**5. Orthosis**

It is suggested to administer the stretching according to the patient's daily schedule and his/her posture [2]. The stretching can be carried out actively or passively (by someone else or with FES). We can use the positioning, for example standing, sitting, or lying down with using splints and orthosis, to achieve a

*Neurostimulation and Neuromodulation in Contemporary Therapeutic Practice*

prolonged stretching. Another important point is that while stretching a muscle, the antagonist muscle shortens, so there should be a balance in the stretching schedules for all the muscles [2, 32]. Regarding the duration of stretching, studies have suggested 20, 30, or even 60 minutes. So, there is no single protocol [30], but it seems that the efficacy increases with longer durations. Also, it seems that

The patient should be given written instruction on stretching. Stretches should include the back muscles, quadriceps, hip flexors, hip adductors, hamstrings, calf muscles (gastrocnemius and soleus), wrists, and fingers, and should be performed actively or passively. The therapist should modify the stretching based on each

As well as improving the effective stretching and subsequent maintaining of range of motion, correct positioning also helps in altering the spasticity pattern, modifying asymmetry, and decreasing the risk of pressure-induced skin injuries [33]. The golden key to good positioning is to change the position during the day. An ideal position is important in both lying and sitting; moreover, the presence of exacerbating factors and triggers (e.g., pressure sore, pain) is critical in position selection. Performing passive exercises before positioning is helpful; for example, when the patient tries to use a T roll for the leg flexion position, performing several knee and hip flexions and bending the hips and knees up toward the chest and

In correct positioning, muscles should be stretched and longer than usual. For example, these are the suggestions to improve the positioning in a patient with continuous spasticity-induced hip adduction: The patient should monitor his/her sitting position and try to keep his/her knees apart while sitting so that he/she does not get accustomed to the wrong position. The impact of trunk and pelvis positions on the legs should be evaluated. In a flexed posture with a posteriorly tilted pelvis, the legs tend to be in internal rotation and adduction; so, having a firmer seat base, a contoured cushion, or extra trunk support may facilitate a more anteriorly tilted pelvis position, trunk extension, and better lower limbs alignment. In patients unable to reduce adduction, using aids including a pummel, rolled-up towel,

In patients suffering from spasticity, the sitting position should be modified to

Patients with weakness in the trunk and neck extensors can use the tilt-in-space systems [37, 38], where the patient seat has a reclining at the back and flexion at the hip. In this system, hip flexion decreases the extension tone and spasticity as well as

established, maintain comfort, and reduce fatigue [35, 36]. The main requirements for a good sitting position are a firm seat base and backrest with subtle changes by altering the seat base to promote an anterior tilt of the pelvis to help in achieving hip

improve the performance, accommodate to contractures and deformities

flexion, abduction, and external rotation as well as trunk extension.

stretching before the exercises has a more favorable effect.

patient's condition.

abdomen facilitate this position [34].

**4.7 Wheelchair and seating**

**94**

cushion or T roll can help in reducing the adduction.

**4.6 Positioning**

Orthoses or splints are tools for improving limb performance and preventing deformity. These appliances are usually custom-made [39]. Non-removable splinting devices made of plaster or casting tape are referred to as "casts." Casts are also a type of splint. Orthoses are used for the following treatment goals [27, 39]:


In administering orthoses, in addition to discussing the treatment goals with patients, the method of use, duration, and times of use should be discussed as well. In each visit, the patient should be asked about pain, discomfort, and sleep disorder, while muscle wasting and the places under pressure by orthosis should be examined. Incorrect orthosis usage and feeling discomfort with orthosis use can exacerbate the symptoms and cause new deformities. There is no contraindication for administering orthoses; however, some problems addressed in **Table 4** can limit the use of splints, so these points should be noticed during the follow-up visits and proper solutions should be considered [2].

The most common splints based on the usage area are discussed here according to the evidence from different sources and guidelines. Evidence grading is according to **Tables 5** and **6** [40]. However, some of the splints are not mentioned here, we did not intend to deny their effects but only the splints with the best evidence are discussed.


2–12 weeks and should be adjusted with improvements at the end of the range

• While using non-custom-made splints, necessary precautions should be taken

• Using ankle casts at the end of dorsiflexion range can prevent contractures in ABI patients (2C). Primary casts should be replaced every 5–7 days depending on the change in the range of motion until the patient can maintain the plantar grade position. The last cast should be used as a bivalved plantar grade cast for

• The ankle splint can prevent the limitation of the ankle's range of motion when the ankle is at a plantar grade position (2B). The recommended duration of use

• While using non-custom-made splints, necessary precautions should be taken

• The plantar spasticity ankle foot orthosis (AFO) can be used for better walking. In the case of mild spasticity, the single midline posterior stop AFO is used. The type of AFO with pins in the posterior channels can be used for more severe cases. Moreover, in patients with weak extensors of hip or knee, the solid type is recommended while the hinged type is suitable for patients with adequate control. In patients with crouched gait and passive range of motion in hip joints

• It is possible to use casts at the end of range of motion for acute brain injury and stroke patients to improve the knee's range of motion (2D). The cast

• Short-term application of the cast (1–4 days) entails fewer complications

• Using casts at the end of range of motion in acute brain injury and stroke patients can prevent contractures (2C). The cast should be replaced every

• Use this cast with caution in the patients with acute lesions (acute brain injury and stroke) and decreased level of consciousness for preventing secondary

• Knee splints can be used for standing control and walking improvement as well.

should be replaced every 5–7 days. Use the cast for 2–12 weeks.

18 hours a day until the splint can maintain the range of motion.

for ankle splint is 6–10 hours at night for 2–5 weeks.

and pelvis, a ground reaction force AFO can be used.

compared to the longer uses (5–7 days) (2C).

5–7 days. Use the cast for a 2- to 5-week period.

complications such as pressure sores (2C).

of motion.

to prevent pressure sores (2D).

*Rehabilitation Medicine Management of Spasticity DOI: http://dx.doi.org/10.5772/intechopen.93008*

to prevent pressure sores (2B).

Performance improvement [41]:

Contracture improvement [40]:

Contracture prevention [40]:

**5.2 Knee**

**97**

Contracture prevention [40]:

### **Table 4.**

*Precautions for the use of splints or orthoses.*


### **Table 5.**

*GRADE quality of evidence grading.*


**Table 6.**

*Strength of grade.*
