Both occupational therapists and orthotists play a major role in the evaluation and treatment of children with central nervous system (CNS) dysfunction and peripheral nerve injuries with involvement of the hand and the wrist. Treatment for wrist instability, weak wrist/hand function, muscle imbalance, or abnormal muscle tone may require a wrist extension orthosis to support or restrict certain movements. Other problems may occur that inhibit the use of the hand, such as inability to rotate the forearm to orient it while reaching, decreased ability to extend the fingers to release an item, and poor wrist extension to achieve prehension during tabletop fine motor tasks. Poor hand function often negatively affects multiple aspects of daily life including self-care, play, educational activities, or leisure activities.1
Children with obstetric brachial plexus palsy (OBPP) or cerebral palsy (CP) may present with upper-limb functional limitations secondary to muscle weakness and imbalance, often presenting with poor alignment of the wrist and the hand. A child with OBPP is typically found to have muscle imbalance and weakness versus a child with CP who may exhibit heightened abnormal tone or spasticity and muscle weakness. Both children display compromised movement of their hand for functional use. A child with CP hemiplegia often positions the wrist in flexion while the thumb and the fingers are flexed. The position is generally influenced by spasticity or abnormal tone. For a child with OBPP with active wrist and finger flexors but weak or absent extensors, the pattern of use may be similar to the problems encountered with a child with CP hemiplegia. The active finger flexors for the child with CP and OBPP cannot be used efficiently because of the inability to stabilize the wrist into extension while the force of the flexors is transmitted across the wrist.
Motor and sensory impairments are commonly seen among children with CP and OBPP. They may demonstrate poor in-hand manipulation skills, reduced strength into wrist extension, inability to use thumb-finger prehension, and decreased bimanual coordination. In the long-term, positioning the affected wrist into flexion can lead to overlengthened wrist extensors and tightness of the wrist flexors. This can eventually cause reduced range of motion, potential muscle contractures, and muscle imbalance. For the child with CP hemiplegia, the increased abnormal tone of the fingers and the thumb flexors may inhibit the ability to fully extend the fingers and lead to weakness. In the case of OBPP, the final outcome is often increased weakness. In either situation, custom dorsal or palmar-based wrist-hand orthoses (WHOs) are often used to help position the wrist-hand complex in optimal alignment for use. A WHO that terminates proximal to the carpometacarpal points will allow for functional finger flexion. Although this finger flexion allows for grasp, patients often experience an absence of intrinsic or extrinsic extensor muscles that makes it difficult or impossible for them to release objects placed in their hand.
In contrast to WHOs, well-fitting elastomeric orthoses such a Dynamic Movement Orthosis® (DMO) provide proprioceptive input to the wearer through direct contact and compression of cutaneous tissues, which is believed to enhance sensory awareness.2 The cutaneous stimulation from the direct skin contact, deep pressure, and stimulation of mechanoreceptors is thought to enhance joint positioning sense and body awareness.3–5 As the deep pressure receptors provide information to the proprioceptive feedback system, positional limb and body awareness improves and the child is able to direct movement and specific muscle activation more accurately.
Unlike traditional rigid orthoses, DMOs are fabricated from a stretchable, breathable Lycra® (D.M. Orthotics Ltd, Cornwall UK) material, which allows the wearer to actively move the affected body part while still receiving the needed support. To fabricate a DMO glove, numerous measurements of the patient’s upper limb are obtained (Figure 1). Careful attention must be taken to ensure that the measurements accurately reflect the anatomy while resting in a functional position. During the fabrication process, elastic panels are incorporated into the orthosis as specified by the orthotist. When the orthosis is properly donned, these panels are placed under tension, providing a directional pull that encourages proper biomechanical alignment. The panels of the DMO glove can assist with wrist and finger extension, thumb stability, and forearm supination or pronation. In addition, an external removable thermoplastic wrist support can be incorporated onto the palmar side of the glove to assist with positioning the wrist if the Lycra wrist extension panel extension does not suffice.
Two children were included in this case study. Written consent through the LaRabida Children’s Hospital policy was obtained from the parents before the study began. Videos were taken of the children as they completed the Melbourne Assessment of Unilateral Upper Limb Function (Melbourne Assessment). Each child was evaluated at baseline (T0), 1 month of wearing the DMO (T1), 3 months of wearing the DMO (T2), and 6 months of wearing the DMO (T3). The subjects were each measured and fit with a single custom DMO glove that extended from immediately proximal to the interphalangeal (IP) joint of the thumb and proximal interphalangeal (PIP) joints of digits 2–5 to approximately one-half inch distal to the elbow at the time of fitting (Figure 1). Each orthosis had elastic panels to induce wrist extension, thumb abduction, and forearm supination or pronation as well as a zippered forearm opening to facilitate donning.
Initially, the subjects wore the DMO glove for 1–2 hrs a day and gradually worked up to 6–7 hrs for the next 7 days. Once the subjects were able to tolerate the DMO for 6–7 hrs, they wore the DMO glove daily and removed before going to sleep. They continued the daily schedule of wearing the DMO glove for a period of 6 months. Both subjects continued with active occupational therapy during this 6-month period to improve/maintain the active functional use of their hand.
DATA COLLECTION AND INSTRUMENTS
The Melbourne Assessment evaluates 16 functional tasks by scoring the quality of unilateral upper-limb motor function involving reach, grasp, release, and manipulation.6 The assessment is a criterion-referenced test used to measure quality of upper-limb function and is videotaped and independently scored by a trained rater. Percentage scores (possible range, 0–100) were calculated, with higher scores reflecting greater unimanual capacity of the impaired upper limb. Both subjects completed the Melbourne Assessment at each session.
Subject 1 (S1) is a 5-year-old boy diagnosed with left hemiplegia CP. He presented with left spastic hemiplegia and was referred to occupational therapy to improve his movement and control of his left upper limb. Active, controlled movement of his left arm was limited because of his increased muscle tone and overall weakness. Although he was able to actively isolate flexion and extension of his elbow, he could not actively supinate his forearm. Subject 1 was able to reach overhead and forward, with the humerus internally rotated, the elbow flexed, and the forearm pronated. In addition, he lacked wrist stability, which caused his hand to be maintained in flexion and ulnar deviation. He also had difficulty grasping objects because his thumb was positioned in flexion, and he was unable to fully extend his fingers (Figure 2). While wearing the DMO glove, S1 displayed increased wrist extension and improved functional thumb position. Subject 1 was able to flex and extend his fingers with his wrist positioned in neutral (Figure 3). By the 6-month mark, S1 was able to actively extend his wrist against gravity without the DMO, although he was not able to take resistance.
Subject 2 (S2) is a 3.6-year-old boy diagnosed with right OBPP. He was born full-term with a birth weight of 9 lbs 14 oz. His mother reported that he had right shoulder dystocia with a diagnosis of right brachial plexus, initially low Apgar score, and mild respiratory distress. At the age of 8 months, he had surgery for nerve exploration and removal of neuromas. He was referred to occupational therapy at 2 months of age to improve his right arm and hand function.
At the age of 3.6 years, S2 could actively flex his arm overhead to 110–150°. Using a manual muscle test scale (1, trace; 2, poor; 3, fair; 4, good; and 5, normal), S2 exhibited an upper trapezius strength of 3 of 5 and deltoid strength of 3 of 5. The active biceps measured 3 of 5, and triceps measured 3 of 5. His wrist extensor strength was 2− of 5; finger extensors, 2− of 5; and thumb extensors, 2 of 5. Wrist flexor and finger flexor strengths were 3 of 5. He demonstrated improved strength around his shoulder girdle, and scapula strength was 3 of 5. The subject was able to pick up objects with his right hand and subsequently maintain a weak grasp. When he wanted to release an item that was placed in his hand, he did so by flexing his wrist to loosen his grip (Figure 4). Unlike S1, S2 had difficulty maintaining his wrist in a functional position while wearing his DMO glove, so we incorporated a one-eighth–inch modified polyethylene (MPE) palmar-based orthosis to provide additional support (Figure 5). By the 6-month mark, S2 had increased his wrist extension from a 2− of 5 to a 2 of 5.
The data collected from the Melbourne Assessment show that performance of unilateral activities in both subjects improved significantly while wearing the DMO glove (Table 1). Using univariate repeated-measures analysis of variance (ANOVA), the data show that there is a functional improvement over time (p = 0.007). The SAS 9.2 (Cary, NC, USA) was used for the analysis.
It has been reported that long-term wear of Lycra-based arm orthoses, when combined with goal-directed training, can result in improvement of selected movements during functional tasks in children with CP.7 Although limited in scope, the patients described in this study demonstrate that the DMO glove may improve the use of the affected upper limb in select children with CP and OBPP, as measured by the Melbourne Assessment. Our results show that activities requiring grasping or releasing of objects improved with the use of the DMO glove. For example, during task 9 of the assessment, which involved rotating a colored cube in a variety of directions, both subjects were initially unable to demonstrate isolated movement of the thumb and the fingers along with forearm supination. By 6 months of use, both demonstrated the ability to turn the cube over using their fingertips and thumb while working on a table surface. Similarly, both subjects exhibited increased ability to grasp small pellet-type objects between their fingers and place them inside a small plastic film container.
Our study suggests that daily use of the DMO and consequent improved alignment of the wrist-hand complex may facilitate better functional use of the limb. Use of the orthosis may allow the overlengthened antagonist muscles to shorten, enabling the extensors of the wrist and the fingers to contract more effectively. In the case of our subjects, it appeared that the position of the fingers at the metacarpophalangeal (MCP) joints was closer to end range, which helped assist active extension and ultimately to perform functional activities. By the 6-month period, there was measured improvement in both active wrist and finger extension for each subject. Consequently, their movement became more efficient, which may be suggestive of an increase in hand control. Both subjects also appeared to be more aware of their affected hand during bimanual play and self-care tasks such as tying a shoe (Figure 6). It is also likely that the improved muscle balance may have enhanced the outcome of the strengthening program throughout the 6 months. Perhaps, these observations are due to the proprioceptive input created by the tight fit of the orthosis; however, more research is needed in this area.
Although it is difficult to get valid statistics with only two subjects, given multiple time points, it is possible to run an ANOVA with repeated measures. Further studies involving larger subject groups are needed to more accurately determine the effectiveness of these types of orthoses for children diagnosed with CP and OBPP. The use of more subjects will facilitate the development of evaluation protocols used to determine who the best candidates for this device are. Children with dense sensory and motor loss or with muscle grades at trace and zero are not appropriate for the DMO, as well as children with significant spasticity representing considerable increase in tone with difficulty in performing passive movement.
When considering the use of any orthosis, thoughtful consideration must be given to determine which device or devices will best help achieve the patient’s goals. An understanding of basic musculoskeletal biomechanics will provide a strong foundation for rational decision making related to the design of the orthosis. In addition, when working with pediatric patients, a major key to a successful outcome is family support and compliance monitoring.
Our study suggests that compression-type orthoses such as the DMO are therapeutically helpful tools that may improve functions essential for daily living in individuals with sensorimotor deficits. Although we incorporated a rigid external support onto the palmar aspect of one of the DMOs, we feel that these extra supports should be used only for those children with poor wrist extensors, when the DMO alone is unable to support the wrist. It is also important to consider the use of a rigid orthosis for nighttime use that will help maintain the wrist-hand complex in an alignment that will prevent contractures and overlengthening of the muscles.
In the case of our two subjects, daily use of the glove in combination with therapy led to improved facilitation of fine motor control for daily activities. The use of a DMO for a child’s upper limb can improve his/her ability to participate in play and activities of daily living. We recognize the limitations of this case study due to the small sample size, and we plan to further investigate the use of such orthoses with studies that include larger and more diverse patient populations in hopes of identifying various diagnoses that may benefit the most.
The authors thank the Moira Tobin Wickes Orthotics Program at the Ann & Robert H. Lurie Children’s Hospital of Chicago for providing the orthoses; Sanjeev Akkina, MD, for his statistical assistance; and the patients and their families who participated in this study.
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Keywords:© 2014 by the American Academy of Orthotists and Prosthetists.
cerebral palsy; hemiplegia; obstetric brachial plexus palsy; orthosis; splinting; hand splint; compression garment