In a post‑craniotomy patient with left frontotemporal‑parietal decompression for a subdural hematoma who now has flexor‑dominant upper‑extremity spasticity (biceps, wrist, finger flexors) and extensor‑dominant lower‑extremity spasticity (quadriceps, ankle plantar‑flexors) after initiating oral antispasticity medication and intensive range‑of‑motion/positioning therapy, how do I determine when orthoses or splints are indicated?

Orthoses and Splinting in Post-Craniotomy Spasticity

In your post-craniotomy patient with established flexor-dominant upper-extremity and extensor-dominant lower-extremity spasticity who is already on oral antispasticity medication and intensive therapy, you should initiate orthoses now—specifically, resting hand/wrist splints for the upper extremity and ankle-foot orthoses (AFOs) for the lower extremity—to prevent contractures, improve positioning, and support functional goals. 1

When to Initiate Orthoses: Clinical Decision Algorithm

Upper Extremity Indications

Initiate resting hand/wrist splints when:

• Lack of active hand movement is present, even with ongoing therapy 1
• Flexor spasticity affects the wrist and finger flexors (as in your patient) 1
• The patient requires assistance with hygiene, dressing, or limb positioning due to spasticity 1
• You are implementing combined treatment approaches, such as early botulinum toxin injection to wrist and finger flexors 1

Important caveat: The evidence for resting hand splints is controversial—the Royal College of Physicians guidelines recommend against their use, while Veterans Affairs/Department of Defense guidelines recommend for their use. 1 The American Heart Association/American Stroke Association takes a middle position: resting hand/wrist splints "may be considered" (Class IIb, Level C evidence) when combined with regular stretching and spasticity management. 1 However, splints and taping are NOT recommended for prevention of wrist and finger spasticity after stroke (Class III, Level B). 1 The distinction is critical: use splints for established spasticity (your patient), not for prevention in patients without spasticity.

Lower Extremity Indications

Initiate ankle-foot orthoses when:

• Active plantarflexion during swing phase of gait is present 1
• Ankle plantarflexion contractures are developing or present, as these affect gait quality and safety 1
• The patient has extensor-dominant lower-extremity spasticity involving ankle plantar-flexors (as in your patient) 1
• You aim to improve gait function while simultaneously preventing ankle contracture 1

AFOs serve dual purposes: improving gait mechanics and preventing contracture development. 1

Specific Orthotic Recommendations by Body Region

Hand and Wrist Splinting

• Customize splints to the individual patient—off-the-shelf options rarely provide optimal positioning 1
• Apply splints as part of a comprehensive program that includes:
  • Regular stretching (daily, with proper technique taught to patient/family) 1
  • Spasticity management (oral medications, botulinum toxin injections) 1
  • Range-of-motion exercises (passive and active-assisted) 1
  • Positioning of the upper limb in various appropriate positions within the patient's visual field 1

Ankle-Foot Orthoses

• Customize AFOs to individual patient needs 1
• Use resting ankle splints at night and during assisted standing to prevent contracture progression 1
• Consider AFOs as part of gait training and physical activity programs 1
• Combine with botulinum toxin Type A injections for focal lower limb spasticity to increase range of motion 1

Timing Considerations

Your patient is at the optimal window for orthotic intervention:

• 60% of stroke patients develop joint contracture on the affected side within the first year 1
• Wrist contractures occur most commonly in patients who do not recover functional hand use 1
• Elbow contractures within the first year are associated with spasticity presence within the first 4 months 1
• Early intervention with positioning, splinting, and botulinum toxin (when indicated) may prevent established contractures 1

Positioning Strategies to Implement Concurrently

Shoulder Positioning

• Position the hemiplegic shoulder in maximum external rotation for 30 minutes daily (either in bed or chair) to prevent shoulder contracture (Class IIa, Level B) 1

Standing Protocol

• Standing on a tilt table for 30 minutes daily is probably useful in preventing contracture (Class I, Level C) 1

Additional Interventions for Established or Progressive Contractures

If contractures progress despite splinting and positioning:

For Mild to Moderate Contractures

• Serial casting or static adjustable splints may be considered for elbow and wrist contractures (Class IIb, Level C), though data are conflicting 1

For Severe Established Contractures

• Surgical release (brachialis, brachioradialis, biceps muscles) may be considered for substantial elbow contractures with associated pain (Class IIb, Level B) 1

Monitoring and Safety

Regular assessment is essential:

• Perform daily skin inspections using objective scales like the Braden scale 1
• Monitor for pressure ulcers, which are associated with impaired circulation, older age, and incontinence 1
• Ensure proper wheelchair seating and support surfaces to prevent skin injury 1
• Teach patients, staff, and caregivers about prevention of skin breakdown 1
• Watch for muscle deconditioning as a complication of prolonged immobilization 2, 3
• Inspect for skin breakdown with poorly fitted splints 2, 3

Common Pitfalls to Avoid

• Do not delay orthotic intervention until contractures are established—early application is key 1
• Do not use splints in isolation—they must be part of a comprehensive program including stretching, positioning, and spasticity management 1
• Do not apply splints without proper fitting—poorly fitted orthoses cause skin breakdown and reduce compliance 2, 3
• Do not forget to educate patients and families on proper stretching techniques to avoid injury and maximize effectiveness 1
• Do not overlook skin inspection—regular turning (at least every 2 hours), good hygiene, and specialized mattresses/wheelchair cushions are essential until mobility returns 1

Integration with Spasticity Management

Your patient is already on oral antispasticity medication, which is appropriate. Consider:

• Targeted botulinum toxin injections into localized upper limb muscles to reduce spasticity, improve range of motion, and facilitate dressing/hygiene (Class I, Level A) 1
• Targeted botulinum toxin injections into lower limb muscles to reduce spasticity interfering with gait function (Class I, Level A) 1
• Oral antispasticity agents are useful for generalized spastic dystonia but may cause dose-limiting sedation (Class IIa, Level A) 1
• Physical modalities such as neuromuscular electrical stimulation or vibration applied to spastic muscles may temporarily improve spasticity as an adjunct to rehabilitation (Class IIb, Level A) 1