Orthoses and splinting in neurological rehabilitation: ankle-foot orthoses, hand splints and casting

An orthosis is an external device that supports or corrects part of the body. In neurological conditions, weakness, altered tone and loss of sensation can allow joints to fall into poor positions, soft tissues to shorten and skin to be damaged. NICE guidance on neurological rehabilitation says to provide equipment, including orthoses and splinting, to support movement and protect against injury and secondary impairment.

NHS inform describes orthotics as equipment supporting a part of the body to improve the ability to move and be active, with some used for a short period and others for life. An orthotist examines how the person moves and recommends devices to their needs, which change over time.

The stroke guideline says to consider ankle-foot orthoses for people who have difficulty with swing-phase foot clearance, which shows as tripping and falling, or stance-phase control problems such as knee and ankle collapse or knee hyperextension that affect walking. The ability to put the orthosis on should be assessed, or help arranged, and effectiveness checked for comfort, speed and ease of walking. Assessment and treatment should take place within a stroke rehabilitation programme by qualified professionals.

For leg weakness caused by an upper motor neurone lesion, NICE neurological rehabilitation guidance says to consider functional electrical stimulation in addition to gait training, and points to its interventional procedures guidance on drop foot of central neurological origin. An orthosis and stimulation are alternatives rather than a combined default.

NICE says not to routinely offer wrist and hand splints to people with upper limb weakness after stroke, but to consider them for people at risk, for example those with hands immobile because of weakness or high tone. Aims include maintaining joint range, soft tissue length and alignment, increasing passive movement, facilitating function such as assisting grip, aiding hygiene by enabling access to the palm, and increasing comfort, for example with a sheepskin palm protector to keep nails from the palm.

Splints must be fitted by appropriately trained professionals, and a review plan should be set. The person, family and carers should be shown how to put the splint on and take it off, look after it and check for redness and skin breakdown, with a point of contact if worried.

The neurological rehabilitation guideline says that as part of rehabilitation to restore or maintain limb structure and function, serial or removable casting can be provided. It also warns that inappropriate use of interventions may limit the possibility or extent of recovery, mentioning casting and people with functional neurological disorder in particular.

For people who are unable or less able to sit up, stand or move unaided and who are at risk of skin breakdown, pain, sleep disturbance, respiratory problems or contracture, NICE suggests considering 24-hour postural management. Examples include regular changes of position, bed positioning, wheelchair and seating systems, arm supports and splints.

In cerebral palsy, the NHS says physiotherapists advise on walking aids and on arm or leg braces called orthoses, and that exercise and stretching aim to stop muscles shortening and losing range. NHS inform notes that orthotic needs change with time. Adults with long-term conditions should therefore have devices reviewed, not simply replaced.

Poor fit is the commonest reason devices are not used. Orthotists adjust straps and shapes, and users may need alternative footwear to accommodate an orthosis. Skin should be checked after first wear and then regularly, particularly where sensation is reduced, and any persistent redness should be reported. NICE advises a review plan and an accessible contact, and equipment should be reassessed when walking, tone or weight change.

People who are expected to use a device in the long term can ask the rehabilitation team how to obtain repairs and replacements, and NICE says services should help people to access equipment and funding when the NHS does not supply it.