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Splinting

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Splinting of the upper extremity in the management of tetraplegia is a well-accepted therapy intervention and has been an accepted practice for many years in the management of SCI especially in the acute phase of injury for the prevention of contractures and for joint protection (Curtin 1994; Krajnik & Bridle 1992). The therapeutic goals of splinting are the immobilization, protection and support of the joints of the wrist and hand, prevention of joint malalignment, prevention and reduction of soft tissue shortening and contractures, prevention of soft tissue overstretch, counteracting hypertrophic scars, support of weak muscles, improvement of function and pain relief (Curtin 1994; Krajnik & Bridle 1992; Paternostro-Sluga & Stieger 2004). It has been shown that elbow flexion contractures greater than 25 degrees have significant impact on the independence with the spinal cord injured person especially in the ability to transfer and complete depression lift for pressure relief (Bryden et al. 2004; Dalyan et al. 1998; Grover et al. 1996). The most common static hand splints for tetraplegic patients are the resting pan or paddle splints, wrist extension splints (Futuro-type splint, long opponens splint and dorsal cock-up splint and spiral splint), short hand splints and tenodesis splints (Curtin 1994). Splints are also used to position the elbow in extension as flexion contractures of this joint are very common due to lack of triceps innervation and the effects of increased tone and spasticity (Bryden et al. 2004; Grover et al. 1996).

Table: Splinting of the Hand

Discussion

Even though splinting and orthotic fabrication is an accepted practice, there is minimal research data on the effectiveness of this intervention (DiPasquale-Lehnerz 1994; Krajnik & Bridle 1992), although there are numerous anecdotal descriptions of orthotic devices and rationales for orthotic intervention (DiPasquale-Lehnerz 1994). Curtin (1994) and Krajnik and Bridle (1992) also found formal assessments were often not done due to; a lack of time and staff shortages; inconsistent documentation; absence of standardized tests available for spinal cord injured patients; limited funding to purchase equipment; and/or patient declined to participate in formal assessments due to boredom and frustration. Krajnik and Bridle (1992) noted that therapists considered observation of the patient when involved in a functional activity as the most informative assessment although this was not an objective means of documenting a patient’s status and progress. There appears to be a variety of splints made for similar purposes because there is little research as to what splint is best for the level and stage of SCI (Krajnik & Bridle 1992). It was noted by Harvey et al. (2006) that the use of splints are also viewed as a major inconvenience to both the client and therapist and the overall effect of the splint needs to be substantial in order to justify the inconvenience and discomfort. Harvey et al. (2006) also reported that clients were initially agreeable to wear splints at the beginning of their treatment, but by the end of treatment they were less compliant.

In Paternostro-Sluga and Stieger’s (2004) review, the therapeutic aims of splinting and the choice of splint depend on the disease and the individual functional problem resulting from the impairment. These authors also concluded that there is insufficient evidence from clinical trials on splinting strategies in CP or SCI patients. The studies also referred to research looking at hand splints for clients with an acquired brain injury or stroke (McPherson et al. 1982; Rose & Shah 1987).

Harvey et al. (2006)noted in their study that twelve weeks of nightly stretch does not reduce thumb web-space contractures in people with a neurological condition (stroke, ABI, SCI). Even with careful monitoring of the fit of the splint for the thumb joint, it was unclear if the splint was able to produce enough torque to the thumb joint for a sufficient stretch. The study also raised questions concerning if the length of time wearing the splint was enough, if the time spent wearing the splint was accurately reported by the client and if there a difference in outcomes when considering the type of neurological condition being splinted.

DiPasquale-Lehnerz (1994) noted that there was no significant improvement in hand function as it related to passive range of motion, strength of prehension or coordination in subjects with C6 tetraplegia who wore a thumb opponens orthoses during sleep as compared to those subjects with C6 tetraplegia who did not wear such an orthosis. The study did show over time a significant improvement of hand function especially pinch strength, and functional use (turning cards, picking up small objects, simulated feeding and holding onto light cans) for those wearing the splint.

There are several published surveys that addressed the use of splints in the spinal cord population with the majority of splints being functional use splints (i.e., feeding splint, writing splint, typing splint or an application for an assistive device) (Garber & Gregoria 1990; Krajnik & Bridle 1992). More research is needed in this area using larger study sizes and studying the type of neurological condition being splinting prior to determining if splinting is effective in contracture reduction.

Conclusion

There is level 2 evidence (from one randomized controlled trial; DiPasquale-Lehnerz 1994) that wearing a thumb opponens splint will improve pinch strength and functional use of the hand.

There is level 1b evidence (from one randomized controlled trial; Harvey et al. 2006) that 12 weeks of nightly stretch with a thumb splint did not reduce thumb web-space contractures in persons with a neurological condition (i.e., stroke, ABI, SCI).

  • There is clinical and intuitive support for the use of splinting for the prevention of joint problems and promotion of function for the tetraplegic hand; however, there is very little research evidence to validate its overall effectiveness.