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NeuroRehabilitation 00 (2012) 1–12
Casting for upper limb hypertonia: A
retrospective study to determine the factors
associated with intervention decisions
Kathy Kuipersa,∗ , Laura Burgerb and Jodie Copleyc
Department of Occupational Therapy, Princess Alexandra Hospital, Woolloongabba, Queensland, Australia Strive Occupational Rehabilitation, Queensland, Australia
The University of Queensland, School of Health and Rehabilitation Sciences, Division of Occupational Therapy, Queensland, Australia
Abstract. Aim: To determine if a Clinical Reasoning Protocol assisted occupational therapists to consistently choose casting as an intervention in the context of moderate/severe upper limb hypertonia and possible contracture. Methods: Sixty-four intervention decisions (including strength/movement training, splinting and/or casting) were drawn retrospectively from initial t reports at a community clinic. Associations between identiﬁed upper limb characteristics, stated clinical aims and intervention decisions were analysed using logistic regression. Results: Casting was statistically signiﬁcantly likely to be chosen in the presence of moderate (CI95 1.88–39.80, p = 0.01) or severe hypertonicity (CI95 1.34–135.98, p = 0.03), and if the stated clinical aim was to reduce hypertonicity (CI95 2.01−18.10, p = 0.001) or contracture (CI95 1.31–12.73, p = 0.02). When reports included both these clinical aims, there was a highly signiﬁcant association with the decision to cast (CI95 5.67–9.13, p = 0.001). Where casting was indicated as appropriate, but not chosen as an intervention, mitigating factors included older age (70–95 years), limited personal support and a clinical aim of comfort/hygiene maintenance.
Conclusion: Occupational therapists using the Protocol consistently chose casting as an upper limb intervention for adults who demonstrated moderate/severe hypertonicity, contracture or limited functional ability. Prospective research is required to determine intervention outcomes following use of the Protocol. Keywords: Hypertonicity, spasticity, upper limb, casting, clinical decision
1.1. The upper limb following brain injury
Hypertonicity is deﬁned clinically as increased resistance to movement. It arises from changes in neural excitability (spasticity) and in the biomechanical proper∗ Corresponding author: Kathy Kuipers, Acting Advanced Clinician and Team Leader, Geriatric and Rehabilitation University, Department of Occupational Therapy, Princess Alexandra Hospital, Woolloongabba, 4102, Queensland, Australia. Tel.: +61 7 3176 5008; Fax: +61 7 3176 7207; E-mail: Kathy email@example.com. gov.au.
ties of muscular and connective tissues [19,48]. Hypertonicity in the upper limb is common for children and adults with acquired brain injury secondary to cerebral
palsy, traumatic brain injury or stroke. In combination
with other consequences of brain injury, for example
muscle weakness and learned non-use, hypertonicity in
the affected upper limb may lead to reduced capacity
for performing controlled reach, grasp, manipulation
and release of objects [5,16,19].
General patterns of altered upper limb movement and
posturing are recognised as occurring following brain
injury , nevertheless the combination of underlying impairments and consequent performance characteristics are variable for each person [19,53]. Individual
ISSN 1053-8135/12/$27.50 2012 – IOS Press and the authors. All rights reserved
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K. Kuipers et al. / Casting for upper limb hypertonia
upper limb presentation differs according to the cause,
size and location of the brain lesion , and to the distribution and severity of positive and negative symptoms of the Upper Motor Neuron Syndrome (UMNS) .