1. occupational therapists and physiotherapists
Splinting for the prevention and correction of contractures in adults with neurological dysfunction
Practice guideline
for
occupational therapists and physiotherapists   
CPD Session: PowerPoint, notes and group activities
The slides and information in this CPD session can be used as a template, and can be adapted to reflect local need and priorities.
The overall aim of this resource is to support a continuing professional development session to explore the occupational therapy and physiotherapy practice guideline Splinting for the prevention and correction of contractures in adults with neurological dysfunction (COT and ACPIN 2015).
The resource comprises this PowerPoint presentation and notes which can be used for a one-hour facilitated workshop, or for individual self-directed learning.
There are some interactive activities which are intended to be used to encourage reflection on current practice and to explore some areas in more detail.
Pre-requisite materials:
Guideline document: Splinting for the prevention and correction of contractures in adults with neurological dysfunction (COT and ACPIN 2015)
Implementation tools i.e.
Audit Form.
Quick Reference Guide.
It is essential that workshop facilitators familiarise themselves with the full guideline document and implementation tools in advance.
Implementation Toolkit/CPD Session
© 2015 College of Occupational Therapists.
This PowerPoint may be copied and adapted for non-commercial use

2. Learning outcomes
To explore aspects of the practice guideline recommendations in relation to current practice.
To develop an understanding of the importance of using practice guidelines to inform practice.
To explore and develop an understanding of how to use the Audit Form for use with the evidence-based recommendations.
Slide 3 Practice question
Slide 4 Guideline objective
Slides 5-6 Methodology and recommendation grading
Slides 7 Recommendation areas:
Lower limb – ankle and knee
Upper limb – hand and wrist, and elbow
Slides List of the recommendations (Activities 1 and 2)
Slides Key steps for consideration
Factors for caution when splinting
Factors to consider when splinting would not be advised
Slide 19 Final recommendations
Slides Impact of the guideline (Activity 3)
Slide 25 Practice guideline resources
Information used in the session is taken from the full practice guideline document and the other implementation tools, particularly the audit tool.
Activities 1 and 2 can potentially be applied to any of recommendation areas. Choose the one that you think would yield as much discussion as possible by the group in order that they may take plenty of ideas away to think about.
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3. for the prevention and correction of contractures?
Practice question:
What is the evidence for the use of splinting in adults with neurological dysfunction
for the prevention and correction of contractures?
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4. Key objective of guideline
To promote best practice in the use of splinting in adults with neurological dysfunction for the prevention and correction of contractures. To assist clinicians with their clinical reasoning, an exploration of the physiological background to the development of contracture has been included in the guideline.
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5. Methodology 2. Guideline scope defined involving stakeholders
1. Guideline development group established
5. Critically appraise articles
4. Screen findings
3. Literature search
6. Development of practice guideline recommendations
7. Peer review, stakeholder and service user consultation
The College of Occupational Therapists’ guideline development process is rigorous and is Accredited by the National Institute for Health and Care Excellence.
Selection of a topic
1. Establish the Guideline Development Group
Submit a proposal
2. Define the scope and practice question(s)
3. Literature search
4. Screen findings
5. Appraisal and grading of the evidence
6. Formulate the recommendations
Write the guideline
7. Peer review and consultation involving stakeholders (includes
occupational therapists and physiotherapists as end users) and service
users
8. Ratification by the COT Practice Publications Group
Publication and Implementation
Review – within 5 years.
Stakeholder, service user and carer engagement and involvement was fundamental to the development of the guideline.
In this guideline development project, the guideline was also informed by a Delphi Survey with occupational therapists and physiotherapists, and interviews with service users (see full guideline for details).
9. Published by
COT 2015
8. Final draft approved by COT Practice Publications Group
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6. Evidence-based recommendations
Recommendations are based on the evidence available within 33 critically appraised papers.
Each recommendation is assigned:
A strength scoring 1 or 2 (Strong or Conditional)
A quality grading A, B, C or D
(High, Moderate, Low or Very Low)
Each relevant article of evidence identified from the search (database inception to April 2013) was critically appraised by two members of the guideline development group, and a quality of evidence grading subsequently determined based on that assessment.
The quality of evidence grading reflects the typical hierarchy given to study design. For example the highest level (A) reflects consistent results from randomized controlled trials, whilst the lowest (D) includes studies such as case studies or expert opinion. Higher level studies are perceived as being less susceptible to bias.
The strength of the recommendation is scored as either strong (1) or conditional (2). This is based on the benefits and risks of the evidence. A strong recommendation indicates that benefits appear to outweigh the risks for the majority of the target group, where as a conditional or suggested recommendation, means that the risks and benefits are more closely balanced or there is more uncertainty.
40% of the evidence used was derived from studies of high or moderate quality: 12% of the evidence was graded as high (A), 28% as moderate (B), 36% as low, and 24% as very low (D). All nineteen of the recommendations are graded as conditional.
Each recommendation is specific and is based on the appraised evidence. Details about the studies referenced can be found in the evidence tables section (Appendix 6) of the full guideline.
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7. Recommendation areas Lower limb
Ankle – contracture correction, contracture prevention
Knee – contracture correction, contracture prevention
Upper limb
Wrist and hand – contracture correction, contracture prevention
Elbow – contracture correction
The recommendations are based on the synthesis of the best available evidence, and in line with the scope of the guideline. It should, therefore, be noted that the guideline is not able to be fully reflective of all issues related to the correction and prevention of contractures.
Recommendations, based on the evidence, were developed for the lower limb (ankle and knee) and upper limb (wrist and hand, and elbow). These cover both correction and prevention in all examples with the exception of the elbow, for which there was no evidence found in relation to contracture prevention.
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8. Ankle: Contracture correction
Lower limb
Ankle: Contracture correction
It is suggested that ankle casts are used at end range (for people with ABI and stroke) for improving range of movement at the ankle joint.
(Booth et al 1983 [D] ABI; Carda et al 2011 [B] stroke; Lehmkuhl et al 1990 [D] ABI; Moseley 1993 [C] ABI; Moseley et al 1997 [B] ABI; Pohl et al 2002 [C] ABI and stroke; Singer et al 2003a [B] stroke and ABI; Singer et al 2003b [C] stroke and ABI; Verplancke et al 2005 [B] ABI; Yasar et al 2010 [D] stroke) 2C
It is suggested that ankle casts are applied at end range to improve
joint range of movement in conjunction with botulinum toxin A (in people
with stroke and ABI) when presenting with clinically significant spasticity
(see also RCP 2009).
(Carda et al 2011 [B] stroke; Farina et al 2008 [B] stroke; Verplancke et al 2005 [B] ABI; Yasar et al 2010 [D] stroke) 2B
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9. Ankle: Contracture correction contd..
It is suggested that adjustable ankle splints applied at end range can be
used (in people with stroke and ABI) for improving joint range of
movement.
(Grissom and Blanton 2001 [D] stroke and ABI; Lai et al 2008 [C] ABI
and stroke) 2C
It is suggested that caution is exercised when considering the use of
non-custom-made splints for the correction of contractures (at the ankle
in people with stroke and ABI) due to the risk of pressure sores.
(Grissom and Blanton 2001 [D] stroke and ABI) 2D
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10. Ankle: Contracture prevention
Lower limb
Ankle: Contracture prevention
It is suggested that ankle casts at end range dorsiflexion (in people with
acute ABI) can prevent loss of range of movement.
(Conine et al 1990 [C] ABI) 2C
It is suggested that an ankle splint can be used for preventing
the loss of range of movement at the ankle joint (in people with
stroke) when positioned at plantar grade.
(Robinson et al 2008 [B] stroke) 2B
It is suggested that caution is exercised when considering the use of
non-custom-made splints for the prevention of contractures (at the
ankle in people with stroke) due to the risk of pressure sores.
Implementation Toolkit/CPD Session
© 2015 College of Occupational Therapists

11. Knee: Contracture correction
Lower limb
Knee: Contracture correction
It is suggested that casts may be used for the correction of contracture
(in people with ABI and stroke) with the knee joint positioned at end
range of movement.
(Booth et al 1983 [D] ABI; Lehmkuhl et al 1990 [D] ABI; Pohl et al 2002
[C] ABI and stroke) 2D
It is suggested that short-duration cast application (1–4 days) may
produce a lower complication rate than longer-duration cast application
(4–7 days).
(Pohl et al 2002 [C] ABI and stroke) 2C
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12. Knee: Contracture prevention
It is suggested that casts at end range of movement at the knee joint
may be used (in people with stroke and ABI) for the prevention of
contracture.
(Pohl et al 2002 [C] stroke and ABI) 2C
It is suggested that caution is used when considering casts for acute
patients (with ABI and stroke) and at lower levels of arousal because of
possible risks of secondary complications (e.g. pressure areas).
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13. Hand and wrist: Contracture correction
Upper limb
Hand and wrist: Contracture correction
It is suggested that splints should not be used routinely for the
correction of range of movement but may be beneficial in selected
cases (in people with stroke and ABI).
(Abdolvahab et al 2010 [D] stroke; Amini et al 2009 [D] stroke; Beaty
and Murphy 2013 [C] stroke; Bürge et al 2008 [A] stroke; Charait 1968
[D] stroke; Doucet and Mettler 2013 [C] stroke; Fayez and Sayed; 2013
[C] stroke; Lannin et al 2007a [A] stroke; Lannin et al 2003 [B] stroke
and ABI; Leung et al 2012 [A] stroke and ABI; Shamila et al 2011 [D]
stroke) 2B
Activity 1
Prior to showing the next slides 14 and 15, ‘Hand and wrist: Contracture prevention’, Activity 1 can be carried out.
Tell the group that the next section deals with contracture prevention for the hand and wrist.
Split the group into pairs and ask them to discuss what they think would be the likely recommendations covered in this section. Prompt them to think about examples of their own best practice in this area.
Following discussion, ask the pairs to share 1-2 examples with the group; you might want to record on a flipchart the groups’ suggestions to refer back to these ideas when you show the recommendations.
On completion of the activity present recommendations which are on slides 14 and 15.
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14. Hand and wrist: Contracture prevention
Upper limb
Hand and wrist: Contracture prevention
It is suggested that splints should not be used routinely to prevent loss
in range of movement at the wrist and hand (people with stroke and
ABI) but may be beneficial in selected cases.
(Basaran et al 2012 [B] stroke; Bürge et al 2008 [A] stroke; Harvey et al
2006 [A] stroke and ABI; Lannin et al 2007a [A] stroke; Lannin et al
2003 [B] stroke and ABI; Shamila et al 2011 [D] stroke) 2B
It is suggested that splints in conjunction with botulinum toxin A (in
people with stroke and ABI) may reduce spasticity as a component in
preventing loss of range of movement in selected cases.
(Carda and Molteni 2005 [C] stroke and ABI) 2C
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15. Hand and wrist: Contracture prevention contd..
It is suggested that electrical stimulation of wrist and finger muscles
combined with a custom-made wrist and hand splint should not be used
routinely to prevent loss in range of movement (in people with stroke or
ABI).
(Leung et al 2012 [A] stroke and ABI) 2A
It is suggested that a custom-made wrist and hand splint should not be
used routinely to prevent the increase (or worsening) of spasticity (in
people with stroke and ABI).
(Basaran et al 2012 [B] stroke; Bürge et al 2008 [A] stroke; Jung et al
2011 [C] stroke; Leung et al 2012 [A] stroke and ABI; Shamila et al
2011 [D] stroke) 2B
It is suggested that a splint in a neutral wrist position may be beneficial
(for people with stroke) for prevention of hand pain associated with joint
malalignment.
(Bürge et al 2008 [A] stroke)
Activity 2
Once the recommendations have been presented, the questions below can be used to encourage the group to talk about the recommendations in relation to their own suggestions:
Do they cover the best practice examples they identified?
Why might these not be the same?
You may want to refer back to the methodology of creating evidence-based guidelines and how it is based on the published literature - evidence-based practice guidelines support practice, but can only reflect current evidence.
It may be important to emphasise that just because their own examples are not covered, this does not necessarily mean they are not best practice.
Occupational therapists and physiotherapists also need to adhere to other service standards, consider the service user’s perspectives and apply their clinical judgement and reasoning when providing interventions for adults with neurological dysfunction who have, or are at risk of contractures.
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16. Key steps for consideration when splinting adults with contractures
(COT and ACPIN 2015 p40)
While developing the guideline document, the clinical experience of occupational therapists and physiotherapists across the UK was drawn upon through the use of the Delphi method survey (Black 2006, Hasson et al 2000) over a period of four months.
There was a lack of consensus among therapists as to when to include splinting for contracture management in clinical practice. This is perhaps not unsurprising given the multitude of biopsychosocial variables that can influence a personalised approach to therapy intervention. There was strong consensus however, about when not to include splinting as a clinical intervention.
The table on this slide, and Boxes 8.1 and 8.2 on the next two slides, outline the key considerations for and against splinting as part of a comprehensive goal-directed treatment and management plan for contracture.
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17. (COT and ACPIN 2015 p41) Implementation Toolkit/CPD Session
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18. Following presentation of slide 18, the Audit Form can now be used to further consider the recommendations for hand and wrist contracture prevention.
Ask the pairs/small groups to discuss one of the hand and wrist contracture prevention recommendations (give each group a different recommendation), sharing their current practice in relation to the recommendation and the audit criteria, and how they would evidence this. If the audit criteria are not current practice then they should look at what an action plan might consist of to implement the criteria for that recommendation.
Provide the group with an opportunity for feeding back from the activity.
(COT and ACPIN 2015 p41)
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19. Elbow: Contracture correction
Upper limb
Elbow: Contracture correction
It is suggested that casts at end range are used (for people with ABI
and stroke) for improving range of movement at the elbow joint.
(Hill 1994 [C] ABI; Lehmkuhl et al 1990 [D] ABI; Moseley et al 2008 [B]
ABI; Pohl et al 2002 [C] ABI and stroke) 2C
It is suggested that short-duration cast application (1–4 days) may
produce a lower complication rate than longer-duration cast application
(4–7 days).
(Pohl et al 2002 [C] ABI and stroke)
The final two recommendations relate to elbow: contracture correction.
No studies were identified that looked at the use of splints in the prevention of contracture at the elbow
Activity 3 – can be carried out before moving onto the next slides
Divide into groups again and ask them to consider what they think the impact of these guidelines will be for themselves, their service managers, the users of their service, and the commissioners of services.
Obtain feedback from the groups before going through the suggested impacts on slides
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20. Impact of practice guideline for you: the practitioner
Challenges / affirms your current practice.
Informs your practice.
Provides evidence to support your practice (completion of Audit Form).
Provides a vehicle for you to justify your practice.
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21. Impact of practice guideline for managers
Articulates the need for splinting as a useful adjunct in the therapist’s toolbox in the prevention and correction of contractures.
Provides a structure to audit the work of occupational therapists and physiotherapists within the service to improve service quality.
Provides a vehicle for justifying service provision.
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22. Impact of practice guideline for commissioners
Provides evidence of the need for occupational therapy and physiotherapy for adults who have or are at risk of contracture from neurological dysfunction and require splinting as one part of a comprehensive goal-directed neurological rehabilitation or management programme.
Provides guideline recommendations developed by a NICE Accredited process.
NB: Highlight the significance of the guideline having been developed by the COT Guideline Development process which is NICE Accredited, e.g.
Practice guidelines developed using the College of Occupational Therapists’ NICE Accredited guideline process are clearly visible in search results on NICE Evidence.
Guidelines developed via a NICE Accredited process are eligible for consideration as evidence in the development of NICE Quality Standards.
Provides robust evidence-based recommendations that can demonstrate to commissioners the benefits of occupational therapy and physiotherapy for the community on whose behalf they are commissioning services.
Further information at:
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23. Impact of practice guideline for service users
The recommendations reinforce the fundamental importance of the service user perspective.
In being adopted by services and occupational therapists, the guideline should improve the consistency and quality of intervention for users of services.
Gives assurance that practitioners use the available evidence to support interventions.
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24. “This one is sporty looking… put on a pair of shorts and you look like you have had a sports injury”
“. . . in hospital I was really skinny, when I got out I put on weight and the splint was too tight and had to stop wearing it.”
“Until the serial casting started, getting my left heel down was always a struggle”
“. . . can’t wear nice shoes, having to buy two pairs, one pair bigger to get the splint in; it’s expensive and embarrassing, I wouldn’t want to take a splint to a shop.”
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25. Practice guideline resources
College of Occupational Therapists and Association of Chartered Physiotherapists in Neurology (2015) Splinting for the prevention and correction of contractures in adults with neurological dysfunction: practice guideline for occupational therapists and physiotherapists. London: COT.
Audit tool
Quick Reference Guide
Feedback form
The full practice guideline together with implementation resources can be accessed from the College of Occupational Therapists website: and ACPIN website:
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