh MacDonald: I'm Josh McDonald.
Miranda Materi: And I'm Miranda Maturey and we are Hand Therapy Academy.
josh MacDonald: Let's talk a little bit about casting mo mobility to mobilize stiffness, CMMS.
Miranda Materi: Great. Yeah, that's a mouthful.
josh MacDonald: Yeah. Yeah.
Miranda Materi: And so when I think of CMMS is I think of the plaster casting, is that what we're talking about?
josh MacDonald: Yeah.
Miranda Materi: and the plaster casting, so not fiberglass casting, not splinting casting.
josh MacDonald: Right. The true CMMS, I stumbled over casting mobility to mobilize stiffness. So the the point of it is to say the parts that are moving well, we're going to immobilize those. So we're casting the mobile stuff in order to mobilize the stiff stuff. So like the classic example is the patient with the super stiff hand where they have MCP mobility, but IPs don't move.
josh MacDonald: And so you're trying to work to get that composite fist and you try to do like an intrinsic minus stretch and they got nothing. So you cast them with MCPs in extension, typically a forearm based for a little bit more stability. MCPs and extension, IPs free. I've seen it with like a dorsal hood piece just so you're not tagging those fingers on things, bumping into stuff. But then they're supposed to live their life for a week at a time in between recastings and stretching sessions to get those IPs moving and loosen up.
josh MacDonald: Typically the intrinsics are the offending muscle groups.
Miranda Materi: Right. Yeah. So I think it can be very effective, right? And there's supposed to be some healing properties with the plaster versus other materials. Um, but it's a commitment, right? And you need to have everybody on board.
josh MacDonald: Yeah.
josh MacDonald: Yeah. Yes. Everybody. So it's real hard to explain to a surgeon when they go for their four week followup, why they're in a cast again, if you haven't been super clear with the surgeon, what you're doing and they're on board with it.
Miranda Materi: Right. And if this is a condition that has come up after distal radius fracture, right? Like, I think you were telling me about a patient, why, why do they have that, you know, overfiring of their intrinsics versus the intrinsic minus position?
Miranda Materi: And, you know, are to mobilize someone that's like a distal radius fracture that's presenting like that?
josh MacDonald: So
josh MacDonald: Yeah. Yeah. And when I immobilize, am I also immobilizing some things that I don't want to like just a distal radius fracture? Well, they've got finger stiffness, but man, now I'm locking their wrist down. And so that's going to have all kinds of downstream complications too.
Miranda Materi: Yeah, so who is the ideal candidate?
josh MacDonald: Yeah. Um, I think that those who are big proponents of it would say the earlier, the better. Right. But I think, It's tough to explain to a patient who's showing some early signs of stiffness in that typically intrinsic plus position that, all right we're going to cast you early and that's going to help you move better.
josh MacDonald: Like you can explain it and they can understand it, but you have to have someone who buys in and says like, yes, I see this as a, as a valuable option, but I'm honest, like I have a patient right now who would be a fantastic candidate for it. She had a trigger finger release of all things and is now in this intrinsic plus position. And her intrinsics are tight as all get out. She's visiting us for spring training, is hanging out for a couple extra weeks. Now that spring training's over, she's going to go golf and swim and do all these things. And I said, hey, do you want to throw a cast on your hand? And she's like, heck no.
josh MacDonald: Like, that's not what I want to do. Like, all right, that's totally fine. I get that. But that's an option on the table if you want it.
Miranda Materi: Yeah. Well, and then I think it's so important for the doctor, especially if it's like a hand surgeon that's sent this patient to you for them to be on board with it too. Right. Because if something goes wrong with that cast and it rubs their ulnar styloid raw in there, you know, like, I feel like I know sometimes we just do things as part of our treatment, you know, but I feel like for this one, I always feel better if the doctor is saying, yes, let's do that.
josh MacDonald: Yeah.
josh MacDonald: Yeah. Yeah. Yeah. Anytime I'm putting someone in a cast, I want to make sure the doctor's on board with that because it, it, it's kind of, it's not overstepping bounds. It's really not. It's within our scope of practice. Absolutely. But it can definitely be perceived as, wait a minute.
josh MacDonald: I didn't want to cast them. I wanted them to to therapy to get moving and we value movement. And so having that conversation on the front end is super important that this is about mobility.
Miranda Materi: Yeah, and while you're doing it, because you know, when the patient goes in, they may not explain it exactly how you work or why we're doing it.
josh MacDonald: Yeah.
josh MacDonald: Yeah. Yeah, yeah. There aren't many times when I rely on a patient to communicate a therapy concept to the doctor. Like, it's just going to get lost in translation.
Miranda Materi: Yeah, it seems wrong.
josh MacDonald: Yeah. Yep, yep. And it's usually going to, like, when they try to explain to us, well, what did the doctor tell you? I don't know. He said I'm fine. Okay, well, give me more in information. And they don't, this it goes the other way, too. So I want to make sure I've explained things the doctor if I'm doing that with a patient.
Miranda Materi: Yeah, definitely. I think it's important.
josh MacDonald: Yeah. There are some, like... lighter versions less buy-in versions than that i've tried some in the past with mixed success i will sometimes for those patients make a like hand-based ulnar gutter thermoplastic splint that keeps mcps in extension and ips free little strap across the web first web space and around the wrist and it functions both as an exercise splint to try to do passive range of motion with mcp blocking active range of motion and then i'll tell them hey as much as you can live in this thing when you're doing your chores when you're making dinner maybe when you're working but they also it's removable and so they're going to take it off they're probably going to spend most of their time with it off not on so you definitely don't get the 100 buy-in and it's also not the plaster and the the neutral heat that comes from that and the value of the plaster itself
Miranda Materi: Right. And I've done that too, where I've done like just a cast around the MCPs, you know, to block them where, you know, they can still slide it on and off, but then, you know, really trying to say, Hey, you, for this to work, I, can you please just wear it for like four days and we'll see if your range of motion improves, you know, or until you come back to the clinic, um, because then you really don't know. Right. And then ask them to tell you how many hours they wore it for.
josh MacDonald: Yep. I've seen some devices. Usually there conferences and clinics and things. It's a little device. It's like a low jack you can put on their splint and it tracks how much they're wearing it, their dynamic splint or whatever.
Miranda Materi: Yeah.
josh MacDonald: And I think, i don't know, you're an adult. If you don't want to wear it, don't wear it. You don't have to lie to me. If you don't want to wear it, that's fine. Don't wear it. You you can make that choice and I'm not going to, I'm not going to guilt trip you about it.
Miranda Materi: Right, right. And this this is what I recommend. And you know, you write, let me know the hours and give it a chance and
josh MacDonald: Yeah. Yeah. But I do feel like when it is removable, you get, you get such small percentage of actual wear time that it's not really CMMS.
josh MacDonald: Obviously it's not the same thing. It's an exercise splint and maybe a little bit more.
Miranda Materi: Right.
Miranda Materi: Right. And, you know, there's, I guess we should tell there's courses where you can go to become trained with the casting. And then of course, if you're doing with plaster, you have to think of how am I going to get this off later?
josh MacDonald: Yeah.
Miranda Materi: Right. So you, maybe you buy the plaster. It's super cheap. You buy the foam padding underneath or the, I don't know, gosh, it's in my mind what's called the soft wrap you put on before, but then like when come back, how are you going to get this splint, this cast off?
josh MacDonald: Yeah.
josh MacDonald: Yeah. Yeah.
Miranda Materi: So. so
josh MacDonald: We just did the welcome to hand welcome to hand therapy moments. And I remember having a panic when a patient came back in, the doctor had casted him. um Oh no, i put him that's what I put him in a Delta cast.
josh MacDonald: He was a scaphoid fracture, super sketchy patient. We put him in a Delta cast and said, come back in a couple of weeks, we'll take it off. He came back like a week later and said, I spilled milk. down my arm and into the cast and it smells awful. You have to take it off. I will pay you cash to take this off and give me a new one and let me wash my hand. I could not find our cast saw.
josh MacDonald: We were super busy at the moment and I am hunting i I had every cabinet open and I could not find our cast saw. You those little Mighty Might scissors that we have? I took a forearm based thumb spiker off with Mighty Might scissors.
Miranda Materi: I
josh MacDonald: I was sweating profusely the whole time. Like I'm gonna stab this guy or I'm gonna give myself a thumb injury.
Miranda Materi: know.
josh MacDonald: I'm gonna pinch skin or something. We got it off, but get a get a cast saw. They're cheap on Amazon. Get a cast saw if you're gonna do this.
Miranda Materi: Yeah, or some really good shears and then make sure you put the cut guard underneath.
josh MacDonald: Yes, yeah, yeah, yeah.
Miranda Materi: if you're desperate.
josh MacDonald: Yeah, I have had like when we do Delta casting, sometimes I'll put the cut guard inside, like between the soft, um soft wrap and the casting.
Miranda Materi: Yeah, have a wound or something.
josh MacDonald: I'll put it in there and they just walk around with it. And I leave just a hint of it sticking out either end. So I know the path to take. So it's just they're waiting for me. So I'm not trying to fish it through scratching skin if a and risking that. Yeah, yeah, for sure.
josh MacDonald: Yeah.
Miranda Materi: And then just so everyone knows with delta casting, you can treat it like a splint. You can cut it and put straps on it where it's removable like a splint. So when we say delta casting, it can be um either used for like casting where they can't take it off or where you make it removable.
josh MacDonald: Yeah. Yeah. um And those those skills casting with plaster and casting with Delta cast are unique skill sets. And so if that's something you're going to start to pursue, if you don't already have it at your clinic, take some time to practice, get some extra material, even buy it on your own if you have to and practice at home. There's great videos out there. I think Delta cast as a company itself has good how to videos on a lot of upper extremity stuff just to get comfortable with.
josh MacDonald: the wrapping pattern of some of these splints and the working time because you put that delta cast material in the water and the clocks ticking before that role not good anymore
Miranda Materi: Yeah, and it's really an art. Once you once you have it, you've got it, but I think it takes some time to learn.
josh MacDonald: yeah
josh MacDonald: Yeah. Yeah. All right. So I don't know if everyone else is using it. Let us know what you think. If you use CMMS or not, if it's a thing you find success success with, let us know. um You can contact us on Instagram or Facebook, or you can email us at info at handtherapyacademy.com.
