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Orthoses

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Upper limb orthotic devices (e.g., splints or kinesthetic tape) are a well-accepted therapy for the management of SCI, particularly in the acute phase of injury (Curtin, 1994; Krajnik & Bridle, 1992). They are generally used to minimize or prevent contractures, spasticity and pain through immobilization and protection/support of the joints, as well as soft tissue (Curtin, 1994; Krajnik & Bridle, 1992; Paternostro-Sluga & Stieger, 2004). Joint and muscle contractures can severely impact independence for individuals experiencing SCI. For example, elbow flexion contractures greater than 25 degrees significantly effect an individual’s ability to transfer and complete depression lifts for pressure relief (Bryden et al., 2004; Dalyan et al., 1998; Grover et al., 1996).

The most common static hand splints for patients with tetraplegia include: the resting pan or paddle splints, wrist extension splints (Futuro-type splint, long opponens splint and dorsal cock-up splint and spiral splint) and 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).

Although orthoses are widely used, few studies have investigated the efficacy of splinting for the management of upper limb function following SCI. The methodological details and results from three studies are presented in Table 2.

Table 2: Orthoses

Discussion

Although splinting and orthotic fabrication is an accepted practice, there is minimal research on the effectiveness of this intervention (DiPasquale-Lehnerz, 1994; Krajnik & Bridle, 1992). A variety of splints serve similar purposes and little is known about what splint is best for the level and severity of SCI (Krajnik & Bridle, 1992).

In one RCT, Harvey et al. (2006) noted that twelve weeks of nightly splinting does not reduce thumb web-space contractures in individuals with a neurological condition (stroke, acquired brain injury, SCI). Even with careful monitoring of the fit of the splint, it was unclear if it was able to produce enough torque to the thumb joint for a sufficient stretch. The study also raised questions about the proper length of time an individual should spend wearing a splint, if the time spent wearing the splint was accurately reported and if there is a difference in outcomes when considering the type of neurological condition being splinted. Most importantly, clients and therapists perceived the splint as a major inconvenience. As time went on in the trial, patients became less compliant and both therapists and patients agreed that the overall effect of the splint needed to be substantial in order to justify the inconvenience and discomfort.

In one RCT, DiPasquale-Lehnerz (1994) found significant improvements in hand function (as measured by the Jebsen-Taylor Hand Function test) in subjects with tetraplegia who wore a long or short thumb orthosis while sleeping. Unlike Harvey and colleagues, a significant improvement in pinch strength and functional use (e.g., turning cards, and picking up small objects) was observed.

In one pre-post test, Portnova et al. (2018) demonstrated varying improvements in hand function while using a wrist driven orthoses. For example, one participant improved their time to pick up small objects by 29 seconds, while another took 25 seconds longer. Moreover, two users significantly increased their grasp strength with the wrist driven orthoses. However, the limited number of participants in this trial (n=3) prevents a more conclusive understanding about the use of a wrist driven orthoses as an assistive device.

In summary, the choice of splint depends on an individual’s therapeutic aims and functional problem(s) resulting from the impairment(s), however, there is insufficient evidence from clinical trials on splinting strategies in SCI patients. This is supported by Paternostro-Sluga and Steiger’s review (2004). Future research should focus on determining the efficacy of orthoses as rehabilitative or assistive devices, as well as the type and duration of splint necessary for different levels/severities of SCI.

Conclusion

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

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

There is level 4 evidence (from one pre-post test; Portnova et al. 2018) that wearing a wrist driven orthoses as an assistive device may improve hand function and grasp strength.

  • Minimal clinical research evidence exists on the use of orthoses in preventing joint problems or improving hand function.