A recent pilot study published in the Journal of Prosthetics and Orthotics reported the efficacy of maintaining elbow range of motion by comparing two devices, the Ultraflex and bivalve cast, following botulinum toxin type A (Botox, Allergan) injection and serial casting. The patients in the study were three 7-year-old children with a primary diagnosis of cerebral palsy and significant bilateral elbow flexion contractures.
To control spasticity in the biceps and brachioradialis in both upper extremities, thereby allowing the opposing muscle group (the triceps) to become stronger, botulinum toxin was injected into the former muscle groups. The muscle-weakening effects of botulinum toxin lasted from 3 to 5 months.
“After the children were injected, I casted both arms to provide the length through serial casting,” said Audrey Yasukawa, MOT, OTR, of the pediatric program at the Rehabilitation Institute of Chicago and one of the authors of the study. To improve muscle or tendon length, a series of four casts were applied, each series lasting 7 to 10 days.
|(Left) A patient wears an Ultraflex orthosis.
(Right) Wrist hinge on Ultraflex orthosis, which holds the joint in a position of low-magnitude stretch. It has a humeral portion and a forearm cuff, which statically positions the wrist in neutral with tension across the elbow into extension.
Comparing the Devices
“Once I got the length, I wanted to maintain and preserve that length by a maintenance device. We applied the bivalve cast to one arm and the Ultraflex to the other arm.”
According to the study, a bivalve fiberglass long arm cast is often used to position the arm in submaximal range after serial casting. It is worn at night and used to maintain passive range of motion, preventing further contractures. The authors state that the bivalve cast has limitations, one of them being its inability to accommodate changes in range of motion that may occur at the elbow joint from increased spasticity. Additionally, it may not be cost effective.
The Ultraflex orthosis is another method of maintaining range of motion, wrote the authors. The device holds the joint in a position of low-magnitude stretch. It has a humeral portion and a forearm cuff, which statically positions the wrist in neutral with tension across the elbow into extension. The tension can be changed with an adjustable spring tension load at the elbow joint.
Five months into the study, the botulinum toxin lost its effectiveness, allowing the muscles that were injected to reinnervate. The biceps, explained Yasukawa, became tight again.
“When this happened, the children could not fit into their bivalve casts or the Ultraflex,” she said. “I had to make new bivalve casts and all the orthotist had to do was adjust the tension on the Ultraflex orthoses.”
Yasukawa said that for years she had been using bivalve casts, but children kept coming back because the casts eventually did not fit. The children lost their range and she would have to make a new cast at their new range. With the Ultraflex, the therapist does not have to fabricate anything. He or she can simply adjust the tension accordingly.
“With the Ultraflex, we can make qualitative changes in the range,” she said. “This is not so with the bivalve cast because it is static.”
|A patient’s wrists before botulinum toxin injections (Left) and the patient with serial wrist casts (Center).
This child wearing a bivalve cast on one arm, which is a cast cut in half and made into a splint, and the Ultraflex (pink color) orthosis on the other arm (Right).
Results of the Study
In the eighth and final month of the study, it was found that the use of the Ultraflex showed better maintenance of elbow range of motion than the bivalve cast, said Yasukawa.
“In fact, the kids with the Ultraflex gained range of motion whereas the children using the bivalve cast were back to square one.”
Even though parents reported that the Ultraflex was more difficult to don compared with the bivalve cast, they preferred the Ultraflex due to its improved range and easy adjustments. According to the study, both devices require consistency in monitoring and checking of skin integrity and fit.
“The post-botulinum toxin treatment is critical for maintaining muscle length and rebalancing muscle strength around the involved joints,” said Yasukawa. “I have found that working with an orthotist is an important link in managing spasticity in children with neurological impairments.”
Recently, Yasukawa and her colleagues have injected botulinum toxin into the wrists and elbow flexors in children with severe wrist and elbow spasticity as well as limitations in range of motion. The wrists were serially casted to at least neutral or greater range. The children were fitted with the Ultraflex, which has the humeral, forearm and wrist components. The humeral and forearm portion allowed the tension at the elbow into extension.
“The wrist component is statically positioned,” said Yasukawa. “However, it can be adjusted in small increments to position the wrist for comfortable alignment. This appears to be the best device for managing both wrist and elbow range of motion.”
Yasukawa also has used the Ultraflex in children with mild to moderate cerebral palsy hemiplegia. The spasticity in the arm positions the upper extremity into elbow flexion, forearm pronation and wrist flexion.
According to Yasukawa, using the Ultraflex to position the arm into forearm supination or neutral with elbow extension seems to be effective in maintaining the range of motion for a child with abnormal tone in their growing years.
For more information:
- Yasukawa A, Malas B, Gaebler-Spira D. Efficacy for maintenance of elbow range of motion of two types of orthotic devices: a case study. Journal of Prosthetics and Orthotics. 2003;15:72-77.