Orthotic positioning of the hand is both an art and a science.
A variety of upper extremity conditions may benefit from a soft orthosis.
Soft orthoses are preferred by many patients and this may improve wearing compliance.
There are a variety of materials and fabrication techniques utilized for soft orthoses.
Orthotic positioning of the hand is both an art and a science. The definition of orthotic , according to the Merriam-Webster dictionary, is “a device for supporting, immobilizing, or treating muscles, joints, or skeletal parts.” Depending on the condition, the goals, and the patient’s requirements, an orthosis made of soft materials can be the treatment of choice. Soft orthoses can be flexible, semiflexible, or rigid, depending on the properties of the material and/or the combination of materials used. The type and combination of materials used are limited only by the therapist’s imagination. Various products are available and are constantly being developed. Some examples include neoprene, Neoplush, Breathoprene, foam, FabricForm, Plastazote, Velcro, leather, Coban, and Molestick. The activities of daily living (ADLs) requirements of the patient must be considered in the design of the orthosis because many patients find soft orthoses more easily tolerated. Soft orthoses may actually improve orthosis-wearing compliance as well as facilitate the patient’s return to work. A study by Callinan and Mathiowetz found that patients with rheumatoid arthritis preferred soft orthoses and were more likely to follow their prescribed treatment regimen with their use. Henshaw and colleagues applied a semiflexible wrist support for injured workers who were medically cleared for light strengthening, work hardening, and return to work ( Fig. 126-1 ). In their questionnaire, 92% of the patients found the semiflexible support device useful during work-related and nonwork-related activities.
It is important to remember that some patients may not be able to tolerate some of the materials used in soft orthoses. Neoprene, as noted by Stern and colleagues, can cause allergic contact dermatitis and miliaria rubra (i.e., prickly heat) in some patients. Latex allergies now affect 1% to 6% of the U.S. population, stressing the importance of screening for allergies before orthosis application. Many of the materials used by therapists are currently available in latex-free options. Patients should be instructed to discontinue orthotic use if symptoms occur.
This chapter highlights examples of soft orthoses that have been applied to specific conditions commonly seen in the clinic. This is by no means a complete list, but is meant to give the reader guidelines and suggestions for soft orthosis application. Step-by-step fabrications of two common soft orthoses are included in the online figures.
Common Conditions for WhichSoft Orthoses Are Used
Carpal Tunnel Syndrome
Patients with carpal tunnel syndrome can have higher intratunnel pressures, resulting in increased pressure on the median nerve. The position of the wrist changes the configuration of the carpal tunnel, affecting these pressures. These increased pressures result in symptoms affecting the median nerve distribution. Weiss and colleagues reported the lowest carpal tunnel pressure at approximately 2 degrees of extension and 2 degrees of ulnar deviation. Patients who have symptoms at night are often fitted with a prefabricated wrist orthosis to keep the wrist in a near-neutral position. Many commercial wrist orthoses are a combination of metal stays, fabric, and Velcro. Care must be taken in fitting the orthosis to adjust the metal stay to ensure that the wrist is placed in a near-neutral position. Due to the proximal migration of the lumbricals into the carpal tunnel during digit flexion, some clinicians also recommend including the digits in the night orthosis. Apfel and colleagues recommend limiting motion of the digits by 75% in the orthosis based on their study. Patients whose symptoms are aggravated with repetitive wrist movement may have difficulty wearing a rigid orthosis at work that can interfere with hand activities. A semiflexible support that prevents the extremes of range of motion (ROM) may be beneficial in these cases. The degree of limited ROM varies with the type of orthosis applied. A study by Palmer and colleagues defined functional ROM of the wrist as 5 degrees of flexion, 30 degrees of extension, 10 degrees of radial deviation, and 15 degrees of ulnar deviation. A study by Ryu and colleagues found that functional ROM was 40 degrees of wrist flexion and extension and 40 degrees of combined radial and ulnar deviation. An orthosis that allowed this degree of motion would allow the patient to engage in many activities of daily living. The degree of ROM to be limited by the orthosis should be dependent on the response to the orthotic intervention as measured by the patient’s symptoms. A circumferential orthosis by Henshaw and colleagues (see Fig. 126-1 ) uses a combination of athletic tape and Coban to partially restrict motion. Metal stays from commercially available orthoses can be removed for a quick semiflexible orthosis ( Fig. 126-2 ). Removing only the dorsal stay allows more wrist extension, and removing only the volar stay allows more wrist flexion. Schultz-Johnson developed a neoprene wrist orthosis ( Fig. 126-3 ) with a pocket for a thermoplastic stay. The stiffness of the orthosis can be determined by the rigidity of the thermoplastic stay inserted. A circumferential orthosis made from a thin fabric/thermoplastic material called FabricForm can also allow partial ROM during activities ( Fig. 126-4 ) and be custom fit to the patient. Exposure to vibration has been shown to increase carpal tunnel symptoms. Antivibratory gloves ( Fig. 126-5 ) and/or tool adaptations can be helpful in decreasing these symptoms.
Postoperatively, some patients have persistent pain, aching, or incision site sensitivity. This has been referred to as pillar pain. A soft orthosis has been used to protect the tender incision site with padded gloves during activities and at night to secure silicone or mineral gel sheeting to soften a scar ( Fig. 126-6 ). Cupping the hand by decreasing or bridging the distance between the thenar and hypothenar eminences can be comforting to some patients by using a soft orthosis ( Fig. 126-7 ) or Kinesio Tex Tape ( Fig. 126-8 ). Pain relief with this technique may be due to supporting the somewhat altered position of the carpal bones after release of the transverse carpal ligament.
Cubital Tunnel Syndrome
The second most common nerve entrapment in the upper extremity is ulnar neuropathy or cubital tunnel syndrome. The cubital tunnel is narrowed with elbow flexion, increasing ulnar nerve symptoms in some patients. Rigid (low-temperature plastic) night orthotic positioning in slight elbow flexion (30–35 degrees) and slight pronation was found by Hong to decrease ulnar nerve symptoms in a study with 10 patients. Soft orthotic positioning in this condition has been used to increase patient comfort and compliance with night orthotic wear. Soft orthoses from several commercial manufacturers as well as a folded, rolled bath towel were tested by Apfel and colleagues, and all limited elbow flexion to less than 90 degrees in their cadaver model. Custom soft elbow orthotic positioning with a foam material called Plastazote can be applied circumferentially to the elbow. It is secured with Velcro, and the foam promotes comforting neutral warmth during night wear. During ADLs, many patients with cubital tunnel report posterior elbow tenderness at the ulnar nerve. Some patients report decreased pain and sensitivity by wearing elbow pads for protective padding. Some clinicians treat this condition by having the patient wear the padding dorsally during ADLs and volarly at night to restrict elbow flexion.
de Quervain’s Tenosynovitis
Tenosynovitis of the first dorsal compartment involves inflammation of the tendon and sheath of the extensor pollicis brevis and abductor pollicis longus musculotendinous units. Conservative treatment includes immobilization of the wrist and thumb. Some patients may object to wearing a rigid orthosis and may prefer to attempt treatment with a soft orthosis. A reduction in stress to the inflamed tendons may be achieved with a semiflexible orthosis ( Fig. 126-9 ), especially if it can provide some degree of dynamic thumb extension by means of reinforced seams and stays. This may reduce the load of the inflamed tendons and partially restrict extremes of motion. This may be helpful for musicians in whom this inflammation develops due to the positions involved in playing an instrument and the degree of repetition. As symptoms improve, a custom-sewn Lycra sleeve can provide gentle compression and light support for repetitive activities ( Fig. 126-9C ). A more rigid orthosis, or perhaps surgery, may be needed if the patient does not respond to a trial of soft orthotic positioning. Patients in a later phase of treatment, who are weaning off their rigid orthoses, may also benefit from a semiflexible support.
Lateral and Medial Epicondylitis
Inflammation, degeneration, and/or pain at the origin of the wrist extensor muscles near the lateral epicondyle has been referred to as tennis elbow or lateral epicondylitis . Golfer’s elbow or medial epicondylitis refers to inflammation, degeneration, or pain at the origin of the flexor–pronator muscles at the medial epicondyle. In both cases, wrist and/or elbow orthotic positioning has been used to rest the structures and decrease pain. Some patients reject rigid orthoses in favor of smaller forearm bands available from several manufacturers. These soft forearm bands are thought to disperse or change the forces to the involved tendons. Care must be taken to avoid a possible nerve compression, especially of the radial nerve, with bands applied too tightly. It is important to monitor the patient’s symptoms after application of a forearm band. The band should be discontinued if symptoms increase, and more rigid orthotic positioning of the wrist and/or the elbow may be needed.
Carpometacarpal Joint Osteoarthritis
Many patients with thumb carpometacarpal (CMC) osteoarthritis (OA) demonstrate metacarpal adduction with subluxation of the CMC joint, metacarpophalangeal (MCP) joint extension or hyperextension, and interphalangeal joint flexion. Orthotic positioning for pain reduction and joint protection in this condition would include gently positioning opposite that of the potential deformity in patients who are passively correctable. This includes MCP joint flexion, metacarpal abduction, and stabilization of the CMC joint ( Fig. 126-10 ). Some patients request a flexible option for daily activities. Some of the prefabricated orthoses, in an attempt to abduct the metacarpal, can actually increase MCP joint extension, which could aggravate the potential deformity. Leonard recommends orthoses that are custom made of neoprene ( Fig. 126-11 ) to provide the appropriate forces. The Comfort Cool prefabricated orthosis ( Fig. 126-12 ) was reported by Weiss and colleagues to decrease pain and reduce first CMC joint subluxation and was preferred by patients over the short opponens thermoplastic orthosis. A radiograph with the orthosis in place during tip pinch can assist in determining whether the soft elastic forces have been applied correctly, opposite the developing deformity ( Fig. 126-13 ). Step-by-step instructions for making a soft OA orthosis are included online.
Rheumatoid Arthritis: MCP Joint Ulnar Deviation and Palmar Subluxation
Nighttime rigid orthotic wear is commonly used in the treatment of rheumatoid arthritis to place the joints in gentle alignment. Callinan and Mathiowetz found that patients preferred soft orthotic positioning at night with a -inch volar thermoplastic insert ( Fig. 126-14 ) to immobilize the wrist, resulting in increased patient compliance. Soft orthoses worn for activities can allow easier manipulation of objects and are preferred by many patients when rigid orthoses tend to limit use of the hand. Gilbert-Lenef designed an orthosis fabrication ( Fig. 126-15 ) that uses Durable II strapping material, which improves alignment and decreases the MCP joint ulnar deviation position. Other materials that can be effective for this orthosis include Neoplush, which is a sheet of neoprene with a nylon lining on one side and a Velcro hook-sensitive pile plush on the other. This facilitates adjustable digit alignment and decreases the need to sew on strap attachments. A prefabricated neoprene alternative is commercially available ( Fig. 126-16 ) in a hand- or forearm-based option. It is important to remember that the digits should not be forced into alignment with these soft orthoses. Forcing digits can cause tilting of joint surfaces instead of smoothly gliding into proper position, as described by Brand. Tilting of joint surfaces can cause additional damage and bring about the wearing away of joint surfaces (see Chapter 95 ). Simple stretch gloves worn at night have also been found to be helpful in decreasing morning stiffness and pain.