PANat Urias Johnstone User manual

PRO-Active approach to Neurorehabilitation
integrating air splints* and other therapy tools
(* Urias®Johnstone air splints)
PANat:
Theoretical framework, clinical
management and application of
the Urias® Johnstone air splints.
1. Theoretical Framework
2. User Guide
2017

© Rights reserved PANat 2009, revised 02/2015, version 2017 2
TABLE OF CONTENT
1. THEORETICAL FRAMEWORK AND CLINICAL MANAGEMENT OF PANat........... 3
SUMMARY ........................................................................................................................ 4
INTRODUCTION.................................................................................................................. 4
THEORETICAL FRAMEWORK OF PANat ....................................................................................... 5
CLINICAL MANAGEMENT ....................................................................................................... 5
INTEGRATION OF PANat INTO THE REHABILITATION PROCESS ........................................................... 6
CONCLUSION .................................................................................................................... 7
PRO-ACTIVE -WHAT IS IN THE WORD?..................................................................................... 8
APPENDIX ........................................................................................................................ 9
REFERENCES....................................................................................................................10
2. APPLICATION OF THE URIAS®JOHNSTONE AIR SPLINTS USED IN PANat .. 11
ADVANTAGES OF USE..........................................................................................................13
GENERAL INFORMATION.......................................................................................................14
LONG ARM AIR SPLINT -70 CM AND 80 CM ..............................................................................17
HALF ARM AIR SPLINT -53 CM.............................................................................................20
HAND AIR SPLINT (DOUBLE CHAMBER )-20 CM.........................................................................24
HAND &WRIST AIR SPLINT (DOUBLE CHAMBER)-30 CM ..............................................................26
ELBOW AIR SPLINT -40 CM.................................................................................................28
FINGER AIR SPLINT (ONE SIDED SINGLE CHAMBER)-15 CM...........................................................31
FOOT AIR SPLINT...............................................................................................................33
FOOT AIR SPLINT (DOUBLE CHAMBER) ......................................................................................35
LEG AIR SPLINT (DOUBLE CHAMBER)-60 CM,70 CM AND 80 CM ....................................................38
LEG &FOOT AIR SPLINT FOR RESTING (SPECIALLY DESIGNED FOR PATIENTS WITH MULTIPLE SCLEROSIS) ......41
LEG &FOOT AIR SPLINT FOR STANDING (SPECIALLY DESIGNED FOR PATIENTS WITH MULTIPLE SCLEROSIS) ....43

© Rights reserved PANat 2009, revised 02/2015, version 2017 3
PRO-Active approach to Neurorehabilitation
integrating air splints* and other therapy tools
(* Urias®Johnstone air splints)
1. Theoretical framework and
clinical management of PANat
G. Cox Steck, dipl. Physiotherapist FH, accredited Teacher of PANat
Manuscript reviewed and accepted by the PANat group of teachers March 2009, revised February 2015
v2015

© Rights reserved PANat 2009, revised 02/2015, version 2017 4
Keywords: PRO-Active, hemiplegie, repetitive, Johnstone air splints, self-directed
training, low motor recovery, external focus of attention
Summary
This document gives an overview of the theoretical framework and clinical management
of PANat.
PANat: PRO-Active approach to Neurorehabilitation integrating Urias®Johnstone
air splints and other therapy tools. PANat is a further development of the Johnstone
concept. (Margaret Johnstone, FCSP 1919-2006)[1]
In the 1970’s Margaret Johnstone FCSP[2-3] pioneered the use of air splints in active
training of the hemiplegic limb in the severely impaired stroke patient. This concept has
been updated by integrating contemporary principles of movement science and evidence
based guidelines into the theoretical and practical framework of PANat. It incorporates
low-tech therapy tools in training sessions developed by therapists and ideas of stroke
patients to meet their specific needs.
Introduction
Movement is necessary for the individual to participate and enjoy life at home, in the
community and workplace.
Many stroke patients with low sensory-motor recovery use the unaffected side to
accomplish daily tasks; as such they reinforce failure to integrate the severely impaired
hemiplegic limb into meaningful functional activity. As a consequence they may develop
learned non-use, muscle stiffness, contractures and pain.
Studies have shown that using the air splint for repetitive and early stimulation in
training the upper hemiplegic limb of the stroke patient, with pronounced muscle
weakness or a severely paralyzed arm, can have an effective long lasting effect on motor
function[4-5].
Interventions encouraging specific and intensive training with the hemiplegic limbs are
made possible by adapting the task and the environment using Urias®Johnstone air
splints and other therapy tools ( e.g. rocking chairs, PANat-Laptool1)[6-8] This adapted
situation becomes a learning environment, to motivate patients to train selectively
control of movements with their severely impaired hemiplegic limbs in a part task
activity. This can then contribute over time to a better performance of the agreed upon
goal task.
The PRO-Active approach is particularly suited to treat stroke patients with severe
sensory motor impairments. Incorporating the principles of PANat using interventions
with the hemiplegic limb that are repetitive, intensive and selective in all phases of
stroke rehabilitation, is one method with the potential to enhance the mechanism of
neuroplasticity and to promote effective and efficient goal-directed motor training.
Emphasis is placed on giving the individual an opportunity for self-directed practice with
the hemiplegic limbs both during and outside supervised therapy sessions and in the
home setting.
1www.panat-laptool.ch

© Rights reserved PANat 2009, revised 02/2015, version 2017 5
Theoretical Framework of PANat
The theoretical framework of PANat is based on the contemporary systems theory of
motor control and motor learning[9-16]. This theory suggest that movement patterns
emerge as a result of the interaction of multiple processes and include intrinsic
(perceptual, cognitive and motor processes within the individual) and extrinsic
(interactions between the individual, the task and the environment) factors.
The principles of motor learning and cognitive science, contemporary understanding of
the effects of impairments and secondary adaptations, biomechanics of functional
activities and the clinical applications of neural plasticity are used to guide the treatment
[13].
Air splints and other therapy tools play an important role in training. The exercises,
integrating the environment using externally focused instructions[32] and adapting the
task allow self-directed practice with the hemiplegic limbs. This problem solving process
promotes planning, initiation and execution of the movement sequence with feedback in
´hands-off´ situations. Self directed practice is therefore on-going in both supervised
and unsupervised therapy sessions and at home.
Clinical Management
Clinical management with PANat evaluates the sensory-motor deficits caused by the
stroke in the following way:[16]
1. Function task level: What intervention goal or activity has been agreed upon
with the patient?
2. Strategy: What is the movement strategy: restorative or compensational?
(Activity/strategy level)
3. Impairment: What underlying resources and limitations cause the movement
pattern?(sensory, motor and cognitive impairment- level)
The task is analyzed to give a baseline performance level. A training programme is set
up incorporating the principles of motor learning[17].
The rehabilitation process is guided by the theory of neuroplasticity[18]. Motivation and
commitment is encouraged by focusing on patient specific goal directed activities.
The aim is to encourage repetitive, intensive and targeted training strategies of the
hemiplegic side in a set task or part task activity in order to improve movement speed
and force in the weaker movement pattern of the hemiplegic limbs. The acquired limb
(part-) activity is then immediately linked back to the desired goal of the patient.

© Rights reserved PANat 2009, revised 02/2015, version 2017 6
Integration of PANat into the rehabilitation process
Integrating PANat into the rehabilitation process will incorporate patient centered goals
and use task specific strategies to minimize compensatory movements that occur during
functional activity. This is achieved by maintaining muscle flexibility and extensibility,
strengthening weak muscles, stimulating muscle activity in a functional context and
increasing sensory stimulation[19].
The aim of training is to promote the quality and quantity of activities with the
hemiparetic limbs, in uni- /bi-lateral and bimanual movements whilst preventing
detrimental compensatory strategies. The choice of activity in the training session is
based on the impairments that constrain the patient from performing or completing a
task.
Exercises are performed with an increasing number of repetitions within a well
structured and mostly closed environment. Variability is introduced into the training plan
by changing the complexity of each task, altering the speed and/or the support surface,
adjusting the lever effect with air splints or other therapy tools and introducing cognitive
elements: e.g. dual tasking.
The appropriate choice and use of air splints and therapy tools may be used to reduce
the complexity of multi-joint movements by limiting the ´degree of freedom of
movement´[20] of the joint during a specific activity. They promote selective motor
control of the affected limb in a meaningful task and provide opportunities for repetition
and high intensity training in either individual or group sessions. Finding a balance
between ´hands-on´ and ´hands-off´ practice or self-directed training can improve the
patient’s ability to problem-solve.
The patient’s goal and performance must be re-evaluated regularly and the therapeutic
interventions modified to ensure they maximise their rehabilitation potential.
Air splints and other therapy tools can be used in all phases of rehabilitation from the
acute stage to that of long term management. The emphasis within the training
programme will vary from prevention and treatment of adaptive changes to mobilization
and recruitment of muscle activity.
Sensory-motor deficits respond slowly to change, but the task and the setting can be
structured in a learning environment to stimulate muscle groups needed to accomplish
the planned activity.

© Rights reserved PANat 2009, revised 02/2015, version 2017 7
Conclusion
Effective and efficient training for neurological patients in all phases of rehabilitation with
severely impaired sensory-motor control is challenging. One aim of rehabilitation is to
achieve effective motor behaviour. It is therefore essential that emphasis is also placed
on intensive training and practice with the hemiplegic side throughout the rehabilitation
process.
The PRO-Active approach is well incorporated into different phases of the rehabilitation
process; it integrates current dynamic systems theory of motor control and motor
learning, is evidence based on sensory motor training[4,5,19,28], promotes early
involvement of the carers and enables autonomous training.
Motor learning after stroke is a life-long process. Therapists integrating PANat into
stroke rehabilitation incorporate strategies that can help to treat motor behaviour with
compensatory strategies that occurs during functional tasks. This is achieved on an
impairment level by strengthening weak muscles, maintaining muscle flexibility and
extensibility, stimulating muscle activity in a functional context and increasing sensory
stimulation. On a behavioural level it is achieved by incorporating intensive and
repetitive practice using external focus instructions and feedback during ´hands-on/-
off´ training. This can be practiced when severe sensory, motor, cognitive and
perceptual problems are present.
In addition, the judicious use of the air splints and therapy tools help to reduce the
complexity of multi-joint movements during training, and enhance self-controlled and
targeted motor control within meaningful activities. Time spent in self-directed training
with the hemiplegic limbs in all phases of rehabilitation is increased.
In this approach stroke patients and their carers are encouraged and coached to be
proactive in managing their ongoing rehabilitation. All together they address the specific
problems or limitations caused by stroke and continuously update the treatment
programme.
Practical examples can be looked at
In the PANat User guide
in the Poster –presented in Leuven, Belgium in 2006: Promoting `Force to use it`- Strategies of the
Hemiplegic Limbs of a Patient with Severely Impaired Motor Control Following Stroke: A Case Report.
Cox Steck G., Signer S.
in the article in NOT: “Independent, repetitive arm motor training in severe hemiparesis using the
Johnstone Air Splint / Selbsttatiges, repetitives Armmotoriktraining bei ausgepragter Hemiparese mit
den Johnstone-Luftpolsterschienen nach PANat* / Traitement autonome et repetitif de la motricite du
bras lors d'une hemiplegie prononcee, a l'aide de les attelles gonflables de Johnstone d'apres PANat.”
Wälder F. 2008

© Rights reserved PANat 2009, revised 02/2015, version 2017 8
PRO-Active - What is in the word?
PRO-Active approach to Neurorehabilitation integrating air splints* and other therapy tools (PANat)
*Urias®Johnstone air splints
PRO-Active: Summarizes the clinical management process of PANat
PRO: The decision making process and clinical reasoning to justify the use of air splints and other therapy
tools. (Who, what and why)
Active: The training programme is based upon the principles of contemporary motor learning theories.
(How)
P: Pathology
PANat is primarily for stroke rehabilitation. It can also be used for other neurological problems e.g. multiple
sclerosis and acquired brain injury. The objective and emphasis of the treatment will depend on the
diagnosis.
R: Reframe
The International Classification of Functioning and Health (ICF)[21] is used as the underlying structure to
reframe the problems relating to pathology or diagnosis. Activities, participation and quality of life
(enablement) and underlying impairments (disablement) are taken into account.
The Upper Motor Neurone Syndrome (UMNS) is used to understand the relationship of primary motor
impairments to secondary motor impairments and their relationship to disability after stroke.
O: Objectives
Goal setting is used as a motivational technique to enable the patient to understand why training is
necessary [22-23].
•What is the patient’s goal?
•What are the therapy objectives to meet this goal?
A: Acquisition of skills
The guidelines for acquisition of skills are integrated in the training programme[15].
Emphasis is placed on the initial or cognitive phase of skill acquisition. Using the severely motor impaired
limb to learn a task in an adaptive situation is comparable to learning a new task.
c: carers
An integral part of PANat is the education of carers, family members and friends in understanding and
managing the disease process. Through training they develop skills to continue long term rehabilitation in
the home and to minimize anxiety, boost confidence and facilitate a successful discharge home and social
reintegration. [24].
t: training
Training after damage to the CNS has been shown to improve functional return[15]. The aim is to maximize
recovery and prevent compensatory strategies. Integrating PANat into the rehabilitation process enables the
therapist to initiate early specific training to activate the appropriate muscle groups in a goal-directed, task
oriented context.
Evidence-based guidelines for training are incorporated into the programme[13,16,31].
i: intensity
PANat allows intensive, repetitive, focused, self-directed movements of the hemi paretic arm, and the leg
with integration of the trunk by patients with severely impaired motor control. Air splints and tools can be
applied by all members of the team and carers. This allows on-going sensory-motor training at weekends or
in the home setting. Training can also be practiced in group sessions to encourage efficient use of time and
resources[25-26].
v: variation
The air splints and tools are used as a part of the environment to constrain and promote quality of
movement in meaningful activities or goals[6-8]. This enables task modification or part task in an activity and
makes repetition in multiple variations possible. External focus is used as a form of feedback and instruction.
e: evidence
How effective has the intervention been for these patients? Progress must be continuously re-assessed; the
choice of assessment tool will depend on what is being evaluated.
•Quantitative methods measure statistics (how much).
•Qualitative methods assess planning and adaptive behavioural changes[27].
•Individual objective measures show changes in performance over time.

© Rights reserved PANat 2009, revised 02/2015, version 2017 9
Appendix
Johnstone air splints
The Urias®Johnstone air splints were specifically developed and designed since 1966 for training stroke
patients with severely impaired motor control. The choice of air splint or therapy tool is dependent on the
level of motor recovery, performance capability of the patient and the specific task or activity.
When training according to PANat-principles ONLY the Urias®Johnstone air splints are recommended for
following reasons:
Margaret Johnstone and other PANat instructors designed a variety of air splints to fit the different
training programmes
The material of the Johnstone air splints is made from flexible PVC (according to European
standards), double-layered and transparent. The air splints are designed to be inflated by mouth to
a maximum pressure of 40 mm Hg and for training the stroke patient with severely impaired motor
control.
For further information of application and some practical examples of use of the air splints, please read the
user guide[6].
Self-directed training (´hands-off´)
Self-directed training combined with air splints promotes autonomous practice, incorporating repetitive and
intensive training strategies of the hemiplegic limbs in a defined activity. The starting position for any
activity must be in accordance with the level of motor recovery and functional ability of the patient.
Therapeutic assistance is required to position the patient, mobilize joints and soft tissue prior to applying air
splints ´hands-on´, and in setting up the task to enhance the learning environment. The task, environment
and exercise sequence are adapted to promote an autonomous, problem solving process of planning,
initiation, carry through, completion and evaluation of the movement sequence ´hands-off´. The aim of
training is to promote the quality and quantity of functional activities of the hemiparetic limbs in uni/bi-
lateral and bimanual movements whilst preventing detrimental compensatory strategies. The choice of
activity in the session is based on the impairments that constrain the patient from performing or completing
a task.
Severely impaired motor control
The patients most appropriate for this training are those whose symptoms range from no selective
movement to pronounced weakness with minimal of muscle activity. This approach should be considered for
those patients who have developed secondary negative musculoskeletal and neurological behaviours (soft-
tissue contractures). The Chedoke McMaster Stroke assessment[29] would classify this patient group on the
impairment inventory: Stages 1-4. These patients and particularly those with no selective movements and
with cognitive impairment have difficulty participating in evidence based training methods such as
Constrained Induced Movement Therapy[30].
Degrees of freedom of movement: N.A. Bernstein[21]
This refers to a motor control problem in how to co-ordinate and regulate movement (in the body). The
process of mastering co-ordination and control of movement is managed by reducing the degree of freedom
of movement of a specific joint or a limb thus preventing inappropriate movement.
External Focus of attention[32]
External focus of attention is the focus that is directed at the effect of one’s movement in relation to the
environment.
PANat therapists structure the environment with visual, auditive and tactile cues to enable quality of
movement for strokes with severely impaired motor control. Air splints and therapy tools can be used in the
training session for additional external focus of attention.
Author’s comments
This document will be reviewed regularly and any changes will be acknowledged as the scientific framework
for movement analysis, motor control and motor learning in rehabilitation evolves and clinical expertise
develops. It is recommended that clinical trials are undertaken to assess and evaluate the clinical response
to the use of PANat with this client group.

© Rights reserved PANat 2009, revised 02/2015, version 2017 10
References
1. Obituary –Margaret Johnstone 2007, www.PANat.info
2. Johnstone M. Restoration of normal movement after Stroke, Churchill Livingstone, 1995.
3. Johnstone M. Home Care for the Stroke Patient, Churchill Livingston, 1996.
4. Feys HM, De Weerdt WJ, Selz BE, Cox Steck GA, Spichiger R, Vereeck LE, Putman KD,
Van Hoydonck GA. Effect of a Therapeutic Intervention for the Hemiplegic Upper Limb in the Acute
Phase after Stroke. A Single-Bind, Randomised, Controlled, Multicentre Trial.
Stroke. 1998; 29: 785-792.
5. Feys H, De Weerdt W, Verbeke G, Cox Steck G, Capain C, Kiekens C, Dejaeger E, Van Hoydonck G,
Vermeersch G, Cras P. Early and repetitive stimulation of the arm can substantially improve the
long-term outcome after stroke: A five-year follow-up study of a single-blind randomised trial.
Stroke. 2004; 35: 924-929.
6. Cox Steck GA. User guide for information and instructions to familiarize application and handling of
the Urias®Johnstone air splints used in PANat, Rehabilitation centre, Bürgerspital, Solothurn,
Switzerland, 2009.
7. Wälder F. Selbsttätiges, repetitives Armmotoriktraining bei ausgeprägter Hemiparese mit den
Johnstone-Luftpolsterschienen nach PANat. Ergotherapie & Rehabilitation. 2007; 8: 14-20.
8. Wälder F. Neurotherapeutische Rehabilitation mit den Johnstone Luftpolsterschienen nach PANat.
In: Habermann C, Kolster F. Ergotherapie im Arbeitsfeld Neurologie. , 2. Auflage. Stuttgart: Thieme;
2009: 747 –783.
9. Schmidt RA. Motor Control and Learning: A Behavioural Emphasis, edition 2. Human Kinetics;
Champaign, Illinois, 1998.
10. Krakauer JW. Motor learning: its relevance to stroke recovery and Neurorehabilitation, Current Opinion
in Neurology: February 2006; Volume 19(1): 84-90.
11. Majsak MJ. Application of Motor Learning Principles to the Stroke Population. In: Topics in Stroke
Rehabilitation. 1996; 3: 27–59.
12. Montgomery P, Connoly PB. Clinical Applications for Motor Control, Slack, 2003.
13. Carr JH, Shepherd RB. Stroke Rehabilitation. Elsevier Limited; 2004.
14. Umphred DA. Introduction and Overview: Multiple Conceptual Models: Framework for Clinical Problem
Solving. In: Neurological Rehabilitation, 3rd. Edition. Mosby; 1995.
15. Gentile AM. Skill Acquisition: Action, Movement, and Neuromotor Processes. In: Carr J, Shepherd R.
Movement Science, Foundations for Physical Therapy in Rehabilitation, 2nd ed. 2000.
16. Shumway- Cook A, Woollacott MH. Motor Control Translating Research into Clinical Practice, 3rd.
Edition. Baltimore: Lippincott Williams and Wilkins; 2007.
17. Cox Steck GA. A clinical decision making- goal directed training program.
Rehabilitation centre, Bürgerspital, Solothurn, Switzerland. Unpublished working document 2009.
18. Byl NN. Neuroplasticity : Applications to Motor Control. In: Montgomery PC, Connolly BH.
Clinical Applications for Motor Control. SLACK incorporated; 2003: 79-106.
19. Chambier DC, De Corte E. Treating sensory impairments in the post-stroke upper limb with intermittent
pneumatic compression. Results of a preliminary trial. Clinical Rehabilitation. 2003; 17: 14-20
20. Bernstein NA. The Coordination and Regulation of Movements. New York: Pergamon; 1967:127-134
21. http://www.who.int/classifications/icf/site/icftemplate.cfm H
22. Hammond JS, Keeney RL, Raiffa H. Smart choices: a practical guide to making better life decisions.
New York: Broadway books,1998.
23. Signer- Thöne S. Goal setting process and management in Rehabilitation Centre, Bürgerspital,
Solothurn, Switzerland. Unpublished working document 2010.
24. Thorsen AM et al. A randomized controlled trial of early supported discharge and continued
rehabilitation at home after stroke. Stroke. 2005;36:297-302
25. DeWeerdt W, Selz B et al. Time use of stroke patients in an intensive rehabilitation unit: a comparison
between a Belgian and a Swiss setting. Disability and Rehabilitation. 2000; vol 22 no.4: 181-186.
26. Ada L, Mackey F, Heard R, Adams R. Stroke rehabilitation: does the therapy area provide a physical
challenge? Aust. J Physiotherapy. 1999; 45: 33-38.
27. Kieresuk T, Smith A, Cardillo J. Goal Attainment Scaling, Applications, theory and measurement, 1994.
28. Ottawa Panel. Evidence- Based Clinical Practice Guidelines for Post-Stroke Rehabilitation. Topics in
Stroke Rehabilitation. Spring 2006; vol 13/ Number 2.
29. Gowland C. et al. Chedoke- McMaster Stroke Assessment, 1995.
30. Taub E, Uswatte G et al. Constraint –Induced Movement Therapy: A new family of techniques with
broad application to physical rehabilitation - A clinical review. J Rehabil Res Dev. 1999.
31. www.strokecenter.org/prof/guidelines.htm, www.Americanheart.org
32. Wulf G. Attention and motor skill learning, Champaign, IL: Human Kinetics; 2007

© Rights reserved PANat 2009, revised 02/2015, version 2017 11
PRO-Active approach to Neurorehabilitation
integrating air splints* and other therapy tools
(* Urias®Johnstone air splints)
2. Application of the
Urias®Johnstone air splints
used in PANat
USER GUIDE

© Rights reserved PANat 2009, revised 02/2015, version 2017 12
TABLE OF CONTENT USER GUIDE
APPLICATION OF THE URIAS® JOHNSTONE AIR SPLINTS USED IN PANat:....... 11
ADVANTAGES OF USE..........................................................................................................13
GENERAL INFORMATION.......................................................................................................14
LONG ARM AIR SPLINT -70 CM AND 80 CM ..............................................................................17
HALF ARM AIR SPLINT -53 CM.............................................................................................20
HAND AIR SPLINT (DOUBLE CHAMBER )-20 CM.........................................................................24
HAND &WRIST AIR SPLINT (DOUBLE CHAMBER)-30 CM ..............................................................26
ELBOW AIR SPLINT -40 CM.................................................................................................28
FINGER AIR SPLINT (ONE SIDED SINGLE CHAMBER)-15 CM...........................................................31
FOOT AIR SPLINT...............................................................................................................33
FOOT AIR SPLINT (DOUBLE CHAMBER) ......................................................................................35
LEG AIR SPLINT (DOUBLE CHAMBER)-60 CM,70 CM AND 80 CM ....................................................38
LEG &FOOT AIR SPLINT FOR RESTING (SPECIALLY DESIGNED FOR PATIENTS WITH MULTIPLE SCLEROSIS) ......41
LEG &FOOT AIR SPLINT FOR STANDING (SPECIALLY DESIGNED FOR PATIENTS WITH MULTIPLE SCLEROSIS) ....43
This user guide is developed by Gail Cox Steck, Physiotherapist FH, Switzerland,
in collaboration with the accredited teachers of PANat.
Sandra Signer, Physiotherapist, MAS MHC, Switzerland.
Franziska Wälder, Occupational Therapist HF, Switzerland.
Walter Habils, Occupational Therapist, Belgium.
Anne-Marie Verstraeten, Occupational Therapist, Adv Dip H Sc, Belgium.
Birgitte Gammeltoft, Occupational Therapist, Denmark.
Renata Vodickova, DiS., Physiotherapist, Czech Republic
Copyright © 2009, revised February 2015 www.panat.info
The Urias® Johnstone air splints are manufactured by Arden Medical Limited. http://www.arden-medical.com

© Rights reserved PANat 2009, revised 02/2015, version 2017 13
Johnstone air splints were primarily designed for the stroke patient with
moderate to severely impaired motor control of movement. They provide an
effective and efficient method for training.
The user guide only includes general information and instructions for application and
handling of the air splints. Sample exercises are given to help develop your own exercise
programmes. Responsibility of treatment is guided by the skilled therapists. The overall
aim is to encourage and motivate active training as part of a task activity with the
underused hemiplegic side and to discourage learned disuse with its negative
consequences. Air splints can be used in combination with other low cost easy to use
tools thus allowing a greater intensity and variety of training.
The air splints were developed by physiotherapists Margaret Johnstone and Ann Thorp as
a rehabilitation aid for those with stroke and multiple sclerosis. Their ideas have been
updated and PANat was launched in January 2007 to reflect the development of the
underlying theoretical assumptions and therapeutic uses of these air splints.
To be effective it is essential that the air splints are applied and used as directed by this
user guide.
A number of research articles have used the air splints as passive resting tools applied in
positions and postures that may have a negative outcome on training and potential
recovery (e.g. Poole, 1990; Kwakkel, 1999, Platz, 2009). This is contrary to the aims
and use of the air splints as practiced by the PANat group.
With correct application and use of the air splints, the following advantages can be
observed:
Advantages of use
1. Biomechanical
To prevent secondary impairments of muscle shortening and loss of elasticity in
muscles (e.g. myofascia) and connective tissue (e.g. capsule joints).
To minimise undesirable muscle activity by maintaining joint alignment and
limiting the degree of freedom of movement in multi-joint movements. This is
especially important in the early stages of skill acquisition.
To strengthen muscle groups in functional activities/tasks, by allowing safe pain
free early static or dynamic weight bearing.
To encourage general fitness and strength, enabling the client to increase the time
spent in training.
To promote self-directed exercises in a safe and controlled environment, allowing
the client to progress more quickly, from independent hands-on training to active
problem solving hands-off situations.
2. Sensory
To promote proprioceptive stimulation by weight bearing or limb loading on the
extremities in various activities and postural sets.
To have added sensory input with intermittent pneumatic compression in
combination with the air splints (tactile and proprioceptive).
For further information on theoretical background and courses please contact the
following address: www.panat.info

© Rights reserved PANat 2009, revised 02/2015, version 2017 14
General information
The URIAS®orally inflated air splints are made from specially developed PVC. Based on
the principles of PANat, monitoring change and increasing awareness of the hemiplegic
side are important aspects when integrating specific air splints into the individual’s
rehabilitation programme. Nurses and carers are taught how to apply the air splints and
support the client out of therapy sessions and at home.
With each air splint the following procedures apply:
Preparation prior to air splint application
Application
Sample exercises: use these to develop your own exercise programmes.
Removal
Contra-indications / Precautions
1. Available Urias®Johnstone air splints for adults
for the upper limb
for the lower limb
Long Arm air splint
70 cm ~ Ref: 70-002-0
80 cm ~ Ref: 70-001-0
Foot air splint
Ref: 70-008-0
Long Arm air splint
(double chamber) *
70 cm ~ Ref: 70-102-0
80 cm ~ Ref: 70-101-0
Foot air splint
(double chamber)
Ref: 70-108-0
Half Arm air splint
53 cm ~ Ref: 70-003-0
Leg air splint
(double chamber )
60 cm ~ Ref: 70-007-0
70 cm ~ Ref: 70-006-0
80 cm ~ Ref: 80-006-0
Half Arm air splint
(double chamber) *
53 cm ~ Ref: 70-103-0
Leg & Foot air splint for
resting
(MS patients)
Ref: 71-002-0
Elbow air splint
40 cm ~ Ref: 70-004-0
Leg & Foot air splint for
standing
(MS patients)
Ref: 70-012-0
Hand air splint
(double chamber)
20 cm ~ Ref: 70-005-0
XL –Bariatric air splints
XL Arm air splint
(double chamber)
70 cm ~ Ref: 70-112-0
80 cm ~ Ref: 70-111-0
Hand & Wrist air splint
(double chamber)
- larger hand -
30 cm ~ Ref: 70-009-0
XL Leg and Foot air splint
for resting
Ref: 71-111-0
Finger air splint (one
sided single chamber) *
15 cm ~ Ref: 70-109-S
XL Leg and Foot air splint
for standing
Ref: 71-012-0
Finger air splint
(double chamber)
15 cm ~ Ref: 70-109-0
XL Leg gaiter
(double chamber)
60 cm ~ Ref: 70-017-0
70 cm ~ Ref: 70-016-0
*Not included in the user guide
2. Indications
Stroke patients with moderate to severely impaired motor control.
Patients with soft tissue shortening of skeletal muscle.

© Rights reserved PANat 2009, revised 02/2015, version 2017 15
3. Contraindications
Deep vein thrombus diagnosed or suspected.
Acute lung oedema.
4. Precautions
Small broken areas of skin should be covered with a dressing; the air splint can
then be applied.
Jewellery should be removed from practitioner and client before air splint
application.
A thin cotton sleeve should cover the client’s limb while the air splint is in use as a
protection against sweat rash. This is not necessary for the hand, fingers and
toes.
Pressure should never exceed 40 mm Hg. Pressure should be read when the limb
is at rest.
The air splint should not be worn in direct sunlight. Strong sunlight through the
plastic may cause a burn to the skin.
The limb must be passively mobilised before and after application of the air splint.
No air splint should be left on for more than 45 minutes, but should be taken off
and reapplied and the treatment session continued.
Never use for overnight positioning.
Dispose of air splints in the household waste. Do not burn or incinerate.
5. Inflation of air splints
The air splints should be orally inflated. The warm air from the lungs ensures the
air splint is well fitting and comfortable giving an even pressure over the limb.
If the client experiences any pain the air splint must be removed and reapplied.
Inflation pressure should be checked by a manometer and must not exceed 40
mm Hg at rest (use a 10 cm connection between splint valve and manometer).
Electric/mechanical pumps to blow up air splints are not recommended, as the
advantages of blowing up by mouth are lost (see above). For hygienic purposes
filters with a personal mouthpiece are used.
6. Care of air splints / storage
New air splints should be inflated with the zip open to ensure that the two layers
of plastic separate. After fully inflating the air splint, the valve should be opened
and the air splint rolled up to force all the air out. The air splint is then
straightened and is ready for use.
When not in use, the air splint should be stored flat, or hung up so that the
inflation tube hangs downwards to ensure there is no strain at the junction of the
inflation tube and the air splint. This inflation tube must never be used to handle
or carry the air splint.
To clean the air splints wipe them over with a mild disinfectant, then dry with a
towel. If necessary the valve may be disconnected and washed and the inflation
tube cleaned with a test tube brush dipped in a mild disinfectant, allowed to dry
and then reassembled.
Air splints should be stored at room temperature (+10 degrees).
A personal detachable mouthpiece for inflation is recommended. This is easily
fitted to the inflation tube,
Many clients prefer to have their own air splints and when necessary, carers and
family members are taught to use them by the therapist.

© Rights reserved PANat 2009, revised 02/2015, version 2017 16
7. Accessories
Thin cotton sleeve
Mouth piece; disposable filter bottle
1. Mouth Piece
REF 75-000-0
2. Filter Bottle
REF 75-011-0
1. Mouth piece - a personal detachable mouth piece is easily fitted and carried in
the user's pocket. This can be washed as necessary.
2. Disposable filter bottle - contains crystals which absorb excess moisture. This is
fitted to the inflation tube and when detached, carried in the user's pocket. When
the granules turn from orange to white (clear) the bottle must be discarded.
For the sake of clarity, throughout the text, the patient is referred to as ´he´.

© Rights reserved PANat 2009, revised 02/2015, version 2017 17
Long Arm air splint - 70 cm and 80 cm
Aims of Use:
For active and passive mobilisation of the extended arm without pain in all ranges of movement.
For the prevention and treatment of soft tissue contractures in the shoulder, elbow, wrist and fingers.
To enable early weight bearing of the upper limb in a physiological position.
Preparation
Starting position: Supine (lying on the back) with both arms supported on pillows to ensure symmetrical
postural alignment. The choice of air splint (70 cm or 80 cm) will depend on the length of the hemiplegic
arm. Passive movements of the shoulder girdle and arm are carried out, at the same time muscle pliability
and joint range are assessed.
1
2
Passively mobilise, realign and support the
scapula to permit accurate positioning of the
shoulder and arm.
Carefully bring the extended arm into outward
rotation, flexion and abduction. Encourage the
client to turn his head to the affected side to
watch and follow the movements of the arm and
hand.
3
4
Support the upper arm / hand and mobilise the
elbow.
Shoulder joint is in 60° flexion and rotation is
neutral.
Mobilise the wrist into dorsal extension. The
metacarpals are individually mobilised and the
palm is rounded and flattened. The thumb and
each finger are passively lengthened. Form the
hand into a fist, then stretch it out.
5
6
Ensure the arm is adequately supported on
pillows. Put the cotton sleeve on your own arm
(the right arm if it is the client’s right arm). A
hand shake hold is used to correctly support the
hemiplegic hand.
Apply the cotton sleeve; this is to prevent skin
irritation. Cover the entire arm but leave the
hand free.

© Rights reserved PANat 2009, revised 02/2015, version 2017 18
Application of the air splint
1
2
Close the zip. Put the air splint onto your arm
(the right arm if it is the client’s right arm). Take
the client’s hand in a handshake hold and draw
the air splint over his arm.
The shoulder is outwardly rotated, elbow
extended, wrist in 10° extension, the thumb is
abducted (outward and straight) and the
fingers are straight.
The zip lies parallel to the 5th finger.
The client turns his head and looks towards
the hemiplegic hand.
The air splint is drawn up the arm to leave a
space of 3 fingers’ width from the axilla.
3
4
Place the inflation tube in your mouth. This
leaves both hands free to maintain the position
of the limb in the air splint.
Abduct the thumb applying light pressure over
the thenar eminence (base of 1st metacarpal).
Hold it in this position during inflation.
The fingers are straight and held together - not
apart. The wrist is supported in approx 10°
dorsal extension. Both of your hands are needed
to keep the client’s hand in the optimal position.
Leave a space of 6-8 cm from the finger tips to
the open end of the air splint: this ensures even
pressure over the arm and hand.
5
Correct position.

© Rights reserved PANat 2009, revised 02/2015, version 2017 19
Sample exercises
Use these to develop your own exercise programmes.
Pushing against the therapist’s hand,
a ball or the wall. Support the arm
on pillows to maintain the neutral
position of the shoulder.
The client moves the hemiplegic arm
actively assisted by the non affected
arm to an external focus (the
markers on the wall).
Different activities (e.g. balancing a
rubber ball on the air splint for x
seconds) can be encouraged using
the long arm air splint to stabilise the
elbow, wrist and hand.
Removal of the air splint
1
•Open the valve to release the air. Encourage the client to
help squeeze the air out of the air splint.
•Undo the zip. Ask the client to close his eyes and feel the
changing pressure in the air splint on the arm.
•Take off the air splint.
•If active movement is present encourage the client to move
his limb.
2
Passively mobilise all joints (see preparation for application).
Ask the client if he is aware of changes in feeling or in movement of the limb.
3
Following the removal of the air splint use a variety of objects
to stimulate sensation and selective movement.
Precautions
Do not apply the long arm air splint with the shoulder inwardly rotated.
Do not apply the air splint into the axilla as this may cause pressure on the brachial plexus.
Never pull the air splint off –deflate, open the zip; support the arm and hand and carefully draw
off the air splint thus avoiding any potential trauma to the shoulder.
Do not leave the air splint on for more than 30-45 minutes. Within the course of a treatment
session it may be removed and reapplied if it is being used dynamically rather than as a tool to
stretch soft tissues.
To mobilise tight muscle groups apply the air splint 2-3 times daily for 20 minutes.
Never use the air splints for positioning overnight.

© Rights reserved PANat 2009, revised 02/2015, version 2017 20
Half Arm air splint - 53 cm
Aims of Use:
To control muscle stiffness and stabilise the wrist and fingers during training.
To enable forearm propping in prone lying, sitting and standing.
To prevent and treat soft tissue contractures in the forearm, wrist and fingers.
Preparation
Passive movements of the shoulder girdle and arm are carried out and at the same time muscle pliability
and joint ranges are assessed.
1
2
The half arm air splint can be applied in lying,
sitting and standing. In all positions passive
movements of the shoulder girdle, arm, elbow
and hand are carried out prior to application.
Carefully bring the extended arm into outward
rotation, flexion and abduction. Encourage the
client to turn his head to the affected side to
watch and follow the movements of the arm and
hand.
3
4
Support the arm / hand and mobilise the elbow.
Make sure the elbow is mobilised to end range in
both flexion and extension.
Shoulder joint is in 60° flexion and rotation is
neutral.
Mobilise the wrist into dorsal extension. The
metacarpals are individually mobilised and the
palm is rounded and flattened. Each finger is
passively lengthened. Form the hand into a fist
then stretch it out.
5
6
Ensure the arm is adequately supported on
pillows. Put the cotton sleeve on your own arm
(the right arm if it’s the client’s right arm). Take
the hemiplegic hand in a hand shake hold.
Apply the cotton sleeve; this is to prevent skin
irritation. Cover the forearm but leave the hand
free.
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