Indwelling Thumbs in Children with Spasticity

It has been a BUSY month so far, so this is my first post of the month... the longest I've ever went without writing an entry! Oh well, Happy Spring (almost)!

Lately, I've been working with quite a few children of all ages who have spastic quadriplegia; this is when both legs and arms have extreme tightness due to neurological impairments, and typically the upper body is less functional than the lower body for these children. For the younger children such as infants and toddlers, I often suggest "Joe Cool" or "Benik" splints (sometimes with a harder material inserted between the thumb and index finger) in order to help the thumb not stay tucked in the hand. Some children require night-time splints (e.g. from orthoplast) as well, but I am simultaneously encouraging as much active movement as possible. But unfortunately, active movement isn't always possible; this is especially the case for a child who has suffered a near drowning, CMV, PLV, or a TBI. In that case if a splint isn't tolerated due to too much tightness and orthopedic mal-alignment of the fingers (wrists, IPs and MCPs), then I suggest rolling up a small washcloth within their hand. This gives the web-space a small amount of support without an excessive, painful stretch. If the thumb and fingers continue to be tight over numerous years, then the creases within the palm can become "stuck" to each other which makes it pretty much impossible to open the hand to full passive range of motion, and if it does occur the skin may rip and/or bleed. Even for the kids who may never actively move their hands due to severe physical and cognitive involvement, getting the thumb to not tuck is important... dislocated bones or "windswept" deformities can be painful!

Of course, I always promote massage, stretch, weight-bearing through an open hand, and active use of the muscles when possible. Also, some children need a customized splint created from an orthotist or occupational therapist. Some "ready made" dynamic splints may even work. In these cases, I have to investigate funding ideas if insurance doesn't reimburse for it and if the family doesn't have the financial means to pay for it.

I would love to hear other strategies for helping reduce indwelling thumbs in children with neurological damage. If you have any, send them my way!