Static wrist splint: Its effect on hand function in three women with rheumatoid arthritis

A comparative study of the efficacy and functionality of 10 commercially available wrist-hand orthoses in healthy females during activities of daily living

Objective

Optimal wrist/hand function facilitates the performance of activities of daily living (ADL), which are associated with independent living and increased quality of life. Rheumatological, musculoskeletal, and neurological conditions or injuries can negatively impact hand/wrist function, with wrist-hand orthoses (WHOs) being prescribed to control motion and improve wrist alignment whilst enhancing hand/wrist functionality. The objective of this follow-up study was to quantify and assess the efficacy and functionality of 10 commercially available WHOs during five ADLs.

Design

Randomised comparative functional study of the wrist/hand with and without WHOs.

Participants

Ten right-handed healthy female participants with no underlying condition or pain affecting the wrist/hand that could influence their ability to undertake ADLs.

Main outcome measures

The primary outcome was ascertaining the impact of each WHO during five ADLs. Movement was quantified in sagittal, coronal, and transverse planes with and without WHO use. The resting position, maximum mean flexion, extension, pronation, supination, and radial and ulnar deviation attained were quantified, with the time spent in wrist flexion, wrist flexion and ulnar deviation, wrist extension >15°, and radial deviation recorded. Finally, the time to complete each task was compared between conditions.

Results

At rest, four WHOs maintained the desired sagittal plane wrist position, with only one preventing radial deviation with variation observed in the transverse plane. All WHOs reduced mean maximum flexion, with only 10 out of 50 tests (20%) showing a successful restriction of flexion (p < 0.05) and 14 out of 50 (28%) showing a reduction of the time spent in flexion (p < 0.05). In 42 out of 50 tests (84%), the wrist was extended >15° for a significant amount of time (p < 0.05), with the wrist in radial deviation in 98% for a significant amount of time (p < 0.001). The wrist was flexed and in ulnar deviation for a significant time for 6 out of 50 tests (12%, p < 0.05), whilst all WHOs impacted transverse movement, with 27% reducing it significantly, and all tasks took a longer time to complete, with 46% taking a significantly longer time (p < 0.05).

Conclusion

The WHOs did not control movement sufficiently to successfully manage any condition requiring motion restriction associated with pain relief and were found to increase the time to complete the ADLs. Multifactorial design aspects influenced functionality, and there is a clear need for WHO redesign.

A Comparative Study of Efficacy and Functionality of Ten Commercially Available Wrist-Hand Orthoses in Healthy Females: Wrist Range of Motion and Grip Strength Analysis

Objective: Wrist-hand orthoses (WHOs) are prescribed for a range of musculoskeletal/neurological conditions to optimise wrist/hand position at rest and enhance performance by controlling its range of motion (ROM), improving alignment, reducing pain, and optimising grip strength. The objective of this research was to study the efficacy and functionality of ten commercially available WHOs on wrist ROM and grip strength.

Design: Randomised comparative functional study of the wrist/hand with and without WHOs.

Participants: Ten right-handed female participants presenting with no underlying condition nor pain affecting the wrist/hand which could influence motion or grip strength. Each participant randomly tested ten WHOs; one per week, for 10 weeks.

Main outcome measures: The primary outcome was to ascertain the impact of WHOs on wrist resting position and flexion, extension, radial, and ulnar deviation. A secondary outcome was the impact of the WHOs on maximum grip strength and associated wrist position when this was attained.

Results: From the 2,400 tests performed it was clear that no WHO performed effectively or consistently across participants. The optimally performing WHO for flexion control was #3 restricting 86.7%, #4 restricting 76.7% of extension, #9 restricting 83.5% of radial deviation, and #4 maximally restricting ulnar deviation. A grip strength reduction was observed with all WHOs, and ranged from 1.7% (#6) to 34.2% (#4).

Conclusion: WHOs did not limit movement sufficiently to successfully manage any condition requiring motion restriction associated with pain relief. The array of motion control recorded might be a contributing factor for the current conflicting evidence of efficacy for WHOs. Any detrimental impact on grip strength will influence the types of activities undertaken by the wearer. The design aspects impacting wrist motion and grip strength are multifactorial, including: WHO geometry; the presence of a volar bar; material of construction; strap design; and quality of fit. This study raises questions regarding the efficacy of current designs of prefabricated WHOs which have remained unchanged for several decades but continue to be used globally without a robust evidence-base to inform clinical practise and the prescription of these devices. These findings justify the need to re-design WHOs with the goal of meeting users' needs.

Static orthoses in the prevention of hand dysfunction in rheumatoid arthritis: a review of the literature

Static orthoses are recommended for individuals who have early rheumatoid arthritis (Scottish Intercollegiate Guidelines Network, 2002; College of Occupational Therapists, 2003). These orthoses aim to rest and immobilize weakened joint structures and decrease local inflammation (Janssen et al., 1990; Nicholas et al., 1982); correctly position joints (Nordenskiöld, 1990; Ouellette, 1991); minimize joint contractures (McClure et al., 1994); increase joint stability (Kjeken et al., 1995); relieve pain (Feinberg, 1992; Callinan and Mathiowetz, 1996; Kjeken et al., 1995) and improve function (Janssen et al., 1990; Pagnotta et al., 1998; Nordenskiöld, 1990). Wrist and hand orthoses have been routinely prescribed for individuals with rheumatoid arthritis (RA) for the last 30 years with limited evidence that they are effective in achieving their purported aims. This article reviews the possible deterioration in hand structure that can occur in RA and discusses the theoretical basis for the application of static orthoses in RA. The evidence for the effectiveness of four commonly used static orthoses is then examined.

A crossover trial of custom-made and commercially available wrist splints in adults with inflammatory arthritis

OBJECTIVE

To compare the effect of 3 wrist splints (2 prefabricated commercial splints and 1 custom made) on perceived wrist pain, hand function, and perceived upper extremity function in adults with inflammatory arthritis.

METHODS

Subjects (n = 45, mean age 49 years, mean disease duration 8.6 years) were randomly assigned to treatment order in a 3-phase crossover trial. Splints were worn for 4 weeks, separated by 1-week washouts. Outcomes were assessed at baseline, after each splint phase and washout period, and at 6 months' followup using a pain visual analog scale (VAS), the Arthritis Hand Function Test, and McMaster-Toronto Arthritis Patient Function Preference questionnaire. Data were analyzed with multivariate analyses of variance (MANOVAs), t-tests, and chi-square tests.

RESULTS

There did not appear to be order or carryover effects. MANOVA indicated that wrist splints significantly reduced pain (P = 0.007). The custom leather splint was most effective in reducing pain, from 4.1 cm to 2.8 cm on the VAS (P = 0.001). All splints improved hand strength, and the commercial Rolyan splint provided significantly stronger grip than the Anatech commercial splint (P = 0.04). In contrast to previous studies, splints did not compromise dexterity. There were several significant differences among splints, depending on the outcome measure. Improvements were maintained at 6 months.

CONCLUSION

After 4 weeks' use, wrist splints reduce pain, improve strength, and do not compromise dexterity. Similar improvements were achieved with the custom leather splint and Rolyan commercial splint, which were superior to the Anatech commercial splint.

A comparison of static and dynamic wrist splints using electromyography in individuals with rheumatoid arthritis

This study compared strength, dexterity, and the muscle activation of individuals with rheumatoid arthritis (RA) when different splints were worn. Five persons with RA were observed in four splint conditions (none, static, hinged, spiral) during grip, pinch, and dexterity tests by recording muscle activity of eight muscles in the upper extremity using electromyography (EMG). Statistically significant differences were found in clinical tests when hinged (p<0.001) and spiral splints (p=0.02) were worn. Grip strength decreased when hinged splints were worn, whereas two-point pinch increased and dexterity improved on the Nine-Hole Peg Test with the spiral splint. Although no significant EMG differences were found during different splint conditions, wrist muscles were recruited more for grip, and shoulder muscles were used most during pinch and dexterity tests. Individuals with RA who wore splints had decreased grip when wearing hinged splints, but improved pinch and dexterity were found when the spiral splint was worn. Increased use of proximal shoulder muscles was observed during pinch and dexterity tests with and without splints.

Splints/orthoses in the treatment of rheumatoid arthritis

BACKGROUND

Splints/orthoses are often recommended to patients with rheumatoid arthritis (RA) to decrease pain, decrease swelling and/or prevent deformity. These orthoses include resting hand splints, wrist supports, finger splints and special shoes and shoe inserts.

OBJECTIVES

To assess the effectiveness of splints/orthoses in relieving pain, decreasing swelling and/or preventing deformity and determine the impact of splints/orthoses on strength, mobility and function in people with RA.

SEARCH STRATEGY

We searched MEDLINE, EMBASE, the PEDro data base and Current Contents up to January 2002, and the Cochrane Controlled Trials Register to Issue 4, 2001 using the search strategy developed by the Cochrane Collaboration. Unpublished studies were sought by hand searching conference proceeding and contacting key experts.

SELECTION CRITERIA

All randomized control trials (RCTs) and controlled clinical trials (CCTs), case-control and cohort studies comparing the use of specific orthoses against placebo, another active intervention (including another type of orthoses) or regular treatment were selected, according to an a priori protocol.

DATA COLLECTION AND ANALYSIS

Two reviewers independently selected the studies and abstracted data. The methodological quality of the RCTs and CCTs was assessed using a validated scale.

MAIN RESULTS

Twelve papers reporting on 10 studies met the inclusion criteria. These studies dealt with the following: working wrist splints (5), resting hand and wrist splints (2), special shoes and insoles (3). There is evidence that wearing working wrist splints statistically significantly decreases grip strength and does not affect pain, morning stiffness, pinch grip, quality of life after up to 6 months of regular wear. We found no evidence that resting wrist and hand splints change pain, grip strength, Ritchie Index or number of swollen joints. However, patients who wore these splints for 2 months reported that they preferred use to non-use and padded resting splints to unpadded ones. The one study of special shoes provided evidence of significant benefits of wearing extra-depth shoes for 2 months including less pain on walking and stair climbing and more minutes pain free walking time. Extra-depth shoes with semi-rigid insoles provided better pain relief than extra-depth shoes alone when worn over 12 weeks. Posted insoles prevented progression of hallux valgus angle but did not affect pain or function.

REVIEWER'S CONCLUSIONS

There is insufficient evidence to make firm conclusions about the effectiveness of working wrist splints in decreasing pain or increasing function for people with RA. Potential adverse effects such as decreased range of motion do not seem to be an issue, although some of these splints decrease grip strength and dexterity. Similarly, preliminary evidence suggests that resting hand and wrist splints do not seem to affect range of motion or pain, although patients preferred wearing a resting splint to not wearing one. There is evidence that extra-depth shoes and molded insoles decreases pain on weight-bearing activities such as standing, walking and stair-climbing. Posted insoles may be effective in preventing progression of hallux abductus angle but do not appear to have an impact on pain.

Evidence-based practice: methods to evaluate individual patient improvement

The expectations and demands associated with evidence-based practice in medical rehabilitation require the use of research procedures that are practice based and practitioner oriented. Traditional research methods, including randomized clinical trials, are powerful techniques for determining the efficacy of rehabilitation interventions; however, randomized clinical trials have some practical and ethical limitations when applied to many research questions important to the field of medical rehabilitation, and alternative methods are needed to fully examine the effectiveness of treatment techniques for individual patients and to document clinical accountability. This paper examines the use of single-system designs and N of 1 research strategies. The advantages and limitations of single-system methods are described, and examples relevant to the documentation of clinical outcomes in medical rehabilitation are presented.

Case studies, single-subject research, and N of 1 randomized trials: comparisons and contrasts

Case studies, single-subject research designs, and N of 1 randomized clinical trials are methods of scientific inquiry applied to an individual or small group of individuals. A case study is a form of descriptive research that seeks to identify explanatory patterns for phenomena and generates hypotheses for future research. Single-subject research designs provide a quasi-experimental approach to investigating causal relationships between independent and dependent variables. They are characterized by repeated measures of an observable and clinically relevant target behavior throughout at least one pretreatment (baseline) and intervention phase. The N of 1 clinical trial is similar to the single-subject research design through its use of repeated measures over time but also borrows principles from the conduct of large, randomized controlled trials. Typically, the N of 1 trial compares a therapeutic procedure with placebo or compares two treatments by administering the two conditions in a predetermined random order. Neither the subject nor the clinician is aware of the treatment condition in any given period of time. All three approaches are relatively easy to integrate into clinical practice and are useful for documenting individualized outcomes and providing evidence in support of rehabilitation interventions.

Single-subject research in rehabilitation: a review of studies using AB, withdrawal, multiple baseline, and alternating treatments designs

OBJECTIVE

To review the "methodologic rules" for using single-subject research designs (SSRDs) and to review the use of SSRDs in rehabilitation research of the past decade.

DATA SOURCES

CINAHL and MEDLINE searches using "single subject" and "single system" as key words for the period 1985-1995 yielded 61 articles related to rehabilitation.

STUDY SELECTION

Studies were selected for review if they described one of four commonly used SSRDs, specifically AB, withdrawal, multiple baseline, or alternating treatments.

DATA EXTRACTION

Studies cited were identified by consensus and either exemplify adherence to the experimental rules of SSRDs or illustrate errors that result in threats to the validity of stated findings.

DATA SYNTHESIS

All four types of SSRDs have been reported in rehabilitation studies, sometimes incorrectly.

CONCLUSIONS

SSRDs, with their client-centered focus, are ideally suited for researching human behavior in the rehabilitation practice environment. Although numerous sources clearly identify the methodologic requirements for single-subject experiments, several studies violate the basic rules, threatening the validity of the results of these studies. Other properly applied SSRDs illustrate the strengths of this approach, which can produce empirical support for rehabilitation interventions.

Finger dexterity and hand function: effect of three commercial wrist extensor orthoses on patients with rheumatoid arthritis

OBJECTIVE

To investigate the effect of 3 commercial wrist orthoses on finger dexterity and hand function of patients with rheumatoid arthritis (RA).

METHODS

Forty-two patients with definite RA participated in the cross-over study comparing 3 styles of commercial wrist orthoses. Finger dexterity and hand function of the dominant hand were assessed while splinted and unsplinted, at the initial session and after 1 week of intermittent orthosis use. Finger dexterity was assessed using two subtests from the Purdue Pegboard Test (Purdue) and hand function was assessed using the Jebsen-Taylor Hand Function Test (Jebsen-Taylor).

RESULTS

Both finger dexterity and hand function were reduced by splinting; men and women were affected similarly. There was no difference in finger dexterity or hand function afforded by the 3 orthoses. Results on both the Purdue and Jebsen-Taylor tests showed a significant learning effect across time.

CONCLUSIONS

The 3 commercial wrist orthoses studied reduce dexterity similarly and significantly. When commercial wrist orthoses are to be used during tasks that require maximum dexterity, this reduction should be weighed against the known benefits of splinting.

Immediate and short-term effects of three commercial wrist extensor orthoses on grip strength and function in patients with rheumatoid arthritis

OBJECTIVE

To investigate the immediate and short-term effects of 3 commercial wrist orthoses on grip strength and function.

METHODS

Thirty-six patients with definite rheumatoid arthritis participated in the randomized, controlled, cross-over design study of 3 commercial wrist extensor orthoses. Dominant-hand dynamometric grip strength was assessed at both initial and followup sessions while splinted and nonsplinted. Functional impact was assessed using a written questionnaire.

RESULTS

All 3 commercial orthoses reduced grip strength when first donned. After a 1-week adjustment period, one orthosis, the Smith and Nephew Roylan D-Ring (Roylan), afforded splinted grip strength equal to that of the nonsplinted grip strength. The other 2 orthoses continued to reduce grip strength, and afforded splinted grip strength significantly below that of the Roylan. The Roylan was deemed comfortable by more subjects than the other orthoses.

CONCLUSIONS

The belief that commercial orthotic use increases grip strength, either immediately or after 1 week, is not supported by this study's data. Different styles of commercial wrist orthoses appear to have differing influence on splinted grip strength.

Use of commercially produced elastic wrist orthoses in chronic arthritis: a controlled study

OBJECTIVE

To examine the efficacy of wrist orthoses on pain, motion, and function of the wrist.

METHODS

Consecutive patients were randomized to a treatment group using wrist orthoses or to a control group using no wrist orthoses, in a prospective, controlled, 6-month study.

RESULTS

Changes in wrist joint variables and general disease activity variables were not statistically different between the orthosis group (n = 36) and the control group (n = 33). Patients in the orthosis group had 25% and 12% improvements in grip strength and pinch grip and 50% reduction in pain while using the wrist orthosis.

CONCLUSION

Use of wrist orthoses improves function and reduces pain, but has no effects after 6 months, compared to a control group, on measures of local or general disease activity.

Hand splinting in rheumatoid arthritis. A perspective on current knowledge and directions for research

A theoretical rationale for the use of hand splints in rheumatoid arthritis and selected literature relevant to the efficacy of splints in the acutely inflamed or chronic rheumatoid joint are briefly reviewed. The purposes of this review are to provide a broad perspective on nonsurgical hand splinting and to suggest some directions for future research based on this perspective.