Current Advances in the Use of Pressure
Splints in the Management of Adult Hemiplegia
MARGARET JOHNSTONE MCSP
Key words: Muscle tone, sensory interpretation, inhibition, gravitational
force.
SUmmary: Abnormal muscle tone and loss of sensory interpretation
frequently present as major barriers to rehabilitation. A way must be found
to hold fully corrective inhibiting positioning while rehabilitation is
undertaken. Associated reactions and overtlow of tone must be diverted away
from anti-gravity tonal patterns into the opposing low tonal patterns while
enough limb stability is offered to allow for early weightbearing exercise
and dynamic sensory input. Pressure splints supply this need.
Biography: Margaret Johnstone trained under Miss M I V Mann at the
Royal Infirmary, Edinburgh, and shortly after training obtained a post in
a neurological unit; ever since she has retained her interest in neurological
conditions. After a wide experience she became superintendent in her own
unit and set out to find some answers to the residual disabilities found in
the stroke patient. Ten years later she downgraded herself to obtain a post
in a long-stay hospital where she was given free access to stroke patients
who had severe residual disability and had failed to rehabilitate. From a long
clinical field study in this unit she has written three successful books (brought
up to date by new editions in 1987 and now in nine languages). She offers
a helpful concept which is obtaining satisfactory rehabilitation results world-
wide and here offers her conclusions. She is presently responding to q u e s t s
to present teaching seminars in many parts of the world.
Introduction
NORMAL movement depends on normal muscle tone and
normal sensory interpretation. In the brain damage of stroke,
abnormal tone and sensory loss are usually the main barriers
t o successful rehabilitation. Ways and means t o overcome
the serious dysfunction that results must be introduced into
any worth-while rehabilitation programme. Solve the
problems posed by altered tone and sensory loss and it is
frequently possible t o reach a very high standard of
rehabilitation. Where abnormal tone and sensory loss remain
as major barriers t o rehabilitation, any expectation held out
for sound and advancing recovery is not realistic and much
that is done in the handling and care of patients frequently
results in increasing disability. It has t o be remembered that
normal movement depends on close interaction between
sensory and motor events.
Problem Solving
Considering abnormal tone first, owing t o lack of inhibition
acting on the anterior horn cell because of the brain damage
of stroke and the resulting loss of postural control, postural
muscle tone is no longer under control in relation t o
gravitational forces, and spasticity patterns are seen t o
follow anti-gravity patterns. Where hypertonicity does not
seem t o be the problem and patients present with the heavy
‘floppy doll’ limbs of flaccidity, or hypotonicity, eventually
spasticity usually also occurs and may be noticed first in
the fingers.
In every physiotherapy modality it is necessary to establish
the treatment aim and purpose. In the treatment of stroke
disability, the aim is t o give back t o brain-damaged patients
Physiotherapy, July 1989, vol 75, no 7
inhibitory control over abnormal patterns of movement, in
order t o restore postural control.
With this aim firmly in mind, by incorporating the use of
pressure splints and pressure techniques in the planned
exercise programme, a total treatment may be introduced
which deals with the patient as a whole, leads forwards
toward the restoration of postural control and, at the same
time, deals in a satisfactory way with other disabilities
involved, for example the grave problems associated with
sensory loss.
Ways and Means
The postural reflex mechanism must be re-established. It
has t o be recognised that without normal postural tone there
can be no normal postural reflex mechanism. In newborn
infants all movement is primitive reflex movement and the
postural reflex mechanism leading t o cortical control and
skilled movement develops up through the reflex levels in
the first months of life; this is basic neurology.
It would seem t o make sound sense to follow this pattern,
basing treatment on neuro-developmental patterns. This
concept is known as neuro-developmental therapy or NDT.
But this method can be successful in a stroke patient only
if it is possible t o control the distribution of the patient’s
muscle tone throughout the rehabilitation programme. For
those w h o would not agree with the NDT approach (and
there are a few), t o examine the concept in greater detail
often leads t o greater understanding.
Immediately after the onset of a stroke the rehabilitation
team - be it hospital- or home-based - must go into action.
All those who handle stroke patients must do for them what
the damaged brain can no longer do and, wherever possible,
patients should be taught t o help by establishing self-care
in this area. The great need is t o inhibit unwanted excessive
tonal patterns. Thanks t o the great pioneering work done
by Berta Bobath there are few physiotherapists who would
not agree with her teaching on the need t o establish
inhibiting positioning and inhibiting movement patterns
which are used t o control the distribution of a patient’s
muscle tone. This leads t o probably the most important rule
that has t o be observed in stroke rehabilitation in any on-
going recovery programme, namely that positioning is used
at all times to influence the distribution of tone following
the brain damage of stroke.
Unless a patient‘s trunk and trunk-related problems are
dealt with in the early days there is little chance of reaching
full motor recovery. The onset of trunk spasticity and a
painful shoulder must be prevented. Under the circum-
stances it makes good sense t o consider the main and very
large muscles which hold the the trunk in full extension
against gravity and to expect these muscles t o influence
strongly the anti-gravity tonal patterns.
Isolating these muscles does not present a problem; they
are larger and more extensive than any other trunk muscles
and are t w o in number, namely latissimus dorsi and gluteus
maximus. Because of the extensive origins of latissimus dorsi
it is reasonable t o expect an onset of trunk spasticity and,
because of its insertion into the bicipital groove of the
38I
 b.

Fig 1: Application of arm splint

humerus, serious shoulder involvement. Likewise, because Pressure Splints
of the origin, insertion and size of gluteus maximus it is also
Orally inflatable pressure splints* may be used as valuable
reasonable t o take into account its action on the hip when
tools t o maintain inhibiting positions and t o give limb
holding the trunk upright against gravity.
stability during rehabilitation sessions - orally inflatable
These t w o muscles dominate the spasticity patterns of because warm air moulds the plastic t o the limb and human
trunk and limbs. To inhibit their action, inhibiting positioning lungs will not over-inflate above the maximum pressure
must include flexion of the shoulder and hip and inhibiting
of 40 m m Hg. They give patients and physiotherapists
movement patterns must work against their rotational freedom t o perform valuable exercise routines.
patterns; thus the shoulder must be rehabilitated into For example, the full arm splint carefully and correctly
outward rotation with flexion and protraction, the hip into
applied (fig 1) will inhibit unwanted dominant tone while
inward rotation with flexion and protraction, while lateral
directing tonal overflow into the inhibiting pattern and,
trunk elongation and a freely mobile scapula should be
with the all-over even pressure, will also give the limb the
maintained.
stability that is required for the urgently necessary limb
As might be expected, inhibiting patterns for hemiplegic
loading in the corrective pattern (fig 2).
patients are flexion patterns with the exception of the
forearm and hand. Hence the high failure rate in arm
recovery. Flexion of the forearm and hand is a strong anti-
gravity pattern and in total arm rehabilitation the use of the
necessary inhibiting extension pattern of the forearm must
be combined w i t h flexion and outward rotation of the
shoulder. But this is a non-functional pattern and some
physiotherapists are not prepared t o accept that it must be
maintained at all times and used as a necessary stage in
rehabilitation. In the neurological approach presented here
it must be used, particularly in the early days until trunk and
shoulder function is fully restored and the developmental
sequence leads on t o a fully functional hand.
Beginning rehabilitation with the trunk, side lying patterns
are used and elongation of the affected side is combined
with trunk rotations, taking special care of the shoulder and
hip. It is not the purpose of this article t o set out a full
Fig 2: Limb loading in corrective pattern
exercise programme; the intention is t o present the theory
on which the current use of pressure splints is based. With this treatment aid it becomes realistic and quite
When handling stroke patients it is immediately obvious possible to plan a treatment programme aimed at restoration
that initial care of the trunk can be carried out without an of the postural reflex mechanism by working progressively
adverse effect on the forearm and hand only if a way is found through neuro-developmental patterns. From what has
t o inhibit the associated reactions in the forearm. Rolling on already been said it is understood that patients will begin
t o the side is a flexion pattern. The released postural rehabilitation using rotational patterns, bi-lateral rotation of
reactions (or associated reactions) which occur with all the trunk, outward rotation of the arm with extension of the
attempted movement will give a widespread increase in forearm, and inward rotation of the leg with flexion of the
spasticity and, in this case, this will mean an unwanted knee.
increase of excessive flexor tone in the forearm unless the To lie supine in full extension will increase unwanted
arm is maintained in the full inhibiting pattern. extensor tone, side lying is the most neutral position and
The laying on of t w o hands t o maintain the arm pattern trunk rotations will reduce extensor spasticity. From the point
is not adequate and physiotherapists' hands are required of view of working within inhibiting patterns it makes sound
elsewhere t o give the necessary corrective stabilising sense t o follow the rolling patterns of infants whether or not
resistance t o the trunk. If a way can be found t o divert the the therapist agrees with NDT.
tonal overflow into the low tonal pattern it will become a Central stability with gross motor performance has t o be
vital factor in successful rehabilitation. The problem in the achieved before progressing t o more skilled movements.
past has been how t o hold fully corrective positioning while Stability of the head, neck and upper trunk and stability in
rehabilitation is undertaken. side lying should be an early aim of treatment, leading on
t o balance training with the area of the base being steadily
"The manufacturer of the pressure splints developed by the author reduced t o reach the final aim of achieving firm standing
is Svend Andersen Plastic lndustri A/S of Denmark, using the trade balance. Inevitably, physiotherapists will bring in levels of
name URlAS for stroke splints. There are now marketing firms in reflex activity as they work with patients; tonic neck reflexes,
many parts of the world; in Britain URIAS splints are available from
Thackraycare, 45/47 Great George Street, Leeds LS1 388; and
labyrinthine reflexes, righting reflexes and equilibrium
Whitefield Medical Ltd, 7 Dunlop Square, Deans Industrial Estate, responses will play a large part in the recovery programme
Livingston, West Lothian, Scotland EH54 8SB. xovided distribution of muscle tone is controlled throughout.

382 Physiotherapy, July 1989, vol 75, no 7

This ambitious programme would seem impossible without
the use of pressure splints.
There are other widely recognised neurological facts which
help towards the development and understanding of this
concept where pressure splints are brought into use. For
example, weight bearing increases muscle tone, a valuable
recovery factor provided weight is transmitted through the
inhibiting pattern, thus increasing the low tonal pattern while
excessive anti-gravity tone is inhibited. Exercise against
resistance (or an increasing demand) may be used to produce
a dynamic increase in tonal flow through the whole body,
again a valuable recovery factor provided the distribution of
tone is controlled and directed into the low tonal patterns.
Figure 3 shows an example using resistance against head
extension t o reinforce tonal flow by making use of tonic neck
extension t o increase the tonal thrust through the positioned
arm. The small inflatable boot is used t o maintain an angle
of 90° at the ankle and further break up the tonal pattern
of extension of the leg. (Note: this boot is not used for
standing.)
Fig 3: Stabilising upper trunk and shoulder
Developing infants do a great deal of weight bearing
through their arms and hands; stroke patients must also
follow this weight-bearing pattern if they are t o reach full
hand recovery with precision movements. Therefore the
weight-bearing base is extremely important and, in the arm,
must be such that weight is transmitted through an
outwardly rotated shoulder.
The half-arm splint is illustrated in figure 3. Here it is used
t o control the hand and wrist while work is carried out on
the lower half of the body. This is also an excellent position
for resisted work t o be given t o head, neck, upper trunk and
shoulders. Modified work may be necessary for very elderly
Physiotherapy, July 1989, vol 75,no 7 383
patients, and some may be successfully rehabilitated by
using the sequence of lying t o sitting t o standing, provided
trunk rolling is included. Figure 4 shows a modified prone
position which is kind t o the stiff lumbar spine of elderiy
people.
So far the splints described have been single-chamber
splints dependent on all-over even pressure t o maintain the
inhibiting pattern and t o give limb stability. Apart from the
small boot, no splint had been designed for the leg; it had
not seemed t o be necessary as inhibiting leg patterns are
comparatively easy t o establish and maintain, but the need
t o stand correctly did pose a problem and early standing is
necessary. To cut out any risk of increasing unwanted
excessive anti-gravity tone in the standing leg, weight must
not be transmitted through the ball of the foot, but through
the heel t o a semi-flexed knee and a hip with no outward
rotation. This will inhibit the strong thrust of gluteus
maximus.
With the willing co-operation of the Urias splint makers*
I next designed a leg gaiter and found it was necessary t o
produce a two-chamber splint. It has t o be applied with the
zip fastener d o w n the lateral side of the leg, clearly giving
anterior and posterior sections. During the application,
patients must be standing with good arm positioning (splint
controlled and weight-bearing). The feet must be apart and
pointing straight forward; the upper edge of the splint should
be high up under the ischial tuberosity; the posterior chamber
must be inflated first t o a firm pressure and, as it is inflated,
the patient's weight must be transferred over on t o the
affected foot. If this is done correctly and the foot is correctly
positioned, this inflation will bring the heel down into the
weight-bearing position and the patient will be weight
bearing through a correctly positioned heel, knee and hip,
thus inhibiting strong extensor anti-gravity thrust and a
consequent build-up of spasticity. Finally, the anterior
chamber of the splint is inflated minimally t o give a small
pad of air over the patella. The patient is n o w comfortably
stable and ready t o learn weight transference through the
affected side (fig 5).
In early training the arms are best supported on a suitable
height of table in ulnar border leaning, forearms parallel and
with a half-arm splint maintaining positioning of the affected
wrist and fingers. This inhibited limb positioning fully controls
associated reactions and the tonal increase of weight-bearing
is diverted into the low tonal patterns. The standing exercise

session includes trunk stabilising, gait training by stepping
forwards and backwards with the sound leg, standing while
bending and stretching both knees, and leading on t o
standing only on the affected leg, with single knee bending
and stretching. These exercises also lead t o a stable and
strong ankle. It is important t o note that this gaiter is not
intended as a splint for walking and during the exercise
session the affected foot remains firmly on the floor,
maintaining the corrective starting position.
Finally I found the need t o design a second double-
chamber splint, this time for the hand. It is applied with the
hand in the crawling position. The chamber over the posterior
aspect of the hand must be inflated first - the thumb held
in abduction and the fingers close together and in full
extension as inflation takes place. This initiates an extensor
response in the fingers. A little air is then put into the anterior
chamber for comfort and to give a good weight-bearing base.
This splint is not used t o control the wrist. It is used t o
control the fingers and thumb in early weight-bearing
exercise, maintaining the inhibiting hand position, for
example, in early crawling, sitting propping on the affected
hand or standing leaning on the affected hand. It is also
useful in the final stages of hand rehabilitation t o control the
thumb and fingers while wrist extension is practised.
A broad, short, one-chamber splint is the latest design and
is used for elbow support where stability has still not been
firmly established. It may, where necessary, be used for
elbow support in conjunction with the hand splint in exercise
sessions (fig 6).
Where sensory loss is troublesome, sessions of
intermittent pressure administered with the Flowpulse
intermittent compression system may be introduced.
This treatment mimics the touch, movement and pressure
which leads t o sensory development in the fetus. With the
helpful co-operation of Edinburgh University I set up a
series of bloodflow tests before and after this treatment
and we established 40 mm Hg for three seconds alternating
t o 10 mm Hg for three seconds as safe and useful pressures.
I have tried this treatment for ten years in the clinical field
with very satisfactory results. Length of daily treat-
ment was subject t o availability of the machine but, for
Thirty-five Single-Patient Case Study
(on an elderly population)
Criteria for Entering Study
1. Severe disability.
2. Failure to rehabilitate elsewhere; placed in long-term care.
3. Motorlsensory loss.
4. Other medical problems from mild t o severe.
Aim of Treatment
To reach a reasonable level of self-care and so be able t o
return t o the community and leave long-term care.
Method of Treatment
1. Inhibiting positioning.
2. Movement into patterns which oppose spasticity patterns.
3. Sustained pressure used t o maintain inhibiting patterns,
controlling tonal flow with early mobility and intensive
weight bearing.
4. Intermittent pressure for sensory input (40 mm Hg for
three seconds t o 10 m m Hg for three seconds alternating
for average of 45 minutes twice daily).
384
~~
serious proprioceptive loss, patients received one hour of
treatment twice daily.
In more recent years and with no clear idea of the outcome
I decided t o study some treatment results. Going through
my patient records over t w o consecutive years chosen at
random I selected 35 patients w h o had passed through my
unit. All these patients were chosen because they fitted the
criteria chosen for the study. A copy of this clinical study
is given below. I hoped the study would indicate the main
barriers t o rehabilitation.
Conclusions
The neurological damage of stroke leaves many questions
to be answered. The sensorimotor approach presented
here is based on a concept which sets out t o deal with the
finely balanced facilitory-inhibitory principle on which the
neuromuscular system depends. I have, in my treatment
programmes, also incorporated some PNF principles, Rood
techniques, modified conductive education and a wide
general understanding of tonal flow, abnormal tonal patterns,
and balance training, and considered how best t o influence
tonal overflow t o give a dynamic input towards the recovery
of sensory and motor loss. A return to balanced tone, sensory
recovery and normal movement has remained uppermost
in my treatment aim.
Results I have obtained in the clinical field during the last
15 years (and compared with my results before I used these
specialised pressure splints) seem t o establish a procedure
that gives sound answers to the neurological problems found
in the brain damage of stroke. The pressure splint is a
treatment tool which the physiotherapy profession cannot
afford t o ignore.
REFERENCES
Bobath, B (1978). Adult Hemiplegia: Evaluation and treatment,
Heinemann, London, 2nd edn.
Johnstone, M (1987). The Stroke Patient: A team approach, Churchill
Livingstone, Edinburgh, 3rd edn.
Johnstone, M (1987). Restoration of Motor Function in the Stroke
Patient: A physiotherapist’s approach, Churchill Livingstone,
Edinburgh, 3rd edn.
Johnstone, M (1987). Home Care for the Stroke Patient: Living in
a pattern, Churchill Livingstone, Edinburgh, 2nd edn.
3isabilities discovered by assessment tests
15 (a) Severe motor loss with spasticity i
mild medical problems
10 (b) Severe motor and sensory loss +
mild medical problems
5 As above (a) or (b) + more severe medical problems
5 As above (a) or (b) + very severe medical problems
Outcome of study
n
25 Returned to the community
5 Failed to rehabilitate
5 Died
Thirty-five patients collected over t w o years.
Rehabilitation time: differed from three months to one year.
Physiotherapy, July 1989, vol 75, no 7