Transcript
josh MacDonald: Hi, I'm Josh McDonald.
Miranda Materi: And I'm Miranda Maturi and we are Ham Therapy Academy.
josh MacDonald: We get all kinds of questions from people, usually people studying for the CHT exam, about the week's test or the week's scale. And so we wanted to spend a little bit of time going over that just so that people are familiar with what it is and you've heard about it, and then give you some information on how to maybe use it in your clinic on a regular basis.
Miranda Materi: Yeah, so this scale was um done by Ken Flowers, and it's basically saying like, which splint should I use and when or do they need a splint like and how to objectively determine that I think, over time as clinicians, we kind of develop our own clinical reasoning, but this is a great objective scale to have.
Miranda Materi: And i think it's especially handy if you're a newer grad and actually in for us to write it kind of validates what we're doing.
josh MacDonald: Yeah. Yeah, absolutely. Yeah. We, we tend to push these things all off on new grads, but the experienced therapists need to be reminded or get out of our rut a little bit or just validated like, Hey, okay, I'm on the right track.
josh MacDonald: Yeah.
Miranda Materi: Yeah, and I think it helps insurance show, right? Based on the weeks, life, I'd we scale this as indicated.
josh MacDonald: Yeah.
Miranda Materi: think it's another clinical point.
josh MacDonald: Yeah. Cool. All right so let's go over the actual like official week's tests, the what you're supposed to do, there are four different steps, and then we'll talk about maybe a variation we do in the clinic. So step one, they walk in the door, you take a cold measurement, or basically they're just walking in for their session, you just measure the affected joint or joints without any treatment.
josh MacDonald: Step two, you place the stiff joint in a heat modality with active motion. So that's gonna be something like fluidotherapy or whirlpool, excuse me, for 20 minutes,
josh MacDonald: followed immediately by 10 minutes of the joint held at max end range tension with tolerable overpressure. So you take them out of the movement heat and put them into something, maybe the same modality, but now they're wrapped or stretched at end point of the joint.
josh MacDonald: immediately after you take them out, you take the preconditioned measurement or you've done some stuff and then take a measurement again. And then you compare the measurements before the heat and then after this 30 minutes of heat, 20 and 10, and the outcome gives you the idea of,
josh MacDonald: No splint is needed if they have a 20 degree change or more. They just need more work on modalities and stretching. If it's about 15 degrees, you should do a static splint.
josh MacDonald: If they improve about 10 degrees, then a dynamic splint, and that's one with rubber bands or an elastic tension. And if they improve less than five degrees, they're more likely to need either a static progressive or a serial static where I put it in the heat, I shape it to them on tension, and then each time they improve, I reform that static load splint to their new endpoint range.
Miranda Materi: Awesome. Okay. but So my first question would be, especially if I was reading this in clinic, I'd be like, well, what if I don't use a fluido?
josh MacDonald: Okay.
Miranda Materi: Most people don't use a fluido or I don't have a whirlpool.
josh MacDonald: Right. And 30 minutes in heat. Some of my patients come in and say, I got to leave in 60 minutes and I'm spending 30 minutes in a heat modality. That's a lot of not productive and not billable time for them. So we modify it. Right.
josh MacDonald: um In our clinic, what I usually do to identify, like, what's the best splint option for them? I measure them preheat. I put them seven minutes or seven and a half or something like that in normal at rest heat.
josh MacDonald: ah We use moist heat packs. And then I'll do seven or eight more minutes in end range, like flexion wrapping. Or if it's elbow, I'll put them with the weight of the heat pack, extending the elbow or something like that. So they're on tension.
josh MacDonald: And then I'll measure them after that total of 15 minutes of heat. It's a modified version. It's not quite the same, but it's what can work in our clinic.
Miranda Materi: Awesome. Yeah, I would think that would be that probably needs to be published. Not that any of us time have time, but like we we're really going to truly do it. right I mean, that's but that's what we do the best we can, I guess.
josh MacDonald: Yeah. Yeah. And, and it's, it's tough to do the exact right thing. And, and it doesn't always logistically fit in our schedule of our clinics, but the modified version that I have to say, if I'm documenting, I did a modified version of the week's test and that's what justified they needed the splint.
josh MacDonald: If I'm documenting, it's still good to test the effectiveness of heat on them and see what results are, but know that it's not the official week's test.
Miranda Materi: Right, yep, you definitely need to say a modified version of some sort.
josh MacDonald: Yeah. So let's talk about what these splints look like if I'm going to pick one of these splints as an option. um So Miranda, talk us through what a static progressive splint is.
Miranda Materi: Yeah, so I'll just use an example of a PIP joint contracture. What you're going to do is you're going to make a static splint. So basically there's no movable parts on there, it's static. But when you form it, you're going to put the joint on stretch. So you're using a low temperature thermoplastic or even if you were doing something, um whatever material you're using. But basically a low temperature thermoplastic, you heat it up, you put it on stretch, and then there ah you're holding them at that end range for up to six hours, or maybe it's something they sleep in. And then a week later, you maybe heat up the material.
Miranda Materi: So that's the part where it's static progressive. It has something where you're progressing it each week.
josh MacDonald: Yeah. um So the dynamic progressive is, excuse me, the den the dynamic splint is going to be something that has like a rubber band tension on it. And so that's going to be more like What we would do if I'm trying to get that finger to flex and I put on a volar-based splint and then I put on a sling on the finger and it's pulling down, but it's got rubber band tension on it so that as their tissues relax into it, there's still a progressing load, whereas a static progressive is like a monofilament.
josh MacDonald: So it's a static load. And when their tissues relax, they then have to advance the tension on it. So one is static, one is dynamic because it continues to provide some amount of tension as they relax into it.
Miranda Materi: Um, so it might be more serial static.
josh MacDonald: Yeah. Yeah.
Miranda Materi: Sorry, guys.
josh MacDonald: So, okay. That's okay. So we'll go back. Let's go. Let's revisit.
Miranda Materi: Let's go back and clarify that. And I think this is a common thing, right? Like I think what static progressive and I think that would still be considered sta static progressive because there it's still a static splint that you're progressing.
josh MacDonald: Yeah. Yeah.
josh MacDonald: Yeah. So a serial progressive um is the same base thermoplastic. Like if I'm doing an elbow splint and I'm trying to get them into more elbow extension, so I'm giving a nighttime volar elbow splint and I make one, put it on their elbow and get them to like 90 degrees, minus 90 of extension.
josh MacDonald: When they come in next time, that's gotten easy to put on. So I put the material back in the heat, put it back on them, but now I can get them to minus 80 degrees. so they're doing better. That's serial progressive.
Miranda Materi: Okay, yes.
josh MacDonald: a
Miranda Materi: so Sorry, i go ahead.
josh MacDonald: Yeah, that's okay. So a static progressive version is I've got some load. So ah a good option might be like a Dynas, a Dynas splint version where I've got a cuff on both forearm and upper arm, and I've got some clickable or some torsion line or something that provides a load.
Miranda Materi: Turnbuckle.
josh MacDonald: Yes. A turnbuckle where I can rotate that and it puts the elbow on tension. but then it's static. So if their tissues relax, they have to re-advance that turnbuckle.
Miranda Materi: Okay, so think that sorry so I think this is great because it's static progressive versus serial static.
josh MacDonald: i
josh MacDonald: Yes, yes.
Miranda Materi: So those are two different things.
josh MacDonald: Yes, two different things. So it depends on how they're moving. If they're moving pretty darn well after the heat and excuse me and they're moving 20 degrees or more because the heat, they don't need anything.
josh MacDonald: if they're moving in that maybe 15 degrees more because of the heat, then they might benefit... excuse me, they might benefit from a splint that is like a static progressive. A dynamic splint is the tension with the rubber bands or some kind of adjustable, and that's going to be about 10%.
josh MacDonald: And then if they're really just not moving like five degrees or less because of the heat, that's probably like we talked about a couple of weeks ago, capsular end feel. Then they need a serial static or maybe static progressive. Something little bit more rigid load um just so they have time to adjust to it. The rubber bands just can't overcome that kind of load. So need something a little more sturdy and hardy.
Miranda Materi: Okay, yeah. So an example of this would be like a plaster serial cast.
josh MacDonald: Yes. Yes.
Miranda Materi: or the splint that I described initially.
josh MacDonald: Yeah. Yeah. So it is a confusing topic and the terminology is also a little confusing because things all end up kind of common and and similar in things, but
Miranda Materi: And i just wonder how many people use those interchangeably, probably a lot.
josh MacDonald: yeah. Yeah. And, and,
Miranda Materi: Now we know.
josh MacDonald: and confused and serial static, progressive dynamic, progressive. Yeah. It's, it's all very confusing, but know that you can find that article from Fowler very easily from 2002. Um, let me pull it up again. it is, um,
josh MacDonald: It's a proposed decision hierarchy for splinting the stiff joint with an emphasis on force application parameters. That's the name of Flowers 2002 article if you want to look it up. Or you can also find information on the modified weeks test on our handout, our PDF that's on our membership platform.
josh MacDonald: um If you have questions about that, you can certainly reach out to us. Ask questions, info at handtherapyacademy.com. Or you can find us and our membership information on handtherapyacademy.com.
Miranda Materi: Right, and I think there's also a blog post that we wrote about it too, so it's available for free as well.
josh MacDonald: Yeah. Yeah.
Miranda Materi: So check those out.
josh MacDonald: yeah
