Plaster of Paris - BraceLab...plaster of Paris is a more rapid change in the quality of the soft tissue, photographs do not adequately convey this progress. No objective means of quanti-fying

WHY PLASTER OF PARIS?

Plaster of Paris, a highly compliant material, isoften overlooked in the splinting of hand patients.This article enumerates the advantages of plaster ofParis and illustrates its application in specific clinicalsituations. This information is intended to encouragetherapists to introduce plaster of Paris more readilyinto their treatment armamentarium as a means ofaccomplishing tissue change.

The current primary treatment to mobilize stiffjoints and adherent soft tissue is the application ofintermittent force via mobilization splinting. The sus-tained positioning of joints and soft tissue with plas-ter of Paris provides a gentler and more precisemeans of tissue remodeling than does dynamic orstatic progressive splinting. The only possibleresponse to continual positioning in a plaster of Pariscast is plastic deformation, a permanent change in tis-sue length due to the realignment of collagen fibers.

Removable splints create an elastic response in thetissues such that, on removal of the splint, the tissuereturns to the previous position. The idea of mobiliz-ing tissue by immobilizing it seems contradictory.One must grasp the concept of positioning tissue andwaiting until it has time to adapt to a new length andshape. Bell1 agrees that we must abandon the tradi-tional concept of applying force, and think instead of

the ability to position joints to positively influencethe dynamic remodeling properties of soft tissue.

Because we know that prolonged periods of immo-bility have negative effects,2–14 many cliniciansassume that short-term immobilization of joints andsoft tissue is to be avoided. The risk of losing motion(even temporarily) is so intolerable that plaster ofParis casting is avoided unless it is the last resort forgaining motion. Immobilization of uninjured jointsmust be prolonged, and the extremity kept immobilefor the negative effects of immobilization to stiffenuninjured joints. A loss of motion in one directionusually occurs with plaster of Paris splinting or cast-ing, but clinical experience has proved this to be tem-porary. The unspoken assumption—that all jointsshould be allowed to move in all directions whenregaining motion in the hand—must be abandoned ifefficiency and precision in joint and soft tissue mobi-lization are to occur.

If joint tightness or tissue adherence is present in arecently injured hand, tissue elongation can beregained and motion restored by a brief period of cast-ing. The clinical goal is quickly converted from gain-ing motion to maintaining motion. Thereafter, inter-mittent splinting can maintain the gains. In contrast, ifintermittent splinting and manual mobilization tech-niques are the first choice, many hours of tissue elon-gation are needed to effect permanent tissue change.

Joint stiffness and tissue adherence that are matureand resistant to intermittent mobilization splintingand manual mobilization also respond to positioningwith plaster of Paris casting. In some chronically stiff

Plaster of Paris: The Forgotten Hand Splinting Material

Judy C. Colditz, OTR/L, CHT, FAOTAHandLab, a division of RHRC, Inc.Raleigh, North Carolina

ABSTRACT: This article examines the concept of tissue adapta-tion in response to the application of plaster of Paris splints andcasts. A review of the history of plaster of Paris and its composi-tion, its working properties, and precautions for its use introducesthe reader to this oft-forgotten material. Four designs are describedfor plaster of Paris application—circumferential padded casts, dig-ital unpadded casts, plaster slabs, and contour molds. The discus-sion of clinical application of plaster of Paris covers joint tightness,arthritis, contracted joints due to spasticity, muscle-tendon tight-ness, skin tightness, skin and joint tightness, and edema reduction.In addition, a new application called casting motion to mobilizestiffness (CMMS), developed by the author, is discussed. The useof plaster of Paris to improve postoperative flexor tendon glide isalso discussed. This review article intends to stimulate the readerto use plaster of Paris splinting or casting more frequently to solveclinical problems. J HAND THER. 2002;15:144–157.

144 JOURNAL OF HAND THERAPY

Correspondence and reprint requests to Judy C. Colditz, OTR/L,CHT, FAOTA, HandLab (a division of RHRC, Inc.), 2615 LondonDrive, Raleigh, NC 27608; e-mail: <[email protected]>.

hands, constrained motion in a cast can direct activemotion to the stiff joints, so that they regain both softtissue glide and joint motion. Because the cast is notremovable and all motion is directed repeatedly to thesame tissue, dramatic change occurs without theapplication of external force.

Kolumban15 offers the only study to date that com-pares the effectiveness of serial plaster of Paris cast-ing with the the effectiveness of mobilization splint-ing. In his study with leprosy patients, casting wasclearly superior to dynamic splinting and resulted infewer pressure areas.16 Unfortunately, no compara-tive studies of patients with joint stiffness due totrauma are available. Since the primary benefit ofplaster of Paris is a more rapid change in the qualityof the soft tissue, photographs do not adequatelyconvey this progress. No objective means of quanti-fying these changes currently exist. Direct palpationis the only means of demonstrating the quality ofchange in soft tissue.

Since plaster of Paris casting is frequently used as ameans of mobilization ”splinting,” the words splintand cast become confusing in this context. In this arti-cle, splint is used when the piece is removable(regardless of the material from which it is made) andcast is used when the design (usually made of plasterof Paris) cannot be removed by the patient.

HISTORY

Archives provide numerous reports of various sub-stances being applied to splinted body parts to stiff-en the part for fracture immobilization. It was notuntil 1852 that a technique was developed for apply-ing plaster of Paris directly to an extremity. (It iscalled plaster of Paris because it was first preparedfrom the gypsum mined in Paris, France.) In 1852, aDutch army surgeon, Antonius Mathysen, treatedbattle wounds in the Crimean War with cotton band-ages filled with dry plaster of Paris.17

This somewhat awkward means of plaster applica-tion continued until 1927, when binder ingredients(starches, gums, and resins) were added to improvethe adherence of the plaster to the gauze. These addi-tives made the application of a cast less messy andmore consistent. Later, other additives were incorpo-rated to change the physical properties of plaster ofParis, such as the setting time, which allowed stan-dardized production.18,19

In the first half of the 1900s, plaster of Paris was themost readily available material both for immobiliza-tion of acute injuries and intermittent immobilizationor mobilization splinting. Serial plaster splinting orcasting was used to mobilize stiffened joints due totrauma20 and contractures due to arthritis.19

Bunnell20–22 incorporated outriggers into plaster ofParis splints to provide dynamic mobilization. Brand’swork23 in India with leprosy patients introduced the

use of plaster of Paris for serial positioning of joints,especially the small interphalangeal (IP) joints.

In the 1970s, low-temperature thermoplastic mate-rials became available. These materials, which couldbe quickly molded on the patient and easily altered,revolutionized mobilization splinting of the hand. Atabout the same time, lighter-weight and water-resist-ant synthetic casting materials replaced the tradition-al plaster of Paris casting materials used for acuteinjuries. As a result of these two developments, plas-ter of Paris came to be used less frequently by bothphysicians and therapists. The infrequency withwhich plaster of Paris is currently used in hand ther-apy is reflected by the very brief mention of its use inrecent hand splinting texts.24–27

COMPOSITION

Plaster of Paris is derived from gypsum (calciumsulfate dihydrate), a naturally occurring rocklike sub-stance found in rock salts. When gypsum is heated to128° C, most of the water is driven off, resulting in apowdery substance commonly known as plaster ofParis. When water is added to the dry plaster ofParis, the water molecules incorporate themselvesinto the crystalline lattice of the calcium sulfate dihy-drate, thus giving up most of their kinetic energy inthe form of heat. This hydration process converts theweak and powdery plaster of Paris into a homoge-neous, rock-hard mass.18,19,28

The time required for the plaster to set up varies,depending on the additives.29 Manufacturers clearlylabel their products with the set-up time. Plaster ofParis with minimal additives is called gypsona.When plaster of Paris is used for hand mobilization,gypsona impregnated into leno-weave gauze (a non-raveling, closely woven gauze) is highly recommend-ed (Gypsona Gauze Type-Leno, Smith & Nephew,Inc., Germantown, Wisconsin).

Gypsona has a creamier consistency than the plas-ter of Paris with additives, although the latter is moredurable and water-resistant.29 For removal, a castmade of gypsona may first be softened by soaking.

ADVANTAGES ANDDISADVANTAGES

The advantages of plaster of Paris as a splintingmaterial are 1) its ability to intimately conform1,23,30;2) the decreased possibility of pressure areas, becauseof the increased conformity16,23; 3) the lesser sheer-force (the movement of the splint or cast on the skin)1;4) its porosity, which allows absorption of perspirationand prevents skin maceration23,30; 5) its retention ofbody heat, which provides a gentle, neutralwarmth31–34; 6) its reasonable cost23,30,35; and 7) its usein the construction of comfortable, nonremovablecasts to facilitate tissue response.

April–June 2002 145

No thermoplastic material, regardless of its mold-ing properties, can mimic the ability of plaster ofParis to conform. Synthetic casting materials aremuch stiffer than plaster of Paris,36–38 although theyare stronger.37,38 Strength is a consideration only inweight-bearing casts and large casts over joints influ-enced by spastic muscles.

Thermoplastic splints and plaster of Paris casts areestimated by the author to have similar material costsper application, but the time cost for construction ofa mobilization splint is much greater than for a plas-ter of Paris cast. Synthetic casting materials are about2 to 2.5 times more costly than plaster of Paris.36–38

Disadvantages of plaster of Paris are 1) the skillrequired for precise application and safe removal ofcasts made from it; 2) the sensitivity of hardenedplaster of Paris to water exposure, which may causeinconvenience in the performance of activities ofdaily living; and 3) its heavier weight in comparisonwith thermoplastic splinting materials. Because theperiod when a cast is worn full time is relativelybrief, the weight of the cast is rarely a problem.Besides, the cast will not be unnecessarily heavy if itis skillfully constructed and applied.

PRECAUTIONS

Care must be taken in the application of plaster ofParis to prevent inaccurate positioning or stabiliza-tion, with inappropriately displaced pressure.Pressure areas and circulatory constriction are possi-ble, although these complications are far more com-mon when plaster of Paris is applied to an acutelyinjured hand. Patients with asensate areas are mostvulnerable to complications from inappropriate pres-sure.

The primary concern in the application of plaster ofParis is avoidance of excessive heat from the exother-mic process, which can cause second- or third-degreeburns.18,39–41 Therapists should be fully aware of themultiple factors that influence the exothermic processin plaster of Paris.

The greatest influence on the exothermic process isthe speed of the setting time: The faster the settingtime, the greater the exothermic process.17,40,42 Thesecond most important influence is the thickness ofthe plaster of Paris, with a thicker cast or splint gen-erating more heat.17,40,42 Third, increased tempera-ture of the dipping water also increases the heat gen-erated.19,40,42

Wrapping material over the setting plaster of Parisor covering the cast or splint with pillows preventsthe heat from dissipating and significantly increasesthe internal temperature.40–42 As the cast or splint issetting, the patient should be instructed to avoid cov-ering it until it is completely cool and dry.

Other factors that affect the heat generated by theexothermic process are the humidity and tempera-

ture of the room40 and whether the immersion waterhas had previous plaster of Paris dipped in it.40,42

The thickness of the padding is an insignificant fac-tor in temperature alteration.40 Recommended tem-peratures for the dipping water vary greatly in theliterature.19,28,40,42,43 For each type of plaster of Parisused, therapists should follow the manufacturer’swritten recommendation for immersion water tem-perature.

During cast removal, vibration from the oscillatingsaw blade generates heat. If the cast saw blade is heldin one position, the heat generated by it may burn thepatient. To prevent this, the saw technique mustincorporate an up-and-down movement of theblade.17,44,45

If pressure on the blade is maintained after it hascut through the plaster, a friction burn or abrasion tothe skin will result. Practice is required to developskill in cast removal, so that saw movements are keptsecurely in control and the pressure is released assoon as the blade pierces through the plaster.

As discussed later, plaster of Paris can be applieddirectly to the skin. Contact dermatitis, although rare,should be considered whenever an unpadded cast orsplint is applied.43,46,47

SPLINT AND CAST DESIGNS

Plaster application to the hand has three basicdesigns—circumferential casts (padded over thehand, unpadded over the digit), padded slabs, andisolated contour molds.

Circumferential Padded Cast

Padded casts have a layer of tubular stockinetteapplied directly to the skin, over which cast paddingis applied prior to the application of plaster of Paris.The use of cotton cast padding (Webril undercastpadding, North Coast Medical, Inc., Morgan Hill,California) rather than synthetic padding is recom-mended. Synthetic padding will narrow as tension isapplied, whereas the cotton will shred apart beforeexcessive tension is applied, preventing the possibil-ity of excessively tight application. Synthetic paddingalso usually has more cushion, making the applica-tion of intimately molded plaster of Paris over thepadding more difficult.

A wet roll of plaster of Paris is quickly wrappedaround the padded part, overlapping by 25% to 50%,with four to six layers applied for a non-weight-bear-ing circumferential cast.18,44 As soon as a completeroll of plaster of Paris has been applied, the layers aresmoothed together until it becomes one mass. Oncethe set point is reached, joints cannot be repositionedor the contour changed. Any attempted remoldingwill hinder the interlocking of calcium sulfate crys-tals and weaken the cast or splint.28


Circumferential casts require removal by cuttingdown two sides with an oscillating cast saw. If thepadding and stockinette are cut on one side only, thecircumferential cast becomes a hinged removable cast(called a bivalved cast). The addition of circumferen-tial hook-and-loop straps allows periodic reapplica-tion of the cast during weaning periods.

Digital Unpadded Casts

Because of the tubular shape of the digits, digitalcasts can be applied directly to the skin and easilyremoved by soaking in water or cutting with scissors.(Cast saws are never used on unpadded casts.) Theplaster of Paris adheres slightly to the underlying skin,forming perfect contact for pressure distribution.Multiple layers of 1-inch-wide plaster of Paris stripsare wrapped around the digit and smoothed togetherwhile the joints are gently positioned. Bell-Krotoskiprovides detailed descriptions of this technique.1,16

Plaster Slabs

Plaster slabs are lengths of multiple layers of plas-ter of Paris applied to one or both sides of the extrem-ity. Prior to application, a wet slab is placed on stripsof padding material and smoothed out so that theplaster of Paris layers meld together and adhere tothe padding. The slab is then held in place on theextremity with an elastic bandage or gauze wrap.When two slabs are used, one may be applied andallowed to harden slightly before the second isapplied. The slabs can be removed and reapplied bythe patient (Figure 1).

Contour Molds

Contoured plaster of Paris molds are used to applypositive pressure to scars and, secondarily, to assist inrepositioning joints. Since the plaster of Paris contourswell and does not cause maceration, it is the ideal


FIGURE 1. Plaster of Paris slabs are used to serially position the wrist. Topleft, Multiple layers of plaster of Paris are prepared. Top right, Slabs areimmersed in water and then smoothed out over layers of cast padding. Left, Avolar slab is applied and wrapped in place, and the wrist is held in extensionwhile the plaster of Paris hardens. Above, After identical application of a dor-sal slab, both slabs can be removed and reapplied.

material for application directly over scars, especiallyif the skin needs to be held at length while the positivepressure is applied. The plaster of Paris may beapplied directly to the skin, or one layer of paddingmay be applied underneath. One layer of wet plasterof Paris is applied at a time and is smoothed in place,until the desired size and shape are achieved. To pre-vent friction of the mold on the hand, the mold isapplied with an elastic or self-adherent elastic wraprather than with straps.

Regardless of the design, the most importantaspect of successful use of plaster of Paris is the meld-ing of the layers together, to make a strong and well-molded contour.

CLINICAL APPLICATIONS

Joint Tightness

The periarticular structures of the human jointadaptively shorten under any circumstance in whichthe joint is not carried through the full range ofmotion. If trauma creates scar within the periarticularstructures, the resistance to full motion becomes evengreater. Joint tightness is currently the most commonclinical problem treated with plaster of Paris castingor splinting.

Serial Digital Casting

Serial digital casts are frequently used to decreaseIP flexion contractures. This technique was devel-oped by Brand23 and Kolumban48 in work with lep-rosy patients in India, and it is detailed by Bell-Krotoski1,16 and others.49 Kolumban’s work48 has val-idated the superiority of serial casting for increasingjoint motion in patients with leprosy, compared withboth traditional physical therapy techniques anddynamic splinting.

Both recently injured joints and chronically stiffjoints respond to serial casting. Those who hesitate toapply serial casting for a brief period early in thetreatment of proximal interphalangeal (PIP) jointproblems are missing a valuable opportunity. A fewdays of serial casting will significantly decrease jointedema while enabling the joint to regain the weakermotion of extension.

In many cases, reducing joint edema is as crucial tothe resumption of normal joint motion as is decreas-ing the resistance of the periarticular structures. Abulbous, somewhat fluctuant PIP joint with inflam-mation localized to one or more collateral ligaments isan ideal candidate for a short period of serial castingearly in rehabilitation.

Concerns are often expressed that the circumferen-tial pressure of the cast on a digit may cause ischemiadue to increased swelling. Since the cast is neverapplied in the acute inflammatory stage and since thepressure of the hardened cast is static, the common

response of the digit is decreased edema. The rest thatthe cast provides to the joint contributes to dimin-ished inflammation, which also reduces edema.

Both edematous PIP joints and contracted PIPjoints may gain greater flexion as a result of theextension mobilization casting. In an edematousjoint, greater flexion results from increased room tomove into a closed pack position. In a contractedjoint, the elongation of scar impeding volar platemovement allows the volar plate to more readily foldout of the way during flexion.

An additional advantage of plaster of Paris digitalcasting is the ability to mobilize adjacent joints inopposite directions. In a fixed boutonniere deformity,the DIP joint can be mobilized into flexion and the castallowed to harden. The PIP joint is then cast towardextension with the application of additional plaster ofParis. Conversely, fixed swan neck deformities can begently altered by first mobilizing the DIP joint intoextension and then the PIP joint into flexion.1 Digitalcasts may also be used to mobilize an isolated tightjoint while a thermoplastic splint with outriggers isapplied to elongate a tight muscle–tendon unit.1

Serial Plaster of Paris Slabs

Plaster of Paris slabs are particularly useful forregaining wrist extension after distal radius frac-ture.43 Immediately following mobilization of thewrist in therapy, the wrist is positioned in easy max-imum extension and a volar slab is applied. A dorsalplaster of Paris slab is then applied to hold the wristsecurely against the volar mold. When appliedtogether, these two molds sandwich the wrist andhold it in maximum extension (Figure 1). The patientwears this for prolonged sessions during the day,and sleeps in it. After waking, the patient starts withthe wrist at its maximum extension, rather thanworking to regain the maximum achieved the previ-ous day. When the patient can actively lift the wristout of the volar slab, a new one is molded.

Arthritis

Prior to the development of anti-inflammatorydrugs, plaster of Paris immobilization splints or castswere used to decrease synovial inflammation andreduce pain in patients with inflammatory arthritis.When inflammation subsided, serial plaster of Parissplints or casts were then applied to regain motion inthe stiffened joints.19 Since the advent of anti-inflam-matory drugs, immobilization splinting for control ofsynovial inflammation is rarely used in the UnitedStates. The use of night resting splints19 has contin-ued, but these splints are now made from thermo-plastic materials for ease of construction and greaterdurability.

There remains a large realm of appropriate appli-cation of plaster of Paris to minimize and in some


cases reduce hand joint deformities resulting fromarthritis and other connective tissue disorders. Asjoint deformities or instability begins, the balance ofthe forces crossing the joints of the hand is altered.Deformities are likely to progress if there is no exter-nal influence in the opposite direction. Gentle, slowrepositioning of the joints via serial plaster of Parissplinting or casting allows the soft tissues to resumetheir previous length. This is the ideal way to mobi-lize such joints comfortably.

It is only when forceful serial casting is applied thatconcern for cartilage neurosis via sustained pressure isa consideration. Since rheumatoid arthritis is a colla-gen disorder that increases the laxity of the supportingstructures of the joints, fear of stiffness from a reason-able period of immobilization from serial splinting orcasting is unfounded.

Serial casting to reduce digital deformities, such asboutonniere and swan neck deformities, may beapproached as in the hand with trauma, so long asx-rays show an absence of a fused joint. Even anobstinate joint with a pseudarthrosis can sometimesbe slightly repositioned so that the deformed positionis more functional. Therapists will do no harm if theydiscard any idea of force application in theirapproach to patients with such deformities, andapply plaster of Paris to gently reposition the tissue.

In a patient with severe contractures due to sclero-derma, the possibility of regaining joint motion isobliterated by the nature of the disease. Patients withseverely contracted PIP joints have ischemia of thetaut dorsal skin, and dorsal ulcers are frequentlypresent. These ulcers are hard to heal, because theposition of the severely contracted joint places con-tinual tension on the dorsal skin, and the prominentapex of the flexed PIP joint is prone to abrasion. Acarefully applied serial digital cast (with a thin layerof cast padding over the PIP prominence) will protectan ulcer from pressure or fiction and can slowlyrelieve some of the tension on the dorsal skin, allow-ing the ulcer to heal. Care must be taken that the castis not tight enough to constrict even further thealready diminished blood flow of the finger.

Contracted Joints Due to Spasticity

Inhibitive casting is used as a treatment technique inpatients with cerebral palsy and head injuries, todecrease spasticity and improve joint contrac-tures.31–34,50–53 Although reports of the use of plaster ofParis inhibitive casting are limited to single case stud-ies or general observation, a significant change in qual-ity of movement and amount of joint motion is consis-tently reported.31,33,34 The extremity is cast in a func-tional tone-inhibiting posture that theoreticallyreduces cutaneous input and spasticity by providingneutral warmth and even cutaneous pressure.31–34 Theprolonged positioning also results in muscle lengthen-

ing.31 After initial progress has been noted, the cast isbivalved and worn for limited periods during day. Asone would expect, these patients need long-term cast-ing to retain the gains that have been made.31,33

Most casting of these patients is used to mobilizelarge joints such as the elbow or knee. Both circumfer-ential serial casts and drop-out casts are used. Drop-out casts are circumferential around either the proxi-mal or the distal bone, but the other bone is allowed tomove only in the direction away from the contractedposition. This allows active muscle contraction of thedesired (and weaker) muscle into a greater range ofjoint motion, but it prevents the joint and muscle fromresting in the fully contracted position.32,54,55

This concept of controlling the direction and extentof joint motion has been used by the author to devel-op a new approach to mobilization of the stiff hand—casting motion to mobilize stiffness (CMMS)—whichis discussed below.

Muscle–Tendon Tightness

Tightness of the muscle–tendon unit of either theextrinsic flexors or the extensors is remedied by seri-al positioning of all the joints crossed by the muscle,to regain maximum length.43 Since each joint beingpositioned requires three points of pressure to beaccurately immobilized,56 the multiple joints of thehand and wrist can best be serially positioned usingvolar and dorsal plaster of Paris slabs. If only onecomponent is used, stability of the splint on the handis dependent on the strapping or wrapping, whichover time allows movement of the hand joints in thesplint.57 When plaster of Paris slabs are used bothdorsally and volarly, only one position is availablefor all the joints, and this position is sustained.

This slab technique also provides a safe means ofrepositioning an acutely injured hand while provid-ing gentle compression to minimize edema. Thevolar slab is molded to position the wrist and hand inthe desired position. When the volar slab starts toharden, the dorsal slab is molded. An additionalsmaller slab is molded to hold the thumb (Figure 2).

Skin Tightness

Because both burns and skin grafts provide a largebed of contractile scar, maintenance of skin length inall directions is needed to avert loss of joint motion.Plaster of Paris conformed over an area can comfort-ably position numerous joints accurately and alsoprovide perfectly distributed pressure with a breath-able material.

Plaster of Paris seems to be the ideal material in suchcircumstances, rather than being used only for patientswho are noncompliant, as advocated by some.58,59 Thetissue response with plaster of Paris—the reduction ofsubtle edema, the flattening and softening of the tissue,and its increased mobility in response to gentle pres-


sure59—is always superior to the tissue response withthermoplastic splints. The straps of thermoplasticsplints can never stabilize a splint as accurately as cancircumferential application of plaster of Paris or con-tour molds held in place with wraps.

The prolonged splinting or casting needed bypatients with extensive burn or skin injuries is a chal-lenge. The immobilization imposed by any type ofsplint or cast, whether made of thermoplastic materi-al or of plaster of Paris, is difficult to balance with theneed for joint movement. Plaster of Paris can easilybe applied in a design that allows for splint removal.Bivalved casts, splints, or molded supports wrappedin place with self-adherent wrap or overlappingmolded plaster of Paris slabs can provide well-distributed pressure but also can be removed for skinhygiene and exercise.

Because skin scars can cover any plane of motionand any number of joints, multiple joints often need

to be positioned. When thermoplastic materials areused, all joints must be simultaneously positionedwhile the thermoplastic material is cooling. Withplaster of Paris, one joint can be precisely positionedand the plaster of Paris allowed to harden. Thenadditional plaster of Paris can be added for carefulpositioning of the adjacent joint. By use of plaster ofParis, a contracted hand can be slowly coaxed into amore functional position.59 If motion is lacking inboth directions, Rivers59 suggests using alternatingflexion and extension casts to prevent significant lossof motion in either direction.

Plaster of Paris is well tolerated over open wounds.One study of split thickness skin grafts to the lowerextremity showed that in patients who received castsimmediately after surgery, wound closure was morerapid, graft acceptance was better (72% vs. 100%),and fewer therapy treatments were required than inan uncasted group.35 Since plaster of Paris decreasesfriction of the splint or cast on the wound andabsorbs wound drainage, it allows unimpededwound healing. Wounds with unhealed areas andimmature scars intolerant of friction (such as burnwounds that easily blister) are ideal candidates forthe gentle pressure that plaster of Paris provides.Such wounds are tolerant of plaster of Paris alsobecause collection of perspiration and moisture–anegative aspect of thermoplastic splinting material—is avoided.

Skin and Joint Tightness

If joint tightness accompanies skin shortness due toscarring, plaster of Paris provides direct pressure tothe scar while joints are mobilized with repeatedrepositioning. In the author’s opinion, the concurrentpresence of skin and joint tightness is an absoluteindication for the use of serial casting. This is espe-


FIGURE 2. Dorsal and volar plaster of Paris slabs with a smallthumb slab can slowly and safely reposition joints in the acutelyinjured hand while providing conformed compression to reduceedema.

FIGURE 3. Left, Following severe crush injury,the long finger stump is contracted and the first webspace is tight. Middle, A serial cast is applied (dor-sal view). Right, Extension of long finger stumpand elongation of first web are regained.

cially true in the thumb, where the many directionsof motion and planes of skin movement make mobi-lization difficult. In multiple tissue injuries with skininjury—such as explosion injuries to the palm, skinloss in the first web, and severe crush injuries to thepalm—plaster of Paris is likely to be more useful thanthermoplastic materials (Figure 3).

Edema Reduction

Traditional hand therapy techniques for edemareduction are elevation, active motion, and compres-sion with either elastic gloves or wraps or the appli-cation of massage. Recent increased awareness of theanatomy and physiology of the lymphatic system hascaused many hand therapists to adopt gentlerapproaches when using these techniques, since wehave learned that excessive pressure can preventlymph fluid from entering the initial lymphatics.60,61

Active finger movement while in a wrist cast causesthe skin on the palmar and dorsal surface of the handto move. The soft constraint of the padded plaster ofParis around the metacarpal area provides a lightmassage to the skin that facilitates lymphatic flow.Since the cast retains its original size and shape, thereis no danger of a constrictive force, such as that seenwith proximal compressive wraps.

This response was highlighted by a dramaticreduction in edema in a patient with a severe crushinjury. A small cast was applied around the ampu-tated thumb stump to contour the palmar scar andprovide maximum abduction of the first metacarpal.The presence of the thin padded cast over themetacarpal area resulted in a dramatic reduction ofedema (Figure 4). Use of such a thin cast over themetacarpal area and around the base of the thumbmay in some cases be a preferable edema reductiontechnique in the severely injured hand.

Joint Tightness, Soft Tissue Adherence,Chronic Edema, and Altered Pattern ofMotion in the Chronically Stiff Hand

Casting motion to mobilize stiffness (CMMS) is atechnique developed by the author that uses plasterof Paris casting to selectively immobilize proximaljoints in an ideal position while constraining distaljoints so that they move in a desired direction andrange.62,63 Only active motion is used to gain bothactive and passive joint motion. No passive force isapplied to any joint during the casting. The hand issimply positioned so that the muscle and joint move-ment needed is the only motion that can occurrepeatedly over a long period of time (Figure 5).

In the chronically stiff hand, generalized joint stiff-ness results in joint tightness with a hard end-feel andconstraint of soft tissue movement. Since the cast redi-rects the muscle–tendon excursion constantly to thejoints where it is most needed, cyclic active motionmobilizes the tissue in both directions.64 The activemotion re-establishes the normal collagen cross-link-ing.65–67 Mobilization splinting, on the other hand,moves the tissues in only one direction. Additionalnegative effects of mobilization splinting are constric-tion that contributes to edema, immobilization thatprevents pumping of the venous and lymphatic sys-tem, and the possibility of excessive force, all of whichprolong the inflammatory response.68,69 These factorsand the intermittent nature of mobilization splintingoften make mobilization splinting ineffective in thechronically stiff hand.

The advantages of using active motion to mobilizestiffness in the CMMS technique far outweighs anynegative effects of temporary immobilization of prox-imal joints. The movement of the stiffest joints main-tains lubrication within the collagen cell matrix, pre-vents abnormal cross-link formation, facilitates lym-


FIGURE 4. Left, Patient following severe crush injury with multiple fractures, tendonlacerations, amputations, and open wounds has thin circumferential cast applied to moldpalmar scar and position thumb stump.(Dorsal view; Cast padding is taped between fin-gers) Middle, Pitting edema is present prior to casting. Right, After a few days of castingedema is significantly reduced.

phatic flow, strengthens muscles, and re-establishesindependent glide of tissue layers. Although continu-ous passive motion has proved to be effective in thetreatment of acute joint injuries,70–72 neither laborato-ry nor clinical studies have demonstrated its useful-ness for reducing stiffness once it is present.71,73

Abnormal patterns of motion are established as aresult of the lack of tissue mobility (Figure 6, left). Thepatient repeatedly moves the loosest joints, whichencourages the somatosensory cortex to memorizethis aberrant pattern. Therefore, regaining motion inthe stiff hand is both a complex mechanical and cere-bral issue.

The mechanical problems are shown by the pres-ence of deviate patterns of motion. The most com-mon patterns are the dominant intrinsic flexion pat-tern, in which the metacarpophalangeal (MCP) jointsflex before the IP joints, reinforcing the stiffness in theIP joints; and the dominant extrinsic flexion patternwith stiff MCP joints, in which the IP joints flex fullybefore MCP joints. Almost all patterns of motion willcause a loss of the normal reciprocal balance of ten-odesis, in which finger flexion occurs concurrent towrist extension. A vicious cycle is establishedbecause the tissue stiffness prevents the normal pat-tern of motion, and without the normal pattern ofmotion the stiffness cannot be resolved.


FIGURE 5. Child with severe lawn mower injury at the wrist is fitted with a cast to support the wrist and position the fingers in slightflexion to facilitate maximum tendon glide after flexor tenolysis.

FIGURE 6. Left, Active finger flexion of patient with multiple wrist injuries and 4-month chronic open wound shows abnormal pos-ture and limited motion. Right, Cast with dorsal hood over the fingers immediately re-establishes pinch.

FIGURE 7. Patient with diminished finger flexion followingdistal radius fracture is fitted with a cast with the MCP joints inextension to allow active IP flexion to mobilize the interosseousmuscles.

Depending on the dominant pattern of motion, theCMMS cast blocks and stabilizes the proximal joints.For example, a hand with the dominant intrinsic flex-ion pattern is cast with MCP flexion blocked. If pro-fundus glide is poor, a dorsal hood is added to posi-tion the distal interphalangeal (DIP) joints in relative-ly greater flexion than the PIP joints, ensuring thatthe most likely muscle movement will be that of thethe flexor digitorum profundus. In hands withextremely limited motion, supporting the wrist inextension and placing a hood over the fingers imme-diately positions the fingers so that pinch is possible(Figure 6, right). This quickly converts a nonfunction-al hand to an assisting hand while digital motion isbeing regained.

Arbuckle and McGrouther74 validated the use ofthe dorsal hood to position the IP joints in greaterflexion than the MCP joints. They showed that thenormal pattern of digital flexion is initiated with IPflexion prior to any significant MCP flexion (hookposition). One must be cautioned against blockingthe MCP joints in full extension in the very stiff hand,since tight interosseous muscles may provide toomuch resistance to active IP flexion in the initialstages of mobilization. When reasonable profundusglide is regained, the cast position is changed to fullMCP extension so that IP flexion can mobilize thetight interosseous muscles (Figure 7).

A second example is the hand with stiff MCP jointsbut flexible IP joints. The dorsal hood extends onlyover the proximal phalanges (Figure 8). The patientworks on pulling the proximal phalanx away fromthe dorsal hood using primarily intrinsic muscles(minimal IP flexion) (Figure 8, middle). When agreater range of MCP flexion is gained, a new dorsal

hood is applied to allow this active motion to occur ina greater range of flexion.

Although casting or other immobilization of the IPjoints might be considered to transmit all flexor forceto the resistant MCP joints, the author has not foundthis necessary, even with joints with a significanthard end-feel. At no time is any force applied to anyjoint with the plaster of Paris cast, nor are joints heldat the absolute end-range of motion. The joints aresimply positioned within the cast to optimize activemotion.

Third, if isolated joints are stiff, the cast restrains allproximal (or other) joint movement. Movement occursonly at the site of the greatest stiffness (Figure 9). Thisis particularly helpful with PIP joint stiffness in whichboth flexion and extension are lacking. This is the onlymobilization technique by which motion can begained in both directions at the same time.

The neurologic consequences resulting from thealtered pattern of motion create an additional consid-eration in the rehabilitation process. Since stiffnessproduces an abnormal pattern of motion, the motorcortex learns this pattern of motion as the new “nor-mal.” Neuroscience research shows that animals andhuman beings trained in movement combinationsmagnify the cortical representations of the motorareas used predominantly and that lack of usedecreases the corresponding cortical area.75–77

For motor cortex repatterning to occur, repeatedmotion in the desired pattern is needed over a periodof time.78,79 With removable splints, a patient revertsto the aberrant pattern of motion each time the splintis removed, and repatterning of the cortex is defeat-ed. This explains why mobilization splinting so oftenfails to reduce resistance in the very stiff hand or


FIGURE 8. Patient with hard end-feel stiffness of MCP joints following MCP joint dislocations:. Left, Limited active MCP flexion.Middle, Cast that dictates active MCP flexion in end range. Right, Active flexion after casting.

joint. For progress to occur and be maintained, thepatient must wear the CMMS cast for a significantperiod of time and wean slowly. Since original corti-cal connection patterns persist and can easily be re-activated,78 a few weeks in a cast can convert the pat-tern of motion even if the stiffness has been of longduration.

In the chronically stiff hand, mild pitting edemaaccompanies atrophic, shiny skin and diminished orabsent joint creases. The tissues are firm to palpationand have decreased mobility. The excess fibrosisfrom the prolonged immobility and the presence ofhigh-protein edema impede the flow of lymphaticfluid.60,80,81 Because of the limited active motion, thelymphatic system becomes stagnant. Since the singlemost effective stimulator of the lymphatic system isactive motion,12,60,61,80,82,83 CMMS casting effectivelyfacilitates lymphatic pumping by encouraging activemotion. No other mobilization technique providesthis stimulus so consistently.

Since the initial lymphatics in the skin are easily col-lapsed by excessive pressure,61,84 light pressure isrequired to facilitate lymphatic flow. The cast provideslight pressure to the hand, while movement of thehand within the padded casts provides a facilitatorypseudo-massage to the skin. There is also a direct rela-tionship between ambient temperature and the per-meability of the initial lymphatics.85,86 The insulationof the cast provides neutral warmth, retaining thebody heat. In addition to effecting lymphatic flow, theneutral warmth may assist in general tissue relaxationand facilitate tissue elongation.31,32

Dramatic results have been seen in numerouspatients with chronically stiff hands due to a widevariety of conditions. Each case is unique, and thecast design must be specific to the altered pattern of

motion. The cast must be precisely applied with accu-rate molding to ensure well-distributed pressure.Most therapists are uncomfortable with the tempo-rary loss of motion in some joints and are likely towean a patient out of the cast too early, so that a peri-od of recasting is often required. Therapists must letgo of previous assumptions that motion must begained in all directions simultaneously.

The CMMS technique should not be used onpatients who are claustrophobic or have acuteinjuries or in a patient whose anatomy is so alteredthat a balance of motion cannot be regained when theCMMS casting is discontinued.

Postoperative Mobilization of Flexor Tendon Glide

In unusual circumstances, following flexor tenoly-sis or flexor tendon repair, the application of a plas-ter of Paris cast to stabilize the wrist and allow onlyfinger flexion may be the optimal postoperative ap-proach. If a patient has had limited flexor tendonglide for a period of time, the unimpeded intrinsicmuscles will always be dominant. Placing the handin a cast in which only flexor glide is possible assiststhe patient with accurate muscle pull-through. Inflexor tenolysis, the cast may be applied early aftersurgery.

Limited proximal excursion of the flexor tendonsmeans that the muscles have never been allowed tomaximally contract. Placing the hand in a cast with adorsal hood over the fingers allows the patient towork in the end range of active finger flexion, whichalso allows effective muscle strengthening. When thismotion is regained, extension can be incorporatedinto the exercise program. Stretching and intermit-tent splinting can help the patient regain the exten-


FIGURE 9. Left, 13-year-old patient with unusual pattern of hyperflexion of both the metacarpophalangeal and distal interphalangealjoints with limited proximal interphalangeal (PIP) joint flexion following proximal phalanx fracture. Middle, Cast to prevent motionat all joints but the PIP joint. Right, Final flexion.

sion, since it was dominant prior to the tenolysis.This treatment approach has been particularly usefulwith children and with mentally retarded adults whohave difficulty appreciating the correct motion.

In patients who have had flexor tendon repairs andare in unusual circumstances (such as incarceration)and in patients who have limited comprehension, thehand is placed in a cast with a dorsal hood after3 weeks of immobilization. The dorsal hood protectsthe hand from forced extension but allows activeflexion while stabilizing the wrist. At 6 weeks, whenthe tendon can withstand passive extension, the castis removed and the patient works on regainingextension while maintaining flexion.

Some therapists have expressed concern that thedorsal hood would create IP flexion contractures.Since the joints are moving actively and edema isminimal, this concern has appears to be unfounded.

This type of cast application allows simplificationof the postoperative regimen. The motion with thegreatest deficit is the primary focus. Until adequategains are made in that direction of motion, motion inthe other direction is ignored. Casting can be thoughtof as a jump-start for the greatest deficiency. The fewweeks of casting are, realistically, a very short periodrelative to the maturation process of the healing scar.

CONCLUSION

This article reviews the characteristics of plaster ofParis and re-introduces the concept of tissue adapta-tion in response to the application of plaster of Parissplints and casts. Clinical examples of the use of plas-ter of Paris are discussed, and a variety of applica-tions in cases with specific diagnoses are described.

It is hoped that the reader will question previousassumptions about temporary immobilization ofuninjured joints, concurrent goals of gaining motionin all directions, and methods of edema reduction.Such questions should lead the reader to use plasterof Paris splinting or casting more often to solve clini-cal problems. Therapists who lack plaster of Parishandling skills should seek the assistance of a skilledpractitioner and should apply and remove numerouscasts before using these treatment techniques withpatients.

REFERENCES

1. Bell JA. Plaster casting in the remodeling of soft tissue. In: FessEE, Philips CA (eds). Hand Splinting: Principles and Methods.2nd ed. St Louis: CV Mosby, 1987.

2. Akeson WH, Amiel D, Mechanic GL, Woo SLY, Harwood FL,Hamer ML. Collagen cross-linking alterations in joint contrac-tures: changes in the reducible cross-links in periarticular con-nective tissue collagen after nine weeks of immobilization.Connect Tissue Res. 1977;5:15–9.

3. Akeson WH, Amiel D, Abel MF, Garfin SR, Woo SL-Y. Effects ofimmobilization on joints. Clin Orthop Rel Res. 1987;219:28–37.

4. Akeson WH. An experimental study of joint stiffness. J Bone

Joint Surg. 1961;43A:1022–34.5. Amiel D, Woo SL-Y, Harwood FL, Akeson WH. The effect of

immobilization on collagen turnover in connective tissue: abiochemical-biomechanical correlation. Acta Orthop Scand.1982;53:325–32.

6. Booth WF. Time course of muscular atrophy during immobi-lization of hind limbs in rats. J Hand Surg.977;43A:656–61.

7. Bray RC, Shrive NG, Frank CB, Chimich DD. The early effectsof joint immobilization on medial collateral ligament healingin an ACL-deficient knee: a gross anatomic and biomechanicalinvestigation in the adult rabbit. J Orthop Res. 1992;10:157–66.

8. Grauer D, Kabo JM, Dorey FJ, Meals RA. The effects of inter-mittent passive exercise on joint stiffness following periarticu-lar fracture in rabbits. Clin Orthop Rel Res. 1987;220:259–65.

9. Kasperczyk WJ, Bosch U, Oestern HJ, Tscherne H. Influence ofimmobilization on autograft healing in the knee joint. ArchOrthop Trauma Surg. 1991;110:158–61.

10. Liepert J, Tegenthoff M, Malin J-P. Changes of cortical motorarea size during immobilization. Electroencephalogr ClinNeurophysiol. 1995;97:382–86.

11. Muneta T, Yamamoto H, Takakuda K, Sakai H, Furuya K.Effects of postoperative immobilization on the reconstructedanterior cruciate ligament. Am J Sports Med. 1993;21:305–13.

12. Namba RS, Kabo JM, Dorey FJ, Meals RA. Continuous passivemotion versus immobilization. Clin Orthop Rel Res. 1991;267:218–23.

13. Woo SL-Y, Gomez MA, Sites TJ. The biomechanical and mor-phological changes in the medial collateral ligament of the rab-bit after immobilization and remobilization. J Bone JointSurg.1987;69A:1200–11.

14. Woo SL-Y, Matthews P, Akeson WH, Amiel D, Convery FR.Connective tissue response to immobility: correlative study ofbiomechanical measurements of normal and immobilized rab-bit knees. Arthritis Rheum. 1975;18:257–64.

15. Kolumban S. The use of dynamic and static splints in straight-ening contracted proximal interphalangeal joints in leprosypatients: a comparative study. Presented at: 47th AnnualConference of the American Physical Therapy Association,1960.

16. Bell-Krotoski JA. Plaster cylinder casting for contractures ofthe interphalangeal joints. In: Mackin EJ, Callahan AD, SkirvenTM, Schneider LH, Osterman AL (eds). Hunter, Mackin &Callahan’s Rehabilitation of the Hand. 5th ed. St. Louis, Mo.:Mosby, 2002:1839–45.

17. Salib P. Plaster Casting. New York: Appleton-Century-Crofts,1975.

18. Woo K. Techniques in Surgical Casting and Splinting.Philadelphia, Pa.: Lea & Febiger, 1987.

19. Rotstein J. Simple Splinting: The Use of Light Splints andRelated Conservative Therapy in Joint Diseases. Philadelphia,Pa.: Saunders, 1965.

20. Bunnell S. Surgery of the Hand. 2nd ed. Philadelphia, Pa.:Lippincott, 1948.

21. Beasley RW. The addition of dynamic splinting to hand casts.Plast Reconstr Surg. 1969;44:507.

22. Bunnell S. Active splinting of the hand. J Bone Joint Surg.1946;28:732–6.

23. Brand PW. The reconstruction of the hand in leprosy. Ann RColl Surg Engl. 1952;11:350.

24. Wilton J. Hand Splinting. London, UK: Saunders, 1997.25. Salter MI, Cheshire L. Hand Therapy, Principles and Practice.

Oxford, UK: Butterworth-Heinemann, 2000.26. Van Lede P, Van Veldhoven G. Therapeutic Hand Splints: A

Rationale Approach. Antwerp, Belgium: Provan bvba, 1998.27. McKee P, Morgan L. Orthotics in Rehabilitation. Philadelphia,

Pa.: F.A. Davis, 1998.28. Bleck E, Duckworth N, Hunter N. Atlas of Plaster Casting

Techniques. Chicago, Ill.: Year Book, 1974.29. Lewis R. Handbook of Traction, Casting, and Splinting

Techniques. Philadelphia, Pa.: Lippincott, 1977.30. Flatt AE. The Care of the Arthritic Hand. 5th ed. St. Louis, Mo.:


Quality Medical Publishing, 1995.31. Law M, Cadman D, Rosenbaum P, Walter S, Russell D,

DeMatteo C. Neurodevelopmental therapy and upper-extrem-ity inhibitive casting for children with cerebral palsy. Dev MedChild Neurol. 1991;33:379–87.

32. King TI. Plaster splinting as a means of reducing elbow flexorspasticity: a case study. Am J Occup Ther. 1982;36:671–3.

33. Katz RT. Management of spasticity. Am J Phys Med Rehabil.1988;67:108–16.

34. Barnard P, Dill H, Eldredge P, Held JM, Judd DL, Nalette E.Reduction of hypertonicity by early casting in a comatosehead-injured individual: a case report. Phys Ther. 1984;64:1540–2.

35. Ricks NR, Meagher DPJ. The benefits of plaster casting forlower-extremity burns after grafting in children. J Burn CareRehabil. 1992;13:465–8.

36. Wytch R, Ashcroft G, Ledingham WM. Modern splintingbandages. J Bone Joint Surg. 1991;73B:88–91.

37. Marshall PD, Dibble AK, Walters TH, Lewis D. When should asynthetic casting material be used in preference to plaster-of-Paris? A cost analysis and guidance for casting departments.Injury. 1992;23:542–4.

38. Rowley DI, Pratt D, Powell ES, Norris SH, Duckworth T. Thecomparative properties of plaster of Paris and plaster of Parissubstitutes. Arch Orthop Trauma Surg. 1985;103:402–7.

39. Hedeboe J, Larsen FM, Lucht U, Christensen ST. Heat genera-tion in plaster-of-Paris and resulting hand burns. Burns InclTherm Inj. 1982;9:46–8.

40. Gannaway JK, Hunter JR. Thermal effects of casting materials.Clin Orthop. 1983:181;191–5.

41. Becker DJ. Danger of burns from fresh plaster splints sur-rounded by too much cotton. Plast Reconstr Surg. 1978;62:436–7.

42. Lavalette R, Pope MH, Dickstein H. Setting temperatures ofplaster casts: the influence of technical variables. J Bone JointSurg. 1982;64A:907–11.

43. Tribuzi S. Serial plaster splinting. Mackin EJ, Callahan AD,Skirven TM, Schneider LH, Osterman AL (eds). Hunter,Mackin & Callahan’s Rehabilitation of the Hand. 5th ed. St.Louis, Mo.: Mosby, 2002:1828–38.

44. Parsons TA. Basic casting techniques. Aust Fam Phys. 1991;20:254–70.

45. Williams J. Plaster of Paris: A Manual of Basic CastingTechniques. Auckland, NZ: Joan Williams/Smith & NephewNZ, 1990.

46. Lovell C, Staniforth P. Contact allergy to benzalkonium chlo-ride in plaster of Paris. Contact Dermatitis. 1981;7:343–4.

47. Staniforth P. Allergy to benzalkonium chloride in plaster ofParis after sensitization to centrimede: a case report. J BoneJoint Surg. 1980;62B:500–1.

48. Kolumban S. The role of static and dynamic splints, physio-therapy, techniques and time in straightening contractures ofthe interphalangeal joints. Lepr India. 1969;41:323–8.

49. Colditz JC, Schneider AM. Modification of the digital serialplaster casting technique. J Hand Ther. 1995;8:215–6.

50. Garland DE, Keenan MA. Orthopedic strategies in the man-agement of the adult head-injured patient. Phys Ther.1983;63:2004–9.

51. Mills VM. Electromyographic results of inhibitory splinting.Phys Ther. 1984;64:190–3.

52. Conine TA, Sullivan T, Mackie T, Goodman M. Effect of serialcasting for the prevention of equinus in patients with acutehead injury. Arch Phys Med Rehabil. 1990;71:310–2.

53. Goya-Eppenstein P, Hill J, Philips CA, Philip M, Seifert T,Yasukawa A. Casting protocols for the upper and lowerextremities. Gaithersburg, Md.: Aspen, 1999.

54. Booth BJ, Doyle M, Montgomery J. Serial casting for the man-agement of spasticity in the head-injured adult. Phys Ther.1983;63:1960–6.

55. Cherry D, Weigand G. Plaster drop-out casts as a dynamicmeans to reduce muscle contracture. Phys Ther. 1981;61:

1601–3.56. Colditz JC. Efficient mechanics of PIP mobilisation splinting.

Br J Hand Ther. 2000;5:65–71.57. Taams KO, Ash GJ, Johannes S. Maintaining the safe position

in a palmar splint: the “double-T” plaster splint. J Hand Surg.1996;21B:396–9.

58. Ridgway CL, Daugherty MB, Warden GD. Serial casting as atechnique to correct burn scar contractures: a case report. JBurn Care Rehabil. 1991;12:67–72.

59. Rivers E. Management of hypertrophic scarring. In: Fisher S,Helm P (eds). Comprehensive Rehabilitation of Burns.Baltimore, Md.: Williams & Wilkins, 1984:177.

60. Mortimer PS. Therapy approaches for lymphedema.Angiology. 1997;48:87–90.

61. Ryan TJ, Mortimer PS, Jones RL. Lymphatics of the skin. Int JDermatol. 1986;25:411–9.

62. Colditz JC. Preliminary report of a new technique for castingmotion to mobilize stiffness [abstract]. J Hand Ther. 2000;13:72.

63. Colditz JC. Therapist’s management of the stiff hand. In:Mackin EJ, Callahan AD, Skirven TM, Schneider LH,Osterman AL (eds). Hunter, Mackin & Callahan’s Rehabilita-tion of the Hand. 5th ed. St. Louis, Mo.: Mosby, 2002:1021–49.

64. Weisman G, Pope MH, John RJ. Cyclic loading in knee liga-ments. Am J Sports Med. 1980;8:24–30.

65. Akeson WH, Amiel D, Woo SL. Immobility effects on synovialjoints: the pathomechanics of joint contracture. Biorheology.1980;17:95–110.

66. Donatelli R, Owens-Burkhart H. Effects of immobilization onthe extensibility of periarticular connective tissue. J OrthopSports Phys Ther. 1981;3:67–72.

67. Noyes FR. Functional properties of knee ligaments and alter-ations induced by immobilization. Clinical Orthop Rel Res.1977;123:210–41.

68. Brand PW, Hollister AM. Clinical Mechanics of the Hand. 3rded. St. Louis, Mo.: Mosby, 1999.

69. Merritt WH. Written on behalf of the stiff finger. J Hand Ther.1998;11:74–9.

70. O’Driscoll SW, Kumar A, Salter RB. The effect of the volume ofeffusion, joint position and continuous passive motion onintraarticular pressure in the rabbit knee. J Rheum. 1983;10:360–3.

71. Salter RB. The biologic concept of continuous passive motionof synovial joints: the first 18 years of basic research and itsclinical application. Clin Orthop Rel Res. 1989;242:12–25.

72. Van Royen BJ, O’Driscoll SW, Dhert WJA, Salter RB. A com-parison of the effects of immobilization and continuous pas-sive motion on surgical wound healing in mature rabbits. PlastReconstr Surg. 1986;78:360–6.

73. Meals RA. Post-traumatic limb swelling and joint stiffness arenot causally related experimental observations in rabbits. ClinOrthop. 1993;(287):292–303.

74. Arbuckle JD, McGrouther DA. Measurement of the arc of dig-ital flexion and joint movement ranges. J Hand Surg. 1995;20B:836–40.

75. Liepert J, Bauder H, Miltner WHR, Taub E, Weiller C.Treatment-induced cortical reorganization after stroke inhumans. Stroke. 2000;31:1210–6.

76. Byl NN, Merzenich M, Jenkins WM. A primate genesis modelof focal dystonia and repetitive strain injury, part I: Learning-induced dedifferentiation of the representation of the hand inthe primary somatosensory cortex in adult monkeys.Neurology. 1996;47:508–20.

77. Pascual-Leone A, Cammarota A, Wassermann EM, Brasil-NetoJ, Cohen L, Hallett M. Modulation of motor cortical outputs tothe reading hand of Braille readers. Ann Neurol. 2000;34:33–7.

78. Kaas JH. Plasticity of sensory and motor maps in adult mam-mals. Ann Rev Neurosci. 1991;14:137–67.

79. Merzenich M, Kaas J, Wall J, Nelson R, Sur M, Felleman D.Progression of change following median nerve section in thecortical representation of the hand in areas 3b and 1 in adultowl and squirrel monkeys. Neuroscience. 1983;10:639–65.


80. Casley-Smith JR, Casley-Smith JR. High-protein oedemas andthe benzo-pyrones. Sydney, Aust.: Lippincott, 1986.

81. Casley-Smith JR, Gaffney RM. Excess plasma proteins as acause of chronic inflammation and lymphoedema: quantita-tive electron microscopy. J Pathol. 1981;133:243–72.

82. Junquerira LC, Carneiro J, Kelley RO. Basic Histology. 8th ed.Norwalk, Conn.: Appleton & Lange, 1995.

83. Leduc O, Peeters A, Bourgeious P. Bandages: scintigraphic

demonstration of its efficacy on colloidal protein reabsorptionduring muscle activity. Prog Lymphol. 1990;12:421–3.

84. Miller GE, Seale J. Lympathic clearance during compressiveloading. Lymphology. 1981;14:161–6.

85. Xujian S. Effect of massage and temperature on the permeabil-ity of initial lymphatics. Lymphology. 1990;23:48–50.

86. Ohkuma M. Skin and lymphatic system. Prog Lymphol. 1990;12:45–50.


Documents

Plaster of Paris - BraceLab...plaster of Paris is a more rapid change in the quality of the soft tissue, photographs do not adequately convey this progress. No objective means of quanti-fying