Journal of Hand Therapy 29 (2016) 41e50

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Journal of Hand Therapy

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JHT READ FOR CREDIT ARTICLE #403.

Scientific/Clinical Article

Effects of serial casting in the treatment of flexion contractures

of proximal interphalangeal joints in patients with rheumatoid
arthritis and juvenile idiopathic arthritis: A retrospective study

urlu OT, PT, MSc, PhD a, *, Huri Özdog
Ümit Ug
an MD b
a _
Department of Occupational Therapy, Faculty of Health Sciences, Bezmialem Vakif University, Adnan Menderes Bulvarı Fatih 34093, Istanbul, Turkey
b _
Department of Rheumatology, Cerrahpaşa Medical Faculty, Istanbul _
University, Istanbul, Turkey

a r t i c l e i n f o a b s t r a c t

Article history: Aim: To analyze the effects of serial casting (SC) in the treatment of proximal interphalangeal (PIP) joint
Received 28 April 2015 flexion contractures in patients with rheumatoid arthritis and juvenile idiopathic arthritis.
Received in revised form Study design: Retrospective case-series.
16 August 2015
Methods: The data of 18 patients treated with SC were obtained from their patient records. The angular
Accepted 16 November 2015
changes in the finger joints were analyzed and compared statistically using t-tests.
Available online 24 November 2015
Results: A total of 49 fingers were serially casted with plaster of Paris over a 14-year period. The SC
resulted in significant (26.8
; p < 0.001) reduction in the PIP joint extension loss. Small, but statistically
Keywords:
Arthritis
significant, losses in flexion were associated with these gains. (p < 0.001). Angular changes were also
Flexion contracture observed in the other finger joints. The magnitude of the initial extension loss was the only factor to
Serial casting explain the amount of motion gained (p < 0.001; R2 ¼ 0.38).
Plaster of Paris Conclusion: SC is an effective method to correct flexion contractures in PIP joints in selected patients with
Proximal interphalangeal joint arthritis. The gain is partially related to the magnitude of initial extension loss.
Ó 2016 Hanley & Belfus, an imprint of Elsevier Inc. All rights reserved.

Introduction one’s face. Improper immobilization also contributes to this situa-

tion and may lead to additional soft-tissue changes in the joint.9
Rheumatoid arthritis (RA) and juvenile idiopathic arthritis (JIA) Flexion contractures of the PIP joints are generally challenging
are the most common types of autoimmune connective tissue problems for hand therapists. Exercises and orthoses are common
disorders among adults and children respectively.1 Long-term conservative methods to deal with this problem.9 However, treat-
inflammation of the synovial tissue may lead to weakening of the ment protocols may differ depending on the nature and severity of
supporting structures and corruption of the delicate biomechanical the underlying pathology. There are some studies in the literature
balance of the joint in both disorders.2,3 The balance of the forces reporting the sole or combined effects of these methods.10,11 In
acting on the joints gradually deteriorates as joint deformities or most of these studies, patients have orthopedic problems. However,
instability develops. Deformities tend to progress if no external RA and JIA are chronic disorders in nature and disease
forces are provided in the opposite direction.4 The development of pathomechanisms in the joint differ from those of acute injuries.
flexion contractures in proximal interphalangeal (PIP) joints is a Various types of orthoses have been proposed for treatment of the
common sequela to this process in both disorders and a common problem.12,13 Static or elastic traction orthoses may be preferred
cause of referral to hand clinics.5e7 Structural changes inside the depending on the characteristics of the joint involvement. Static
joint or surrounding soft tissues may lead to a progressive lack of ones have been demonstrated to be effective in alleviating active
extension, hampering the ability to grasp medium to large objects.8 joint disease and pain by resting the inflamed joints,14,15 but the
In addition, patients may have difficulty in some activities of daily number of studies reporting the value of them in preventing or
living such as placing their hands into a narrow space and washing correcting finger deformities is limited.16 Although elastic traction
orthoses have proven to be effective in most orthopedic conditions,
they are used cautiously in patients with RA due to fear that the
force created by stretching may result in further damage to the joint
* Corresponding author. Tel.: þ90 523 22 88; fax: þ90 453 18 70. structures.17 This concern further increases in the active phase of
E-mail address: [email protected] (Ü. Ug
urlu). the joint disease when inflammatory synovium forms a pannus.

0894-1130/$ e see front matter Ó 2016 Hanley & Belfus, an imprint of Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.jht.2015.11.005
42 Ü. Ug
urlu, H. Özdog
an / Journal of Hand Therapy 29 (2016) 41e50

Pannus is an invasive tissue and grows over the surfaces of the joint Data collection
cartilage, into and around the tendons, and into the ligament at-
tachments. This invasion may result in loosening of ligaments, In addition to active range of motion (ROM) data of all joints in
destruction of joint surfaces, and functional disability of tendons.18 the casted fingers, demographic information, treatment and dis-
In the active phase of the disease, weakened and loose periarticular ease durations, and number of casting repetitions were obtained
tissues may not function properly to resist or transmit the dynamic from the treatment records of patients. All measurements and
forces even with appropriate parameters and may be further treatment interventions in the unit were conducted by one of the
damaged when exposed to them. authors of this study. He was the only therapist working in this
Tissue elongation provided by serial casting is another method clinic during the study interval.
to correct flexion contractures.19,20 It provides low load to short- Active ROMs were measured in all finger joints. A wire-tracing
ened periarticular tissues over a prolonged period of time.21 Gentle, method was used to measure ROM. In the study by Ellis et al,33
slow repositioning of the deformed joints via serial casting allows repeatability coefficients for the same observer and different ob-
contracted soft tissues to resume their original length.4 servers were found to be 10.9 and 12.3
respectively for the PIP
The idea of using serial casting to regain extension in inter- joints measured with a wire-tracing method. The corresponding
phalangeal joints was first introduced by Dr. Brand.22 His experi- values obtained with finger goniometry were 4.7 and 7.2
for the
ences with leprosy patients, paved the way for this method for a same joint. Although, a finger in healthy subjects, goniometer was
wide variety of conditions that are associated with joint contrac- shown to be a more reliable instrument in healthy subjects, wire
tures in the hand. Serial casting provides a gentler and more tracing was the preferred method for patients with finger
precise means of tissue remodeling compared to that provided by involvement in our therapy unit. The fact that the arms of a finger
elastic traction or static progressive orthoses. The response to goniometer could not be strictly placed over the phalanges because
continual positioning with serial casting is plastic deformation. of surface irregularities on the bones and soft tissues associated
When a contracted tissue is held under constant tension, a per- with arthritic changes was the major factor in this preference. ROM
manent change will occur due to reorientation of the collagen measurements were taken at the beginning of the therapy session
network.4,23e25 In addition to the realignment of collagen fibers, during the first visit. At the following visits, they were taken
Brand postulated the idea of the addition of new cells during immediately after cast removal. Before the measurements, patients
continual positioning.24,25 However, the idea of lengthening by were instructed to actively move their joint(s) to be measured until
adding cells has not been proven. the limit of motion in the test direction. ROM measurements of PIP
Digital serial casting can be accomplished with various mate- and DIP joints were taken together. Throughout the measurements
rials including Plaster of Paris (POP), thermoplastic tapes such as of these two joints, the wrist was supported in the neutral position.
OrficastÔ and fiberglass fabric coated with a kind of temperature- The loss of extension in PIP and DIP joints was measured in com-
sensitive polymer (QuickCastÔ).26 Among them, POP is the oldest, bined while the MCP joint of the same finger was held about 45
of
and the most versatile material. It is also readily available, cheap, flexion to eliminate the tightness of intrinsic hand muscles. While
conforms to body parts and is skin-friendly.4,27,28 Although serial maintaining the prescribed positions of MCP and wrist joints, pa-
casting is mentioned as an effective method for correcting flexion tients were requested to actively extend their interphalangeal
deformities in many resources,23,26,29 there are only a few studies joints. During the flexion measurements of these joints, the MCP
reporting its effectiveness for this problem.30e32 None of these joint was positioned in neutral, and the patient was requested to
studies use the serial casting for the correction of PIP joint flexion actively flex his or her finger to be measured into a hook position.
contractures in patients with RA or JIA. For the ROM measurements in MCP joints, PIP and DIP joints were
Another concern is the effects of PIP joint immobilization on the held in the relaxed position and the wrist joint was supported in
neighboring joints. This is a concern for all static orthoses.19 neutral.
Immobilization of a joint may lead to increased forces and Before the ROM measurements, a piece of solder wire was cut in
angular demands on the adjacent joints. This can be an even more accordance with the length of the segment to be measured. For the
important concern when serial casting fragile joints patients with measurements of interphalangeal joints, the wire was laid on the
RA or JIA. midline of the finger dorsum. For the MCP joint movements, solder
The main aim of this study was to retrospectively analyze the wire was placed on the proximal phalanx and the associated
effects of serial casting applications in a group of patients with PIP metacarpal bone of the finger to be measured. The wire was placed
joint flexion contractures associated with RA or JIA. We also aimed on the finger only after the joint being measured had reached its
to elicit patient- and disease-related factors that might have an angular limit in one direction. At this point, the solder wire was
effect on the result of treatment. carefully shaped with the angulation of the measured segment.
Then, the wire taking the shape of the segment was carefully
Method removed, while the patient preserved the end position(s) of the
joint(s), and put on a sheet of paper divided into squares for each
This study was conducted in the Rheumatology Department of joint movement. During this transfer process, maximum care was
_
Cerrahpaşa Medical Faculty at Istanbul University. The approval for taken to preserve the form of the wire. The shape of the wire was
_
the study was obtained from the Ethics Committee of Istanbul Bilim directly projected onto the paper via a pen while slightly pressing
University. The study design was retrospective. The data of patients down the ends of the wire with the tips of the index and middle
treated with serial casting to correct flexion contractures of the PIP fingers of the other hand. Joint locations were marked on the
joints were determined from the patient treatment records. A total projected line. After the axis of the goniometer was placed on the
of 49 fingers of 18 patients were identified that underwent serial point corresponding to movement axis of a finger joint, its arms
casting during the 14-year interval from which records were were held parallel to the linear parts of the proximal and distal lines
reviewed. These patients with RA or JIA were identified from those at each side of this point. After making sure that the goniometer
admitted to the outpatient clinic of a rheumatology department was correctly positioned on the paper, the degrees of angle on the
during the period between the years 1996 and 2009. Thirteen of scale was read and recorded below the tracing. For the follow-up of
them had a diagnosis of RA and the others had JIA. All patients, changes in the extension range, the amount of extension lack was
except one with JIA, were female. recorded. The maximum flexion angle was documented to track the
 Ü. Ug
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an / Journal of Hand Therapy 29 (2016) 41e50 43

changes in this direction. This process was repeated for both di- active exercises, power putty activities and the use of a proprio-
rections in all serially-casted fingers. ceptive neuromuscular facilitation technique (contracterelax) to
The effective number of repetitions (ENR) was calculated. It was facilitate PIP joint extension. The exercise session lasted about
equal to the total number of castings resulting in improvement in 10e20 min depending on the number of fingers to be casted.
PIP joint extension loss. If no gain was observed in three consecu- Immediately after the exercise program, the new cast was applied
tive castings, the application was ceased. Therefore, ENR for each to fit the maximum available extension angle of the PIP joint. The
casted finger was equal to the total repetition number minus three. joint was stretched in extension direction until discomfort or pain
For the fingers with no residual extension loss, effective repetition limit was reached during hardening of the plaster. The force was
number was equal to the total repetition number. applied in the vicinity of the PIP joint through the proximal and
Although it was not planned in the initial data gathering pro- middle phalanges to minimize the subluxation effects of the
cess, the patient’s records were reviewed again to answer the stretching. Serial casting continued until no improvement was seen
question, “How long does the effect last?” in the extension range of the PIP joint in three consecutive appli-
cations. After each measurement, patients were informed about the
angular changes in their PIP joints. Once a PIP joint gained its full
Treatment procedures
extension or a plateau was obtained, we tried to preserve the
resulting extension capacity for an additional 4 weeks by means of
PIP joints with flexion contracture were serially casted with POP
a static volar PIP joint orthosis, and exercises and activities pro-
to regain full extension range. Serial casting was applied after the
moting extension of the joint. Examples of finger casts and static
following conditions had been met: no gain in the extension range
volar PIP joint orthoses we have used are shown in Fig. 2. During
with orthoses and exercises; absence of any signs of disease ac-
the follow-up period, patients were invited to the unit every week.
tivity, misalignment and instability in the joint; radiologically-
For patients who were not able to come to the control visits, they
verified sufficient joint space to eliminate the possibility of bony
were contacted by phone to assess whether there were any prob-
ankylosis; at least partially active extension capability in the PIP
lems in their home programs. If a problem was reported by a pa-
joint; and the patients’ willingness to this intervention.
tient, a compulsory visit was arranged. Five patients reported some
Supplies used in the casting application are shown in Fig. 1. The
problems in conducting their home programs. One of them was
serial casting involved only PIP joints. The DIP joint was not
directed to a local physiotherapist. After the 1-month follow-up
included. Inclusion of the DIP joint could provide improved
period, all patients were advised that they could continue to use
leverage if hyperextension of the joint was prevented. However,
their static volar PIP joint orthoses during the night for up to 3
longer leverage might also result in increased subluxation stresses
months, even in the absence of any active joint disease. However,
on the weakened joint structures of the PIP joint in these patient
they were instructed to use them during the day except for exercise
groups. BozÒ or AlbanÒ POP bandages were used. The casting
sessions and to make contact with us as soon as possible in the
technique described by Bell-Krotoski was used for all patients.34
active periods of the disease.
The fingers to be casted were coated with soft paraffin before the
When a planned intervention was applied to a patient in the
application. No padding was used. If the flexion contracture was
unit, appointments for the visits were arranged by the therapist
greater than 45
, a small piece of cotton was placed over the PIP
until the treatment of the specific problem finished. Otherwise,
joints before each casting to prevent possible irritation to the skin
patients were seen during their periodic routine medical visits.
over the dorsum of the joint. The MCP and DIP joints of the casted
finger were free to move. After the casting procedure, patients were
Statistical analysis
instructed to avoid moisture and observe for changes in skin color
and numbness in the casted fingers in case of insufficient perfusion
The descriptive statistics were reported as mean  standard
in the finger. Casting application was repeated every 2 or 3 days.
deviation (SD). Paired-samples t-test was used to compare initial
After removal of the cast(s), patients’ casted hands were immersed
and final ROMs (SPSS 20.0, SPSS Inc., Chicago, IL, USA). Independent
in water with neutral temperature (35e37
C) for about 10 min.
samples t-test was used for the comparisons between the patient
During this “warming-up” phase, patients conducted active finger
groups. The level of significance was set at a p value of less than
exercises by gently squeezing a soft sponge in the water. A
0.05. A stepwise multiple linear regression analysis was used to
therapist-directed exercise program followed this. It consisted of
determine whether some patient- and disease-related factors were
important in predicting the changes in the PIP joint extension angle
between the beginning and end of the treatment. Entry and
removal probabilities were set at 0.05 and 0.10 respectively. Post
hoc power analysis was conducted to compute achieved power
(G*Power 3.1.9.2).35

Results

Characteristics of the patients are demonstrated in Table 1. The

duration of flexion contractures in PIP joints was longer in patients
with RA. Only one patient was left-handed. The majority (60%) of
the serial casting application was conducted on the right (domi-
nant) hands of the patients. The middle and ring on the right, and
index and middle on the left were the most frequently casted fin-
gers. The mean number of casting repetitions was 8.4. Average
duration of the intervention was 16.2 days (range: 8e30). Although
mean ENR was higher in the group of patients with RA (6 vs. 5.4), no
significant difference (p > 0.05) was observed between the patient
Fig. 1. Supplies used in the casting application. groups.
44 Ü. Ug
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an / Journal of Hand Therapy 29 (2016) 41e50

Fig. 2. Examples of finger casts and static volar PIP joint orthoses.

Table 2 demonstrates the baseline and final ROMs in each finger DIP joints significantly increased (p < 0.01 and p < 0.001 respec-
joint. The serial casting resulted in significant (p < 0.001) reduction tively). However, no significant changes were observed in the DIP
(26.8
in mean) in the extension loss of the PIP joints in total pa- joint extension ranges in either patient group. The mean angular
tients. No significant difference (p > 0.05) was observed between differences (gains) per effective repetition were 4.6 (range: 2e7)
the patient groups in terms of mean extension gains in PIP joints and 5.3 (range: 3e8) degrees for the patients with RA and JIA
(RA: 26.4
; JIA: 27.5
). It is evident that some flexion losses respectively. The average gain per effective repetition was 4.8
accompanied the PIP joint extension gains for both RA and JIA pa- (range: 2e8) degrees. In most of the cases, gains were greatest in
tients. Some considerable changes with respect to baseline mea- the first sessions and slowed down until they stopped. Full exten-
surements can also be noticed in the ROMs of the other finger joints sion was regained in seven fingers (RA: 4; JIA: 3) of six patients.
at the end of the casting procedure. The flexion angles in MCP and Table 3 demonstrates the paired-samples t-test results of the
changes in both directions in each casted finger. The average 26.8

improvement in the PIP joint extension range was equal to
approximately 67% of the initial loss. The accompanying decrease
Table 1 (6.3
in mean) in the flexion range of the joint was significant
Patient characteristics.
(p < 0.001). No sign of exacerbation was observed in the joints of
Characteristics Patients Patients Total the casted fingers during and after the procedure. At the end of the
with RA with JIA patients 4-week follow-up period, we did not observe any rebound effect in
Number of patients 13 5 18 all patients who regained full PIP joint extension (seven fingers of
Age (y)a 43.1  7.2 15.7  1.7 34.1  14.3
the six patients). However, four patients with partial gains, lost
Age interval 32e58 13e18 13e58
Disease duration (y)a 8.9  2.7 6.6  1.3 8.1  2.6 some extension (12
in mean) in six of their nine casted PIP joints at
Range 5e15 5e8 5e15 the end of the same period.
Deformity duration (m)a 21.9  7.5 16.5  4.7 20.1  7.1 Although it was minimal in terms of mean angular changes, the
Range 6e36 9e24 6e36 serial casting of the PIP joint resulted in expansion of available
Hand dominance
Right hand 13 4 17
active ROM interval of the MCP and DIP joints in all patient groups.
Left hand 0 1 1 Average active ROMs in MCP and DIP joints increased 3.4 and 5.2

The number of fingers respectively in total subject group (Fig. 3).
received serial casting intervention Disease and contracture durations, age, ENR, disease type, and
Right hand (n)
magnitude of the active extension loss in the PIP joint were
Index 3 1 4
Middle 7 3 10 considered as possible factors that might be important in the pre-
Ring 7 4 11 diction of gains in the stepwise multiple linear regression analysis.
Little 3 1 4 Among the factors entering into the analysis, only the magnitude of
Total 20 9 29 the active extension loss in the beginning was found to be impor-
Left hand
Index 4 2 6
tant (p < 0.001). However only about 38% of the changes (adjusted
Middle 6 3 9 R2 ¼ 0.375) can be explained with this factor.
Ring 1 1 2 Some of the patients treated with serial casting were under
Little 2 1 3 routine control in the unit. Afterwards, we were able to obtain the
Total 13 7 20
data of 11 of these 18 patients. This data was obtained in a period of
Casting repetition (n)a 8.6  3.9 7.8  2 8.4  1.5
Range 4e13 4e12 4e13 6e12 months (mean: 8.8) after the 4-month follow-up period and
Effective repetition (n)a 6  2.2 5.4  1.4 5.8  2 contained 29 fingers (RA: 21; JIA: 8). In two patients (RA: 1; JIA: 1),
Range 4e10 4e9 4e10 their diseases were exacerbated during this period. Five of the
a
Data are mean  SD; effective repetition ¼ the number of casting application previously casted fingers had active joint disease during these at-
resulting in improvement in the PIP joint extension loss. tacks. Some deterioration in the extension range was observed in
 Ü. Ug
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an / Journal of Hand Therapy 29 (2016) 41e50 45

Table 2
The baseline and final range of motions in the serially-casted finger joints.

Joint Measurement Patients with RA Patients with JIA Total patients

Baseline Final Baseline Final Baseline Final

PIP Extension loss 41.3  9.22 14.9  10.2 37.9  7.9 10.4  7.8 40.2  8.9 13.4  9.5
Flexion 94.3  8.16 89.1  7.75 95.1  9.9 86.7  7.3 94.6  8.7 88.3  8.9
MCP Extension loss 5.79  5.78 3.18  3.34 5.8  6.8 5.1  5.2 5.8  6.1 3.8  4.1
Flexion 70.5  12.5 71.8  11.9 69.4  12.6 71.1  12.1 70.1  12.4 71.6  11.8
DIP Extension loss 4.97  4.92 4.76  4.83 6.2  6.6 5.0  5.5 5.4  5.5 4.9  5.0
Flexion 64.8  13.1 69.6  12.4 67  17.9 71.1  16.5 65.6  14.7 70.3  13.8

All measurements are in degrees.

these PIP joints. In the other “healthy” PIP joints, deteriorations We observed that patients recovered the majority of the
were limited to a maximum of 5
(Table 4). extension capabilities in their PIP joints by means of serial casting.
Eight of these eleven patients reported that they conformed to This demonstrates that serial casting is an effective method to
their home therapy programs. Two patients with active joint dis- reduce PIP joint flexion contractures in patients with RA or JIA. The
ease stated that they started to wear their finger orthoses imme- underlying mechanism for this gain can be explained with
diately after they felt the first signs of active joint disease. However, remodeling of the soft tissues responsible for the contractures. Skin
one of the patients was not able to use them due to disrupted and other soft tissues have a dynamic biologic system with constant
conformity between their orthoses and fingers. Two patients with change and remodeling. The best way to lengthen a contracted
active joint disease stated that they used their finger orthoses for at tissue is to continuously put just enough force on it in the desired
least 1 month (range: 1e4 months) during the night before the direction for a long time.25 However, if a patient is able to tolerate
occurrence of the first signs of inflammation in their PIP joints. greater force without pain, the therapist may use a load which can
Among nine patients without active joint disease, eight patients result in tissue damage. The amount of stress that is most effective
stated that they continued to use their static volar PIP joint orthoses for remodeling has not been determined yet.23 Brand suggests to
during the night for at least 2 weeks (range: 2 weekse3.5 months) use the amount of tension required to fully extend a joint gently
after the 4-week follow-up period. through its available ROM.25 Bell-Krotoski and Figarola23 stated
Paired-samples t-test for total patients was the main statistical that 2
or more can be gained per cast change with ongoing-serial
analysis method in this study. Post hoc power analysis demon- casting. An average of 4.8
gain per effective casting can be seen as a
strated that power (1  b err prob) of the study method was 1 (total considerably fast resolution of the contractures. However, this
sample size ¼ 49, effect size ¼ 6.06, a error probability ¼ 0.05, figure represents the average gain throughout the improvement
critical t ¼ 2.01). period. In the partially recovered PIP joints, gains up to 8
per
casting in the beginning slowed down until no gain occurred in
three consecutive casting applications. However, the improvement
Discussion trend in the fully recovered PIP joints (n ¼ 7) was almost linear.
There may be a relationship between the progress trend and gains
We aimed to analyze the effects of serial casting application in a achievable with serial casting. Although casting frequency may
group of patients with PIP joint flexion contracture associated with vary between daily and weekly in similar studies, the proposed
RA or JIA and elicit patient- and disease-related factors that might optimum time is 48 h.23,25,36 Our findings concur that 48 h is the
have an effect on the treatment result. optimum time for cast change. Interrupting the immobilization due
The findings of this study were as follows: 1) The serial casting to serial casting and exercising the joint every other day allow
resulted in 26.8
of improvement (about 67%) in the flexion con- gliding of joint surfaces to maintain healthy cartilage.37,38 The
tractures of the PIP joints, 2) immobilization of the PIP joints during casting procedure was repeated every 2 or 3 days for our patients. A
treatment led to angular changes in the other finger joints, pre- three-day duration was valid for fingers casted on Fridays.
dominantly in the MCP joints, 3) no sign of exacerbation was Therefore, “optimum time” was used in the majority of our cases.
observed in the joints of casted fingers throughout the treatment, We think that this may be a factor explaining the gains in our
4) disease and contracture durations, age, disease type (RA or JIA), patients. In addition, our patients were carefully selected
and number of repetitions were not important factors in deter- patients. There were no major osseous changes in the PIP joints
mining success of the treatment. verified by the examination and radiologic screening. In addition,

Table 3
The comparison of baseline and final measurements (paired-samples t-test).

Joint Measurement Patients with RA Patients with JIA Total patients

Mean SE 95%CI p Mean SE 95%CI p Mean SE 95%CI p

L U L U L U
PIP Extension loss 26.4 1.1 24.2 28.6 <0.001 27.6 1.2 24.9 30.2 <0.001 26.8 0.9 25.1 28.5 <0.001
Flexion 5.2 1.2 2.8 7.7 <0.001 8.4 1.3 5.7 11.2 <0.001 6.3 0.8 4.4 8.1 <0.001
MCP Extension loss 2.6 0.6 1.4 3.8 <0.001 0.8 0.6 0.5 2.0 >0.05 2.0 0.4 1.1 2.9 <0.001
Flexion 1.3 0.6 2.4 0.2 <0.05 1.7 0.9 3.5 0.1 >0.05 1.4 0.5 2.4 0.5 <0.01
DIP Extension loss 0.2 0.5 0.9 1.3 >0.05 1.2 0.6 0.1 2.5 >0.05 0.5 0.4 0.3 1.4 >0.05
Flexion 4.8 0.7 6.1 3.4 <0.001 4.6 0.9 6.5 2.8 <0.001 4.7 0.5 5.8 3.6 <0.001
(decreases)

Mean ¼ Baseline-final measurements in degrees; CI: Confidence interval of the difference; SE: Standard error; L: Lower limit of CI; U: Upper limit of CI.
46 Ü. Ug
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an / Journal of Hand Therapy 29 (2016) 41e50

Fig. 3. Comparison of the movement intervals in each finger joint before and after the serial casting application.

patients had a history of gradual loss of extension in time. These the need for preconditioning before casting.30 They tried to achieve
findings point to arthritis-related gradual soft-tissue changes for maximum PIP extension by hanging a weight on the patient’s finger
the main cause of the problem in the joint. Factors listed in the during preconditioning phase.26 Our approach in this phase con-
inclusion criteria were based on our knowledge on the common sisted of implementation of active and low-resistance exercises
pathomechanisms of these diseases and our previous experiences proceeded by “warming-up” in water. Although the temperature of
with the method, not only in these patient groups, but also in other the water and the duration the hand stayed in the water seemed to
rheumatic conditions such as pediatric forms of systemic sclerosis not affect any physiological changes in connective tissues,41 pa-
and dermatomyositis. tients reported considerable decreases in the level of stiffness in
The immobilization caused by casting can also adversely affect their casted fingers. The increase in the blood flow to the hand via
articular cartilage and dense connective tissues of the joint.38 Non- active exercises conducted in water and changes in viscous and
rigid immobilization with casts for 6 weeks has been demonstrated elastic states of connective tissue may partially explain the patients’
to cause reduction in proteoglycan synthesis, which may have decreased stiffness level.
negative effects on the nourishment of the cartilage.39 In addition, Although the focus was on the extension direction during this
prevention of cyclical compression and decompression achieved by phase, active exercises also contained flexion of finger joints. The
joint movement due to casting may hinder absorption of nutrients reason for using active joint movements in both directions was to
and expel wastes.40 However, the negative effects of immobiliza- allow the gliding of joint surfaces to maintain healthy cartilage.38,40
tion on the joint structures might be minimized due to periodic cast However, active flexion might have slowed the progress in the
changes and active exercises accomplished during the free periods extension direction. Another finding in the casted PIP joints was the
of this intervention. The application of various therapeutic tech- accompanying limitation in flexion angle. Colditz4 stated that the
niques to improve maximum passive ROM before casting has been flexion angle might increase as a result of extension mobilization
reported to increase the effectiveness of the method.26 Pre- casting in the joint. The contracted scar tissue may impede the
conditioning provides a temporary change in the viscous and movement of the volar plate. The elongation of this scar tissue al-
elastic states of the tissues and should be immediately followed lows the volar plate to more readily fold out of the way during
with the application of casting.30 Flowers and LaStayo emphasized flexion. In contrast to the statement by Colditz,4 a significant
reduction of an average of 6.3
occurred in our patients, although
active flexion exercises were involved in the preconditioning
Table 4 phases. This may be partly related to different pathomechanisms of
Changes in the PIP joint extension angles in 29 fingers of 11 patients in a follow-up
period of 6e12 months.
the joint contractures in RA or JIA patients as opposed to those seen
in traumatic injuries.
Angular changes PIP joints with PIP joints with All PIP Although serial casting has shown to be an effective method for
no active joint active joint joints
disease (n ¼ 24) disease (n ¼ 5) (n ¼ 29)
the treatment in this study, the casting with POP has some disad-
vantageous as well. It is bulky and heavy compared to low-profile
No deterioration (n) 12 0 12
0 to 5
deterioration 9 1 11 thermoplastic, OrficastÔ and QuickcastÔ finger orthoses. Indeed,
6 to 10
deterioration 1 3 3 it was generally not possible to cast more than two fingers of a hand
11 to 15
deterioration e 1 1 at the same time, especially in the hands of children with JIA.
0 to 5
improvement 2 e 2 However, the plaster bandages we used in our clinic were generally
PIP: Proximal interphalangeal joint. not high-quality materials compared to fine types of POP for casting
 Ü. Ug
urlu, H. Özdog
an / Journal of Hand Therapy 29 (2016) 41e50 47

of the fingers. Their plaster content was low and we sometimes the treatment. Indeed, all patients allowed their serial castings to
experienced increased hardening duration. Although we used the continue until the therapist terminated treatment.
casting method described by Bell-Krotoski,34 the volume of our Four weeks follow-up was routinely used for all patients treated
finger casts were higher than it should be to obtain sufficient ri- with serial casting for their finger joints in our unit. Therefore, we
gidity to stretch the joint. In addition, some of our patients were were able to analyze the rebound effect for only 1 month. Because
children with small hands compared to those of adults, not leaving the study was not a planned intervention in the beginning, strict
enough space to accommodate more than 2 “bulky” casts most of control visits were not arranged on a regular basis for the follow-up
the time. of long-term effects of the method. However, the majority of these
We did not encounter any skin or perfusion problems in our patients were routine visitors of the unit and seen a few times in a
patients. This was in accordance with the statement by Schultz- year due to other musculoskeletal problems related to their dis-
Johnson.26 Although some cases of burns by the application of POP eases. The data obtained afterwards from 11 patients demonstrated
have been reported in the literature,26 we did not experience such that about three-fourths of the casted fingers (n : 23) largely pre-
an incident in our cases. served the gains obtained at the end of the intervention, when
Although OrficastÔ and QuickCastÔ offer some advantageous considering 5
of deterioration as a minor change. However, in the
over POP in casting PIP joints,42 they were not easily available in majority of the PIP joints (4 out of 5) developing inflammation
the mid-1990’s in the study location. In addition, POP may still be during the period after their 4-week follow-up, up to 15
de-
preferable over OrficastÔ or QuickCastÔ in clinics with limited teriorations was observed. It may be concluded that casted fingers
financial resources. We did not apply any securing techniques for tend to preserve the extension gains in PIP joints provided that no
the casted fingers. Some patients reported minor trauma due to active joint disease occurs. However, only one patient among four
striking their hands on rigid surfaces. losing some extension at the end of the 4-week follow-up period
The conditions for terminating the serial casting application was included in these 11 patients. In the following studies, rebound
have not been clearly stated in the literature. The gains tended to effect can be investigated over a longer period in a more systematic
diminish with time in our patients. We finalized the intervention if manner.
no improvement occurred in three consecutive serial castings. The scheduling and wearing regimen of serial casting described
Based on their experiences in the field, Bell-Krotoski and Figarola in this study reflects the approach we use in our clinic. Unfortu-
stated that continuing casting will not provide any gain if range of nately, little empirical evidence exists to guide therapists in their
motion of a joint does not change over a period of 2 weeks.23 In treatment plans when they treat joint stiffness.20 Total end range
light of this information, the 1 week duration we used for our pa- time (TERT) is considered an important principle when planning
tients might be insufficient. treatments for joint contractures. According to this principle, the
Once a plateau or full PIP joint extension has been obtained, a amount of increase in passive ROM of a stiff joint is proportional to
static volar PIP joint orthosis was used for an additional 4 weeks to the amount of time the joint is held at its end range.30 McClure
maintain elongated periarticular tissues in their new lengthened et al21 proposed an algorithm based on measurements of pain and
positions. That no rebound effect was seen in the fully recovered ROM for the use of the TERT principle. Flowers42 presented a de-
PIP joints (n ¼ 7) at the end of this 4-week period seemed to be cision hierarchy for splinting the stiff hand to extend the TERT
related to their less severe flexion contractures in the beginning. principle to include the element of force. However, therapists’ de-
Indeed, in the majority of these patients, it was possible to relieve cisions may also be influenced by their clinical experiences.20 In
the contracture with passive stretching in the beginning. Four pa- addition, patients’ attitudes towards the use of orthotics may be an
tients lost some of the regained extension angle at the end of the 4- issue. It was not uncommon for us to encounter a patient who
week follow-up period in their six of the nine casted fingers. Three viewed an orthosis as a visual sign of his/her disease and rejected
of them reported that they did not conform to their home programs using it, especially in the community. Therefore, we felt asked pa-
for various reasons. This may emphasize the importance of the tients about their intention to adhere before application of serial
protective methods and routine follow-ups to maintain the gains casting.
provided by serial casting. An ideal follow-up duration after serial The patients who were candidates for serial casting intervention
casting was not reported in the literature. Four weeks after serial were routinely informed about the reasons for applying serial
casting may be an adequate time frame for a strict follow-up pro- casting, possible gains obtainable with the method and the appli-
vided that patients conform to their prescribed orthotics use and cation procedure. However, investigation of patient records after-
exercise programs. Also in the study by Boccolori and Tocco,12 PIP wards revealed that five patients or their parents (RA: 3; JIA: 2), did
joint was held in maximum extension for an additional 4-week not consent to treatment for the following reasons; the require-
period to avoid rebound effect of the elongated periarticular tis- ment for frequent visits, the increased visability of their disease and
sues. However, therapists’ decisions on the length of the protection potential interference in activities of daily living, especially in
period may also be influenced by patient- and disease-related writing and hygienic activities. In addition to the possibility that we
characteristics as well as their experiences. For example, we used were not successful enough in informing the patients of the
longer protection periods for children with dermatomyositis after benefits of serial casting, the acceptance of this method by the
their knee flexion contractures were treated with serial casting. patients might be influenced by sociocultural and disease charac-
They used their static knee orthoses in full extension as long as teristics. To our knowledge, no study has been conducted to elicit
calcinosis continued. Unfortunately well-established protocols for these factors. More information on patient preferences and con-
guiding the therapists’ decision on this matter are not available. cerns may improve the recruitment rates for the application of this
Some therapists may prefer longer protection periods. However the method.
balance between the gains provided with longer protection periods The use of wire-tracing method used in this study to measure
and side effects of immobilization should also be considered. angulations at the finger joints may raise concerns about the
Although we do not have discriminative data available due to the measurements accuracy. Although, Ellis et al33 found that intra-
fact that our patients were followed under the same protocol, and inter-observer reliabilities of finger goniometry was superior to
routine follow-ups, informing patients about the angular changes wire-tracing method, their findings were based on a single healthy
and timely interventions might have improved the adherence to subject.33 In addition, approximately half of the 40 volunteered
48 Ü. Ug
urlu, H. Özdog
an / Journal of Hand Therapy 29 (2016) 41e50

therapists in their study were not familiar with the wire-tracing their clinical judgment and initial response to treatment to decide
method and only seven of them reported that they routinely used whether casting is indicated.
this method in their clinical practices. All these factors might have The amount of initial extension lag and the difference between
supported their study findings in favor of finger goniometry. We active and passive ROMs in the PIP joints might be important pa-
think the wire-tracing method is not a rare method among thera- rameters that could have been evaluated in the regression analysis.
pists to measure ROMs in the small joints of hand. Aligning arms of Unfortunately, these were not available as only active ROM was
the finger goniometer may be difficult while measuring ROMs over measured. We observed that extension lag in many patients.
the swollen or subluxated joints. Wire tracing may be preferred for However, the calculated gains were solely based on the patients’
these problematic joints provided that the shape of the wire is active performances within their available ROMs. It is important to
preserved and are accurately traced on the paper. We think the sustain not only active, but also passive ROMs gained from the
wire-tracing method is valid for use in RA or JIA patients with casting.
moderate to severe hand involvement. The lack of a measurement Serial casting is frequently done by therapists as a last resort to
protocol for wire tracing method and documented information gain the lost motion after other conservative methods fail.4,23
about its reliability on these patient groups is a limitation that Different reasons may underlie the attitudes of therapist to serial
should be addressed by future research. casting. Prolonged periods of immobilization caused by serial
Immobilization of a joint leads to increased compensatory stress casting may be one concern. Many clinicians believe that plaster
to adjacent joints.19 Immobilization of PIP joints in extension can casting is associated with undesired short-term immobilization of
augment the flexion forces on MCP joints and encourages flexion in joints and soft tissues, which should be avoided.4 However, clinical
DIP joints.2,6,28 Indeed, we observed that the total flexion ranges in experiences have demonstrated that if a joint motion is limited due
the MCP and DIP joints of the casted fingers increased at the end of to immobilization, it occurs in one direction and is not permanent.4
the treatment. The augmented forces of the flexor tendons on the Another concern relates to the cartilage neurosis due to sustained
MCP and DIP joints seem to force them in this direction of move- pressure. However, this can occur only when forceful serial casting
ment. In addition, hyperextension of the MCP and DIP joints may is applied. In addition, RA and JIA are collagen disorders and result
occur long term to compensate for extension loss in the PIP joint in laxity of the supporting structures of the joints. These make the
during activities requiring flattening of the fingers. We observed concerns of stiffness from serial casting less than in other situa-
significant reduction in the MCP joint extension loss at the end of tions4 a considerable number of patients for prospective study
the intervention. The contribution of the MCP joint to total exten- designs. Attitudes towards casting may have reduced the total
sion of the finger is supposed to be larger than that of the DIP joint number of patients that were available for analysis in our study.
due to its more proximal location. The magnitude of the angular Among 368 patients with RA or JRA admitted to the occupational
changes in the PIP and DIP joints may depend on the casting and physical therapy unit of our rheumatology outpatient clinic,
duration and the characteristics of the hand use. We did not analyze only 18 were treated with serial casting during a 14-year interval.
the progress of this process in detail by splitting the total casting Our data supports more common use of casting in this patient
duration into smaller parts due to small increases in both joints population. Therefore, it should be considered when there is a fixed
ranging from 3.4 to 5.2
. Our patients stated that their hand capa- contracture.23 Indeed, for the therapists experiencing the dramatic
bilities were restricted due to casts in their fingers depending on effect of serial casting on the resolution of contractures, this
the number of casted fingers and hand dominance. The amount of method is the first choice in their treatment plans.
restriction was higher when more than one finger was casted in the The best way to avoid joint contractures is to prevent them.
dominant hands of the patients with JIA. This might have limited Prevention of joint contractures before they develop is of great
the frequency and intensity of the hand activities. Otherwise, larger importance especially in chronic inflammatory diseases such as RA
angular changes in the MCP and DIP joints could be expected. and JIA. It seemed that a considerable number of the contractures in
Another consequence of the augmented forces on the MCP and our patients was due to their late referrals to the unit. It appears
DIP joints due to immobilized PIP joint could be exacerbation of the that this is a common issue for many therapists and patients.23
joint disease. This is always an increased risk for an arthritic hand.19 Unfortunately, the number of clinics where rheumatologists and
We did not, however, observe any signs of inflammation in the therapists work together to provide treatment for their patients
joints of the casted fingers. Routine medical controls, considerably was limited to only a few during the time interval of this study. One
short average casting duration (16.2 days) and the restriction of the of the authors of this study was the only therapist working in this
hand use might have contributed to this result. This finding of the unit during this time. Unfortunately this unit had to suspend its
study may help to allay any therapist and physician concerns that functions, after the author of this paper left in 2009.
serial casting might create harm in this patient population.
Before the treatment, therapists may want to know the factors
Conclusion
that can be important in the success of the method. Contrary to our
expectations, factors including disease and contracture durations,
In this study we analyzed the effects of serial casting with POP in
age of the patients, disease type, and number of repetitions were
the treatment of PIP joint flexion contractures in 49 fingers of 18
not important factors in determining the success of the treatment.
patients. These patients were a small subset of the 368 patients
This may be related to the strict criteria we used for the application
with RA or JIA admitted to the occupational and physical therapy
of this method. For example, some patients with deformity dura-
unit of a rheumatology outpatient clinic during a 14-year period.
tions longer than 2 years were not treated with this method due to
Although the study design was retrospective, this study does pro-
insufficient joint space. Similarly, PIP joints without any active
vide new information to support the use of PIPJ casting for joint
extension were not casted due to our concern about the insuffi-
contractures in patients with juvenile arthritis.
ciency of extensor mechanisms to preserve the gains. The larger the
magnitude of active extension loss in the beginning, the higher the
expectations from the treatment is. However, only about 38% of the Acknowledgment
changes can be explained with this factor. Since the response to
treatment could not be accurately predicted, therapists should use This study was financially supported by the authors of the study.
 Ü. Ug
urlu, H. Özdog
an / Journal of Hand Therapy 29 (2016) 41e50 49

References 21. McClure PW, Blackburn LG, Dusold C. The use of splints in the treatment of
joint stiffness: biologic rationale and an algorithm for making clinical decisions.
Phys Ther. 1994;74(12):1101e1107.
1. Turkiewicz AM, Moreland LW. Rheumatoid arthritis. In: Bartlett SJ,
22. Brand PW. The reconstruction of the hand in leprosy: Hunterian lecture
Bingham CO, Maricic MJ, Iversen MD, Ruffing V, eds. Clinical Care in the
delivered at the Royal College of Surgeons of England on 24th October, 1952.
Rheumatic Diseases. 3rd ed. Atlanta: Association of Rheumatology Health Pro-
Ann R Coll Surg Engl. 1952;11(6):350e361.
fessionals; 2006:157e166.
23. Bell-Krotoski JA, Figarola JH. Biomechanics of soft-tissue growth and remod-
2. Melvin JL. Hand pathodynamics and assessment. In: Melvin JL, ed. Rheumatic
eling with plaster casting. J Hand Ther. 1995;8(2):131e137.
Disease in the Adult and Child: occupational Therapy and Rehabilitation. 3rd ed.
24. Brand PW. Mechanical factors in joint stiffness and tissue growth. J Hand Ther.
Philadelphia: F.A. Davis Company; 1989:261e339.
1995;8(2):91e96.
3. Philips CA. Rehabilitation of the patient with rheumatoid hand involvement.
25. Brand P. Clinical Mechanics of the Hand. St. Louis, MO: CV Mosby; 1985.
Phys Ther. 1989;69(12):1091e1098.
26. Schultz-Johnson KS. Casting techniques. In: Jacobs MA, Austin N, Austin NM,
4. Colditz JC. Plaster of Paris: the forgotten hand splinting material. J Hand Ther.
eds. Splinting the Hand and Upper Extremity: Principles and Process. Philadel-
2002;15(2):144e157.
phia: Lippincott Williams & Wilkins; 2003:245e266.
5. Van der Giesen FJ, Nelissen RGHH, Arendzen JH, De Jong Z, Wolterbeek R, Vliet
27. Tribuzi SM. Serial plaster casting. In: Hunter J, Schneider L, Mackin E,
Vlieland TPM. A multidisciplinary hand clinic for patients with rheumatic
Callahan A, eds. Rehabilitation of the Hand. 3rd ed. St. Louis: Mosby; 1990:
diseases: a pilot study. J Hand Ther. 2007;20(3):251e261.
1120e1127.
6. Melvin JL, Atwood M. Juvenile rheumatoid arthritis. In: Melvin JL, ed. Rheumatic
28. Bell J. Plaster casting for the remodeling of soft tissue. In: Fess EE,
Disease in the Adult and Child: occupational Therapy and Rehabilitation. 3rd ed.
Philips CA, eds. Hand Splinting: Principles and Methods. St. Louis: Mosby;
Philadelphia: F.A. Davis Company; 1989:135e187.
1987:449e466.
7. Melvin JL. Rheumatoid arthritis. In: Melvin JL, ed. Rheumatic Disease in the Adult
29. Hackett J, Johnson B, Parkin A, Southwood T. Physiotherapy and occupational
and Child: occupational Therapy and Rehabilitation. 3rd ed. Philadelphia: F.A.
therapy for juvenile chronic arthritis: custom and practice in five centres in the
Davis Company; 1989:75e87.
UK, USA and Canada. Rheumatology. 1996;35(7):695e699.
8. Li-Tsang CW, Hung LK, Mak AF. The effect of corrective splinting on flexion
30. Flowers KR, LaStayo PC. Effect of total end range time on improving passive
contracture of rheumatoid fingers. J Hand Ther. 2002;15(2):185e191.
range of motion. J Hand Ther. 2012;25(1):48e55.
9. Prosser R. Splinting in the management of proximal interphalangeal joint
31. Zander CL, Healy NL. Elbow flexion contractures treated with serial casts and
flexion contracture. J Hand Ther. 1996;9(4):378e386.
conservative therapy. J Hand Surg Am. 1992;17(4):694e697.
10. Colditz JC. Spring-wire splinting of the proximal interphalangeal joint. In:
32. Ug
urlu Ü, Özdog
an H. Physical and occupational therapy management of a
Hunter J, Schneider L, Mackin E, Callahan A, eds. Rehabilitation of the Hand. 3rd
patient with systemic sclerosis: a case report. J NAROT. 1998;12(2):17e21.
ed. St. Louis: Mosby; 1990:793e798.
33. Ellis B, Bruton A, Goddard JR. Joint angle measurement: a comparative study of
11. Callahan AD, McEntee P. Splinting proximal interphalangeal joint flexion
the reliability of goniometry and wire tracing for the hand. Clin Rehabil.
contractures: a new design. Am J Occup Ther. 1986;40(6):408e413.
1997;11(4):314e320.
12. Boccolari P, Tocco S. Alternative splinting approach for proximal interphalan-
34. Bell-Krotoski JA. Plaster cylinder casting for contractures of the interphalangeal
geal joint flexion contractures: no-profile static-progressive splinting and
joints. In: Hunter J, Schneider L, Mackin E, Callahan A, eds. Rehabilitation of the
cylinder splint combo. J Hand Ther. 2009;22(3):288e293.
Hand. 3rd ed. St. Louis: Mosby; 1990:1128e1133.
13. Schultz-Johnson K. Static progressive splinting. J Hand Ther. 2002;15(2):
35. Faul F, Erdfelder E, Lang AG, Buchner A. G*Power 3: a flexible statistical power
163e178.
analysis program for the social, behavioral, and biomedical sciences. Behav Res
14. Feinberg J, Brandt KD. Use of resting splints by patients with rheumatoid
Methods. 2007;39:175e191.
arthritis. Am J Occup Ther. 1981;35(3):173e178.
36. Bennett GB, Helm P, Purdue GF, Hunt JL. Serial casting: a method for treating
15. Janssen M, Phiferons J, van den Velde EA. The prevention of hand deformities
burn contractures. J Burn Care Res. 1989;10(6):543e545.
with resting splints in rheumatoid arthritis patients: a randomized single blind
37. Salter RB. The physiologic basis of continuous passive motion for articular
one-year follow-up study. Arthritis Rheum. 1990;33:123e126.
cartilage healing and regeneration. Hand Clin. 1994;10(2):211e219.
16. Palchik NS, Mitchell DM, Gilbert NL, Schulz AJ, Dedrick RF, Palella TD.
38. McKee P, Hannah S, Priganc VW. Orthotic considerations for dense connective
Nonsurgical management of the boutonniere deformity. Arthritis Rheum.
tissue and articular Cartilagedthe need for optimal movement and stress.
1990;3(4):227e232.
J Hand Ther. 2012;25(2):233e243.
17. Hittle JM, Pedretti LW, Kasch MC. Rheumatoid arthritis. In: Pedretti LW, ed.
39. Behrens F, Kraft EL, Oegema TR. Biochemical changes in articular cartilage after
Practice Skills for Physical Dysfunction. 4th ed. St. Louis: Mosby; 1996:639e660.
joint immobilization by casting or external fixation. J Orthop Res. 1989;7(3):
18. Swanson AB. Pathogenesis of arthritic lesions. In: Hunter J, Schneider L,
335e343.
Mackin E, Callahan A, eds. Rehabilitation of the Hand. 3rd ed. St. Louis: Mosby;
40. Mow VC, Proctor CS, Kelly MA. Biomechanics of articular cartilage. In:
1990:885e890.
Nordin M, Frankel VH, eds. Basic Biomechanics of the Musculoskeletal System.
19. Melvin JL. Orthotic treatment for arthritis of the hand. In: Melvin JL, ed.
3rd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2001.
Rheumatic Disease in the Adult and Child: occupational Therapy and Rehabilita-
41. Hardy M, Woodall W. Therapeutic effects of heat, cold, and stretch on con-
tion. 3rd ed. Philadelphia: F.A. Davis Company; 1989:379e418.
nective tissue. J Hand Ther. 1988;11(2):148e156.
20. Glasgow C, Wilton J, Tooth L. Optimal daily total end range time for contrac-
42. Lau C. Comparison study of Quickcast versus a traditional thermoplastic in the
ture: resolution in hand splinting. J Hand Ther. 2003;16(3):207e218.
fabrication of a resting hand splint. J Hand Ther. 1998;11(1):45e48.
50 Ü. Ug
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an / Journal of Hand Therapy 29 (2016) 41e50

JHT Read for Credit

Quiz: #403

Record your answers on the Return Answer Form found on the #3. To measure AROM
tear-out coupon at the back of this issue or to complete online a. a wire-tracing method was used
and use a credit card, go to JHTReadforCredit.com. There is b. a finger goniometry method was used.
only one best answer for each question. c. an electrogoniometer was used.
d. an observation method was used.
#1. Elongation of periarticular tissues by serial casting is accom- #4. In this study, serial casting continued until no improvement
plished through a was seen in the extension range of the PIP joint in ________
a. repetitive load over time consecutive applications
b. high load over a short time a. 2
c. sudden high load on the joint b. 3
d. low load over a prolonged period of time c. 4
#2. Which of the following statements is false? d. 5
a. The serial casting resulted in significant reduction in the #5. The idea of the addition of new cells during continual posi-
extension loss of the PIP joints. tioning has been definitively proven for collagen tissues.
b. Some flexion losses accompanied the PIP joint extension a. true
gains. b. false
c. Disease duration was found to be an important factor in the
prediction of extension gains. When submitting to the HTCC for re-certification, please batch your
d. No sign of exacerbation was observed in the joints of the JHT RFC certificates in groups of 3 or more to get full credit.
casted fingers during and after the procedure.