Use of neuromuscular electrical stimulation and a dorsal wrist splint to improve the hand function of a child with spastic hemipareisis.

[Carmick C. Use of neuromuscular electrical stimulation and a dorsal wrist splint to improve the hand function of a child with spastic hemiparesis. Phys Ther. 1997;77:661-671.]

Key Words: Cerebral palsy, Dorsal wrist splint, Electrical stimulation, Hand function, Spasticity.

Children with spastic cerebral palsy have difficulty with motor control and frequently use ineffective movement patterns. Some movements are stereotypic, without the variation needed for a specific task. These children may have difficulty in isolating specific muscles, or they may not be able to find a needed muscle. In children with upper-extremity involvement, the thumb is often flexed tightly in the palm, resulting in limited and ineffectual movements.[1] Excessive wrist and elbow flexion and forearm proration do not allow manipulation of objects. Release is typically slow, with excessive wrist flexion instead of extension, due to the inability to extend the fingers and wrist at the same time. The wrist flexion mechanically assists finger extension due to the tenodesis effect of the extensor digitorum communis muscle as the wrist drops into flexion.[1] Movement limitations of the wrist, thumb, and fingers may lead to decreased muscle length and contractures, and then to increased muscle tone and increased resistance to passive stretch, with decreased function.[2-5]

The upper motoneuron (UMN) syndrome is associated with positive and negative features. Spasticity (velocity-dependent increase in tonic stretch with exaggerated tendon jerks) along with exaggeration of reflexes are considered to be positive features. Muscle weakness and loss of motor control are considered to be negative features. In the past, spasticity was considered to be the most disabling phenomenon of movement. Currently, many researchers[6,7] consider the negative aspects of the UMN syndrome to be more disabling. Function does not appear to be directly related to muscle tone, but a high correlation between function and strength has been found.[5] The child needs to have just enough strength to complete the task.

Traditional management of spasticity advised strengthening the nonspastic muscles and inhibiting contraction of the spastic antagonists for fear that strengthening spastic muscles would increase spasticity.[8] It was assumed that if spastic muscles were strengthened, spasticity would increase and, on the other hand, if spasticity were decreased, function would improve.[8] Studies on spasticity are challenging these assumptions. Sahrmann and Norton[9] have suggested that subjects with spasticity have a primary motor problem with prolonged recruitment of the agonist and delayed cessation of the antagonist and that spasticity is not the major problem. Dietz and Berger[3] found that mechanical properties rather than motoneuronal activities are responsible for hypertonia. Spasticity has thus been found to have both biomechanical and neurological aspects. Spastic muscles have been shown to be weak muscles.[5,10,11] Results of rhizotomy surgery have shown that decreasing spasticity does not result in an increase of function.[12] O'Dwyer et al[13] reported that the use of biofeedback as a training aid to decrease spasticity in the triceps surae muscle while sitting at a computer did not result in improved gait. It has been pointed out in a review by Bohannon[14] that subjects with neurological disability often lack needed muscle strength, and studies on strengthening spastic muscles did not show increases in spasticity, but there was increased function.[14-17]

Neuromuscular electrical stimulation (NMES) is used as an adjunct to physical therapy to increase strength, range of motion (ROM), motor control, and coordination and to temporarily reduce spasticity.[18] Studies on the effect of NMES on spasticity and function have shown varied results. Neuromuscular electrical stimulation has been used most often on the antagonist to the spastic muscle to produce a reciprocal relaxation effect, but it has also been used directly on spastic muscles for the purpose of fatiguing them.[18] Alfieri,[19] following the traditional thinking, expressed concern that only weak and not spastic muscles should be stimulated. A tendency toward decreasing spasticity resulted in some studies with NMES applied to the agonist of the spastic muscle.[19,20] Hines et al[21] used NMES on the extensor digitorum communis muscle and the ulnar nerve in subjects with spastic hemiplegia. They used sufficient amplitude to cause active finger extension. However, reciprocal relaxation of the finger flexors did not occur; instead, increased activity was found in the spastic finger flexor muscles.

Dimitrijevic and Soroker,[22] using a mesh glove with built-in electrodes, stimulated both finger flexors and extensors in two subjects who had no volitional movement after a cerebrovascular accident. After using NMES, the subjects showed markedly diminished spasticity not only in their finger flexors but also in their biceps muscles. Wrist movement increased, and traces of volitional finger flexion and extension were found. The subjects also had increased ROM in all joints of the upper extremity and reported less pain in their shoulders. Their study was similar to this case report in that both finger flexor and extensor muscles were stimulated and the subjects were not asked to relax. The NMES studies described were not conducted with the same methods or protocols. The outcomes were varied and may reflect the differences in protocol.

Neuromuscular electrical stimulation may be used while the subject sits and waits for the treatment to be over or while the subject is engaged in an activity or task. Recent research in motor learning has shown that if exercise is done in connection with a desired activity or task, there is more chance for carryover to a desired goal.[23,24] Studies of the use of NMES with and without task-specific activities have shown that there is no carryover except in the position facilitated.[25-27] For carryover to occur, it is theorized that the practice must be task specific with variations and with the individual doing some problem solving of the task.[23,24] This case report describes a task-specific physical therapy approach using NMES and a dorsal wrist splint to aid upper-extremity function.

Case Description

The subject was a boy with spastic cerebral palsy and right hemiparesis due to a stroke at birth caused by sporadic oxygen deprivation and meconium aspiration. At age 6.7 years, his physical therapy program was changed from a neurodevelopmental therapy (NDT) approach to a dynamic systems, task-specific motor learning model that included NMES. He received physical therapy for 10 sessions over a 6-week period. One result was that he was able to release his grasp on an object, albeit slowly, without pulling the object from his right hand. He also learned how to use his right hand to hold objects for manipulation by his left hand. The initial program has been described in a previous case report.[28] Physical therapy was not continued after the initial trial period because the parents hoped to find a local therapist. Following a year without treatment, due to their inability to find a local therapist who was experienced in NMES, the child returned to my clinic for physical therapy only; occupational therapy was not restarted.

Function After 1-Year Absence From Physical Therapy

The child returned at age 7.7 years to work on improving hand function. During his 1-year absence from physical therapy and occupational therapy, he enjoyed doing push-ups and bicycle riding. On his return, a manual muscle test (MMT)[29] revealed that he had gained strength in the right triceps brachii and anterior deltoid muscles. Previous MMT grades for the elbow were Good for flexion and Good-minus for extension. Previous MMT grades for the shoulder were Poor for flexion, Fair-plus for extension, and Fair for lateral (external) rotation. Active elbow supination lacked approximately 10 degrees. Functional reaching had been difficult because he substituted flexion with shoulder medial (internal) rotation and adduction. Elbow extension in the supine testing position was in the Good to Normal range. Right shoulder flexion strength was in the Good to Good-minus range, as complete ROM was not always obtained against resistance. Left shoulder flexion was in the Normal range.

A sensory evaluation was not done. Brown et al[30] found that sensory tests of children with hemiplegia did not differentiate between the two hands and were age dependent but that the right and left hands could be compared by a test of hand function. This child had obvious differences between the right and left hands. Figure 1 shows the child at age 8 years as he was trying to place a hand on his opposite shoulder. He did not use the right hand as much as he had near the end of the initial 10 sessions. When the need arose, he would hold an object against his body with the right forearm so that the left hand could manipulate the object. This child did have awareness of light touch, but a stereognosis test was not given because he could not grasp or move an object with his right hand.

[Figure 1 ILLUSTRATION OMITTED]

After the year without physical therapy, the child was no longer able to actively extend the wrist. A trace contraction could be felt sometimes when much effort was used and the physical therapist positioned the hand. The child held the right hand with the wrist in marked flexion. He continued, however, to use the right hand as a helper by placing an object that needed to be held into the right hand with the left hand. Release was very difficult and often not possible unless done with wrist flexion. When placing the hand on an object, the metacarpophalangeal (MP) joints and wrist were flexed, as shown in Figure 1. The thumb was often flexed in the palm, with excessive extension at the distal joint.

Grasp was crude because there was no control of the fingers and thumb. The web space was tight. There was no true opposition. Lateral pinch (thumb and index finger) was used. He lacked the ability to separate the fingers and hold objects with the thumb and first two or three fingers (skill fingers). When trying to hold items with the skill fingers, the ulnar fingers would extend and at times interfere with picking up an item from a table. He could hold small or thin objects against the side of the index finger with the side of the thumb as long as the wrist was in flexion. He was not able to use a three-jaw-chuck grasp. The MP joints often extended when he was trying to extend the thumb for grasp, thus making opposition impossible. There were no in-hand manipulation skills.

Intervention

The child was ambivalent about trying to achieve better hand function. He called the right hand "a dead hand" and preferred to ignore it. A reasonable goal was needed to let him know that there would be an end to physical therapy. The physical therapy goal was for the child to learn how useful a functional wrist extension, at least to neutral, combined with opposition and distal pinch could be. If he achieved these skills, I felt that there would be carryover for other hand functions. In-hand manipulation was not approached because it was not known how much increased function would be achieved. The child's goal was to attain the ability to tie his shoelaces. Shoelace tying is a useful, functional, age-appropriate activity that involves two hands. It was not known how much function could be achieved, so this skill was selected as it does not require in-hand manipulation, speed, or flawless hand function. The child, the parent, and the physical therapist agreed on this goal with the understanding that when it was achieved, physical therapy would stop.

Suggestions for physical therapy often came from Carr and Shepherd[31,32] and Ada and Canning.[33] Although written for adults, the therapeutic suggestions can be used or adapted for children. Neuromuscular electrical

stimulation was used as an adjunct to these suggestions. Two dual-channel NMES units(*) with remote triggering switches (so that each channel can be operated independently) were used for the right hand. Electrode placement is shown for a left hand in Figure 2. One unit was used to alternate finger flexion and extension by the use of one or two remote switches, and the other unit was used to facilitate wrist extension. Muscles were stimulated at various times during functional activities and exercises, depending on the activity and the child's ability at that moment. The activities and exercises are discussed below. Muscles were often stimulated for a maximum of 15 minutes, then different muscles were stimulated, depending on need. If the child was manipulating a toy and needed help maintaining wrist extension, the remote switch was pressed for as long as 15 seconds. As many as four muscle groups were stimulated at appropriate times during the activity. At those times, one of the parents would assist with one remote switch. During reach and release, finger and wrist extension was facilitated. During grasp, finger flexion with wrist extension was facilitated.

[Figure 2 ILLUSTRATION OMITTED]

The timing cannot be as exact as with a normal anticipatory motor response and was sometimes delayed or at times premature. Neuromuscular electrical stimulation was always used during tabletop activities. A small handheld, battery-operated vibrator([dagger]) was often used at the start of physical therapy to help facilitate specific muscles as the child was asked to activate them a few times without a task, just to test his awareness of individual muscle control. Experience has shown that after a few weeks of applying NMES to a specific muscle, the vibrator can be successful as a quick assist to help the child find the needed muscle. The flexor carpi ulnaris muscle was not stimulated due to the strong ulnar deviation. The intrinsic muscles of the hand also were not stimulated because he had a Good lumbrical muscle grade and some active abduction and adduction of the fingers.

Because the child was familiar with NMES, the settings used on the stimulators were mainly those that he had experienced. The amplitude was always set to his tolerance, as it has been found that increased function can occur with low amplitudes, with the maximal amount determined by the child's tolerance.[28,34] According to Rang et al,[35] children with cerebral palsy have thin, weak muscles, possibly due to little voluntary use. Thus, it is not expected that NMES will often produce a visible sustained contraction and be comfortable. The ramp or rise time was set at the shortest setting (ie, 0.5/1s), as he tolerated an immediate stimulation. The pulse width was fixed at 300 microseconds. An asymmetrical waveform was used because the muscles of the forearm and hand are small. When the remote switch was not used, the on and off times were set at 15 seconds. Usually, a rate of 35 pulses per second (pps) was used. When trying to stimulate a muscle that had not been stimulated previously, or when trying to find a difficult muscle (ie, a muscle in which contraction was very weak even with NMES), 7 pps was used in order to be able to increase amplitude with tolerance and obtain a visible or palpable contraction. A problem occurred when trying to stimulate the extensor indicts proprius muscle. If the pulse rate was set at 35 pps, the index finger would strongly and uncomfortably flex unless the amplitude was almost off. Therefore, a pulse rate of 7 pps was initially used, and the pulse rate was gradually increased to 10 pps. Because of the difficulty with the index finger, NMES was also used to stimulate finger flexion on the skill fingers and extension of the index finger. This stimulation seemed to help the child maintain index finger extension. After several months, it became possible to increase the pulse rate to 35 pps at a low amplitude.

Initially, 5.08-cm (2-in) NeuroAid carbon electrodes([double dagger]) were used and cut to fit the child's body size, as shown in Figure 3. I later switched to Uni-Patch Encore Plus electrodes,([sections]) as they conform better to small body parts. The Uni-Patch 3.18-cm (1.25-in) round electrode was used at the active placement, and the Uni-Patch 5.40 X 3.18-cm (2.125 X 1.25-in) rectangular electrode or a 5.08-cm NeuroAid electrode was placed on the inactive site. These thinner electrodes also fit under the splint (described later) more easily than do thicker carbon electrodes. The active electrodes were placed as close to the motor point as possible.

[Figure 3 ILLUSTRATION OMITTED]

At the beginning of each weekly physical therapy session, parent and child described and demonstrated hand function of the previous week. It was important to know whether hand use appeared to improve or regress to help evaluate the physical therapy of the previous week. Shoelace tying was not introduced until basic skills had been learned because it was felt that the child could learn to tie the shoelaces while using wrist flexion and lateral pinch.

Because motivation plays an important role in motor learning, the child selected activities for the session. The physical therapist then decided the order of activities. The upper extremities are normally used mainly for reaching, grasp, and manipulation; weight bearing is not their main function in a 7-year-old child. However, after a long car ride to physical therapy, large motor activities often were practiced to help him become less stiff from so much sitting. Some of these activities would have been used eventually regardless of the car ride in order to use reaching, grasp, and release with a gross motor activity. These activities were done with and without upper-extremity weight bearing and without NMES where wires would interfere. The focus was on shoulder and trunk ROM and strength. The various activities included ball gymnastic games in a prone position, swinging prone in a hammock, and reaching for objects to throw with one hand while controlling the swing with the other hand on the mat. A few times, the child also used a standard swing with the chains held in each hand. At first, the chain was held in the crook of the right arm, and he was not able to pump the swing by himself.

Fine motor activities focused on grasp and release. The child's thumb was so stiff and tight that he could not do opposition without assistance. Passive, active-assistive ROM, and resistive exercises with graded, manual resistance were given where possible to the wrist extensors, finger flexors and extensors, and thumb muscles. The exercises were done both with and without NMES. The finger flexors were spastic, but they were also weak and needed to be strengthened. Normally, the planter-flexor muscles are twice as strong as the dorsiflexors, and the finger flexors are also twice as strong as the finger extensors.[35] The spastic finger flexors were stimulated infrequently during the initial 10 visits and on the first few return visits, however, because of concern that spasticity would increase.[7] After the concern about increasing spasticity was eliminated, the finger flexors were stimulated regularly. The child was given games, crafts, or toys of his choice to encourage specific thumb, finger, and wrist functions. The exercises were done both with and without NMES. With increased ability in grasp and release, toys to perform magic tricks were introduced because they are fun and require both hands. The child enjoyed "cutting" a rope in half and then "restoring" it, which required both hands. Other magic tricks involved hiding and finding a coin in a box and making a ball pass "through" a cup. Such games are motivating, age-appropriate activities and require a variety of hand skills. When controlled active thumb movement became possible, a remote-control car with two buttons on the control for the thumb was used. The child also brought a hand-held computer game that required the use of both thumbs. The computer game was more difficult to use than the remote-control car because speed of hand movement was necessary.

It was felt that the child returned quickly to the level of the previous year and then proceeded further because he soon was able to contract the wrist extensors volitionally and fully extend the wrist if the forearm was supported on a surface. He progressed further by being able to manipulate games and toys that were too difficult to manipulate previously. Grasp was stronger and more often seen with active wrist extension and not just wrist flexion. Full ROM of supination became possible. It was felt that function improved more rapidly because the finger flexors were stimulated more often during the return sessions than during the first sessions and he was more able to maintain grasp.

After 6 months, the child fell and broke his right index finger, which stopped physical therapy for 10 weeks until the cast was removed. He had no pain in the hand or fingers during or after the injury, which indicated limited sensory awareness. When physical therapy resumed, he continued to work on increasing strength of the finger, wrist, thumb, and shoulder muscles.

Outcomes Before Use of a Splint

The child learned to do many activities with the help of the right hand. He was even able to play cards and hold them in the right hand while using thumb opposition (Fig. 4). After a few minutes, he would need to reposition the hand. The hand, fingers, and thumb worked together to hold the cards, as long as wrist extension or the base of the thumb was supported intermittently, and at times constantly, by the physical therapist. Wrist extension was now a Fair grade as long as the forearm was placed on a surface or against his body and he was not holding an object of any significant weight. He was not able to extend the wrist quickly, and he could extend it only with some effort. After 17 months (38 sessions) of physical therapy, the function of his fingers and thumb had improved, but he still lacked enough wrist stability for independent hand function. At times, he could extend the wrist and hold an item for manipulation with the left hand, but he needed to concentrate and he did not use this skill frequently. The lack of wrist extension was especially noticeable when finger flexor strength was needed. The wrist extensor tendons were perhaps over-stretched and the muscle belly was too short to respond quickly and adequately, as is common among children with cerebral palsy.[4,35] The child often would use the left hand to overly flex the right wrist and even give it excessive thrusts into flexion. The movement may have increased sensory awareness of the wrist while maintaining excessively long wrist and finger extensor tendons.

[Figure 4 ILLUSTRATION OMITTED]

The child was frustrated when his therapist supported the hand while he was using it. He wanted to do the activity independently. When support was withdrawn, however, the wrist flexed excessively and he was no longer able to use the fingertip and thumb opposition that was emerging. He had to resort to a lateral finger and thumb pinch. I decided to use external support to stabilize the wrist in a functional position. Experience with splinting other children's feet to have them in a proper position as muscle strength increased led to the idea of using a splint to support the wrist until the muscles gained strength. As with the ankle,[36] a few degrees of motion is essential. I hoped that the splint would promote the child's motor learning, because my hands would not be guiding his movements.

Modified Program With a Dorsal Wrist Splint

On the 39th session, a dorsal wrist splint was fabricated out of Orthoplast[R] ([parallel]) to maintain wrist extension in a functional position. The splint was dorsal so that most sensory stimulation would be in the direction of wrist extension and not wrist flexion. Because children with cerebral palsy often unconsciously push against supports, it was preferred that he push into wrist extension. When the child was using the hand, this appeared to be the case.

The Orthoplast[R] was heated, cooled slightly, and placed along the back of the child's forearm up to the MP joints. The wrist was held in 10 degrees of extension. The Orthoplast[R] was then curved around the arm, wrist, and hand to anchor the splint. The splint was molded to create impressions of the distal end of the ulna, which would help in locating the splint when completed and in preventing the splint from rotating. Three straps were used, two on the forearm and one soft strap through the palm around the web space, which helped to abduct the thumb.

Figures 3 through 7 show the child doing functional activities. Figures 3 and 4 show his progress with motor control with NMES and task-specific exercises before splint use. Figure 5 shows his ability to get distal pinch with the splint. The photographs in Figures 6 and 7 were taken after the splint was used.

[Figure 5-7 ILLUSTRATION OMITTED]

Figure 5 shows the splint the first time it was used and just before the second forearm strap was added proximal to the wrist. The child was working on thumb and index-finger opposition as he picked up a marble-sized ball. The splint provided wrist stability for finger and thumb function while preventing ulnar deviation or excessive wrist flexion.

With the splint, the child was able to use finger and thumb opposition, grasp, and release free of an adult's "helping hands" trying to maintain wrist extension. Electrodes were sometimes used under the splint. For his self-esteem, it was suggested that he wear the splint only at home and that it was not necessary for his friends to see it. He was asked to use it initially to practice grasp, release, and opposition activities during his home program. Card playing and model building were two suggested activities to be done for a few minutes every night or at least three times a week. When he returned for physical therapy, the splint was dirty and showed much use. He said that he liked the splint because he could do things with it. He was not embarrassed to wear the splint in front of his friends. He had worn it to school every day. His mother thought that he chose to wear the splint about 6 hours a day.

During physical therapy sessions, he worked with and without the splint, depending on the activity. Strengthening and weight-bearing activities for the hand and wrist were done without the splint. If wrist support was needed during a task, the splint went on over the electrodes.

Outcomes of the Modified Program-NMES With Dorsal Wrist Splint

The child's hand function appeared to be markedly improved after 6 weeks with the splint, although endurance was limited initially. It was felt that the initial endurance was limited because the child quickly tired of using the hand with wrist extension and needed a break. After 9 months (24 sessions) of wearing the splint daily for at least 6 hours a day, splint use was discontinued at the child's request because he could maintain the hand function without it. He was pleased with his abilities to use the hand, and I believed that if he continued to use the hand and wrist in functional activities, he would have a chance to maintain the increased function.

A benefit of the splint was that wrist flexion decreased. This is similar to deceased ROM when a cast is removed after 6 weeks. The splint gave the child the chance to learn to use the grasp, release, and opposition functionally and independently, without anyone holding the wrist position for him. Thus, motor learning could occur because the wrist extensors were held in a shortened position. When the splint was discontinued, the child could actively extend the wrist and maintain the extension as needed. He could not lift a heavy object with the right hand, but he could maintain wrist extension to hold the object on a table while the left hand manipulated it, as shown in Figure 3. He learned to use the index finger to press toy objects, to pick up poker chips, and to assist when holding toys (Fig. 5).

Shoulder strength and functional grasp changed so that, while using both hands, he was able to hold on and pump himself independently on a swing, as shown in Figure 6, and to hang and swing from a trapeze and drop into a beanbag when he swung over it.

On the last visit (session 62), after a period of 25 months (an average of 1.7 visits per month), the child demonstrated his ability to tie his shoelaces while not wearing the splint, as shown in Figure 7. He had also learned the difficult bilateral activity of putting on his socks and how to use the hand for holding and picking up small objects. He was able to do some model building. Although he could not do in-hand manipulation, his right hand was a functional helper. He was anxious to discontinue physical therapy and use his after-school time for other activities.

Although the child learned to ties his shoelaces, the choice of shoelace tying for a goal was rather naive. Studies on motor learning and skill acquisition have shown that skills are task specific and do not necessarily carry over from one activity to another.[24] On the last visit, he was tested on a new activity. He was asked to make a sandwich out of bread and jam and to cut it in half. Unfortunately, the food was not to his liking, which may have affected his motivation and thus his hand skill. He agreed to make the sandwich if he did not have to consume it. He reached out for the jam jar with the right hand and easily and appropriately held the jar as he used the knife with the left, uninvolved hand. He spread the jam on the bread with his left hand, but his right hand remained "glued" to the jam jar, as the plate with the bread and jam moved about the table. Nothing was said to see whether he could solve the problem. He did not change his movement pattern but operated the hands separately. When asked to hold the bread with the right hand, he had no problem letting go of the jam jar and was able to cut the bread with the knife held in the left hand while holding the bread with the right hand. It was clear that shoelace tying was not task specific for sandwich making. He had never used a knife at home, as his food was already cut. A learning situation had occurred for all three of us. The fact that he still did not consider using the hand to hold the bread, although he spontaneously held a toy or other object for the purpose of manipulation with the left hand, is further evidence that learning one task will not necessary carry over to another.

The child's right-hand score on Mowery's functional classification,[1,37] originally "poor," was now "good" (ie, helper hand with effective grasp and release and some voluntary control). A telephone call to his mother months following discharge revealed that he was still able to tie his shoelaces and that he could cut meat (chicken, but not steak) and use two hands together when necessary. According to his mother, however, the thumb was back in the hand. He did not call his right hand a dead hand but would like to forget about it. He could extend his wrist while holding a lightweight object. He enjoyed building with construction blocks.

Discussion

The child was discharged from physical therapy at 9.9 years of age. After 9 months of wearing the splint and 26 months (62 visits, an average of 1.7 visits a month) after returning to use NMES in physical therapy, he had met his goals and no longer called his right hand a dead hand. His hard work in physical therapy was successful in making the right hand a functional helper.

It would appear that physical therapy may have been discontinued too soon, before he became really facile with the new skill or before some in-hand manipulation involving the thumb was learned. However, he was ready to discontinue physical therapy to pursue other activities. It is important for older children to come for physical therapy only when they are motivated, perhaps when interested in improving a specific skill.

Two factors influenced the duration of physical therapy, which may appear to be excessive. First, it was difficult for me to let go of the belief that muscle strengthening would increase spasticity, which delayed the use of NMES for strengthening the finger flexors. Second, with hindsight, the splint should have been made and used at the beginning of the physical therapy sessions. Unfortunately, the idea of using a hand splint to shorten overly long wrist extensor muscles and allow more independent practice of hand skills did not occur to me until about halfway through the sessions. No studies on using a dorsal splint for function with a child with cerebral palsy were found in the literature. Splints are sometimes used for stretching tight muscles and for managing spasticity,[38] but no studies of splint use for the purpose of external support so that the child can independently practice finger function were found. Research to examine the use of hand splints for this purpose appears to be warranted.

Summary

We should consider the functional gains that the child in this case report made. On his return to the clinic at age 7.7 years, he considered himself a one-handed person and even called his right hand a dead hand. He was not using the hand for anything except to hold paper flat on the table while writing. Although he had previously had about 5 years of twice-weekly NDT physical therapy and occupational therapy, he was not able to use the right hand functionally on his return. This child had far to go from having a nonfunctional, tight hand--which lacked an adequate web space, had poor ROM of the base of the thumb, and lacked muscle strength--to having a functional assistive hand. If the splint had been introduced earlier and his appointments had been more concentrated, a shorter time might have been sufficient to learn new habits, as appears to be the case when learning any new skill. As stated by Brown et al, "The hand becomes increasingly dependent not on the stage of brain maturation but on the previous exposure and practice of the task."[30] With NMES, unused muscles can be stimulated when needed, and the sensory input from NMES can give needed sensory awareness of what is happening in the hand to allow motor learning to occur and to permit motor control.

Acknowledgment

I thank Albert Sherwood for his assistance in the preparation of the manuscript. (*) Respond II and Respond Select, EMPI Inc, 60 W Fay Ave, Addison, IL 60101.

([dagger]) Minimassager, Smith & Nephew, Rolyan Inc, PO Box 1005, Germantown, WI 53022.

([double dagger]) Medtronic Nortech Division, 10237 Flanders Ct, San Diego, CA 92121.

([sections]) Uni-Patch Inc, 1313 Grand Blvd W, PO Box 271, Wabasha, MN 55981.

([parallel] Johnson and Johnson Orthopaedics, PO Box 350, Raynham, MA 02767.

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J Carmick, PT, is in private practice, 3060 Miranda Ave, Alamo, CA 94507 (USA).

This article was submitted January 11, 1996, and was accepted October 24, 1996.