Orthoses
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 affect 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 opponents splint, dorsal cock-up splint, and spiral splint) and shorthand 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 a 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 the three studies are presented in Table 2.
| Author Year
Country Research Design Score Total Sample Size |
Methods | Outcome |
| Harvey et al., 2006
Australia RCT PEDro=8 NInitial=44; NFinal=43 |
Population: Age: N/R; Gender: N/R; Injury etiology: SCI=23, Stroke=14, ABI=7; Mean time since injury: 4 yr. Intervention: Experimental group: thumbs splinted into a stretched, abducted position, every night (average eight hours), for 12 wk. Control group: no intervention. With the bilateral thumb group, splinting was applied to one thumb and no splinting to the other (own control). With unilateral thumb, subjects were divided into experimental and control. Outcome Measure: Palmar abduction of carpometacarpal joint, Subjective attitudes of effectiveness and convenience of splinting. |
1. After 12 wk, control thumbs carpometacarpal angle mean change was 45-47°. Experimental thumbs carpometacarpal angle mean change was 45-47°. The mean difference between these two groups was 1°. 2. Twenty-two experimental subjects wanted to continue with the splinting regime and 20 experimental subjects said their thumb web space extensibility was increased by the splinting. 3. The intra-class correlation coefficient between carpometacarpal angle of the control and unaffected thumbs, before and after treatment, was 0.87. |
| DiPasquale-Lehnerz 1994
USA RCT PEDro=4 NInitial=13; NFinal=9 |
Population: Age: 18-42 yr; Gender: males=12, females=1; Time since injury: 6–8 wk. Intervention: Experimental group was given long or short orthosis to be worn at night (eight hours) as soon as the subject could tolerate it. Outcome Measure: Pinch strength, Functional activity use, Jebsen-Taylor Hand Function (JTHF). |
1. No significant differences were noted between the two groups-all subjects demonstrated improvement in hand function and pinch strength. 2. At eight wks the 13 subjects showed improvement in their performance on the checkers subtest (p<0.01), simulated feeding subtest (p<0.01), and the large light object subtest (p<0.01). 3. At the 12-wk marker, improvement could be seen on the card subtest (p<0.05). 4. An increase in pinch strength was noted at eight wks for all subjects (p<0.05) and at 12 wk nine remaining subjects (p<0.05). |
| Effect Sizes: Forest plot of standardized mean differences (SMD±95%C.I.) as calculated from pre- and post-intervention data.
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| Portnova et al. 2018
USA Pre-Post N=3 |
Population: Mean age=53 yr; Gender: males=1, females=2; Time since injury: 20.8 yr; Level of injury: C4 – C6; Severity of injury: not reported. Intervention: Participants completed hand function tests with and without the use of a cost effective, 3D printed, wrist-driven orthoses (WDO). Outcome Measures: Jebsen Taylor Hand Function Test (JTHF); Box-and-Blocks Test; Grasp strength (pinch dynamometry). |
1. Varying improvements in hand function were observed with JTHF/Box-and-Blocks functional testing. One participant demonstrated improvement on the small object task, while another took 25 seconds longer. 2. Two participants had a significant increase in grasp strength with the WDO (p<0.05), while the other was able to perform a pinching grasp for the first time. |
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 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 of the use of 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 wrist-driven orthoses as an assistive device may improve hand function and grasp strength.
