Sunday, April 29, 2012

IN R.A. PATIENTS CORRECTLY POSITION UPPER JOINTSJOINTS, MINIMISE CONTRACTURES AND DEFORMITIES AND INCREASE JOINT STABILITY


Static orthoses aim to support structures within the
wrist and hand that are vulnerable. The radio-carpal,
carpometacarpal joint (CMJ), metacarpophalangeal
(MCPJ) and proximal interphalangeal (PIPJ) joints
and the thumb web space are key anatomical areas
for consideration when splinting. Where inflammation
causes the potential for muscle imbalance, for
example in swan neck and boutonnière deformities,
orthotics apply a counterbalance force to prevent
or correct extensor tendons slipping across normal
joint fulcrums.


IMPROVE HAND FUNCTION



By adding support to proximal joints, applying
counterbalanced force to deforming joints and
improving biomechanical advantage splints have
the potential to improve hand function (Prosser &
Conolly 2003). In particular improving support to
the wrist can improve grip strength and gross hand
function (Nordenskiöld 1990).
Hand orthotics have some biological and biomechanical
rationale for their use and action, however,
evidence to support and clarify the clinical effectiveness
of orthotics in rheumatology is still emerging
(Adams et al 2005). This evidence is considered
below in regard to five types of orthotics.


THE WRIST EXTENSION ORTHOSIS



Wrist extension orthoses may be custom-made
using either thermoplastic or neoprene material
or commercially manufactured from a soft or reinforced
fabric with a possible addition of a volar
metal support (Fig. 12.1). They may be prescribed
to limit wrist circumduction and decrease torque
during heavy tasks involving the wrist (Cordery &
Rocchi 1998). They may also be used to increase
the mobility of the arthritic hand. Wrist extension
orthoses can stabilise the wrist in a functionally
effective position (10-15 degrees of extension), and
facilitate the action of the extrinsic finger flexors
to improve handgrip strength (Stern et al 1996).
Wrist orthoses provide support to the carpals and
wrist joint and several designs of commercial wrist
splints have been shown to significantly reduce
the electrical activity of the wrist extensors during

lifting tasks in people without RA (Stegink- Jansen
et al 1997). This may serve to reduce potentially
deforming forces on the wrist and carpals.
When worn these orthosis can provide immediate
pain relief and significantly reduce pain on
functional use of the hand (Haskett et al 2004,
Kjeken et al 1995, Nordenskiöld, 1990, Pagnotta et al
2005). Kjeken et al’s (1995) randomised controlled
trial analysed splint wear versus non-splint wear
over 6 months (n  69). There was no difference by
group on pain, joint swelling, grip or hand motion.
However, the control group (n  33) without splints
showed statistically significant improvement in
wrist range of motion that was not evident in the
splinted group. Both Kjeken et al (1995) and Sharma
et al (1991) comment that these wrist orthoses can
reduce wrist movement when worn over a number
of months and the effects of this should be considered
on provision.
In small-scale studies, elastic wrist orthoses have
been shown to improve power grip strength for
individuals with moderate to severe RA (Backman &
Deitz 1988, Haskett et al 2004, Nordenskiöld 1990).
However, they have been reported in a small sample
(n  36) to transiently reduce grip strength
when first worn and to offer no improvement in
grip strength (Stern et al 1996). Although both commercially
available and custom made splints have
contributed towards improvements in pain and
grip strength after four weeks wear in the most able
male patients elastic orthoses can hinder maximum
grip strength (Sharma et al 1991).
Studies examining hand function have shown
that these orthoses are particularly task specific, i.e.



Figure 1 Wrist extension orthosis.



they may be able to assist one particular hand skill
but reduce another (Pagnotta et al 1998, Stern et al
1996). Functional grip strength has been seen to
increase significantly by up to 29% in a woman with
RA when these orthoses were worn (Nordenskiöld
1990) yet dexterity, fine finger movement and speed
of hand activity have not (Backman & Deitz 1988,
Stern et al 1994, 1996).
In summary, wrist extension orthosis have been
seen to increase handgrip strength, hand function
and provided immediate hand pain relief in some
patients. However, they may also contribute to a
less dextrous and less mobile hand. There is little
evidence to demonstrate the long-term effectiveness
of these splints and the quality of evidence available
to indicate the clinical effectiveness of these splints
is weak (Egan et al 2003).


METACARPAL ULNAR DEVIATION ORTHOSIS



These may be small palm-based orthoses or have
the additional support of a wrist and forearm component.
They may be used early in the rheumatoid
disease process to limit the physical factors predisposing
the MCPJs to ulnar deviation. By providing
a medial force to the proximal phalanges, these
orthotics can realign the metacarpals and phalanges
during use to improve functional ability of the hand
and to prevent further MCPJ ulnar drift and volar
subluxation (Adams et al 2005). Therapeutic exercise
MCP splints have also been designed to provide
exercise options for extrinsic hand extensors
and flexors and combat intrinsic plus deformities in
the rheumatoid hand (Wijdenes et al 2003).
There is limited evidence for the clinical effectiveness
of metacarpal ulnar deviation (MUD)
orthoses. In a small repeated measures six months
study patients (n  26) rated them as highly acceptable
and satisfactory (Rennie 1996). When worn
they realigned the MCPJs and maintained that
alignment during functional use of the hand and
significantly improved ulnar drift in middle, ring
and little finger. They also significantly improved
three-point pinch grip strength but did not significantly
improve scores on the Sollerman test of hand
function (Sollerman 1984), reduce visual analogue
pain levels nor improve gross power grip strength.
There was no evidence to suggest that they had any
long-term effect on correcting MCP joint alignment
nor delayed the progression of ulnar deviation.


STATIC RESTING ORTHOSIS



This orthosis aims to decrease localised pain and
inflammation by resting the joint in a correct anatomical
position, provide volar support for the
carpus and proximal phalangeals to prevent subluxation
realigning drifting MCP joints by providing
an ulnar border to the orthosis and restricting
carpal movement (Biese 2002). The rationale that
correct joint positioning at rest can influence joint
integrity has been challenged. Adams et al (2005)
argue that the forces contributing towards joint
deformity are present when the hand is used functionally
thus correct positioning at rest is unlikely
to address or correct these (Fig. 12.2).
It is the most commonly used orthosis for treating
people with RA and the most frequently used
to relieve wrist and hand pain (Henderson &
McMillan 2002). These splints do not permit wrist
or hand joint movement and are recommended to
be worn whilst resting and/or during the night.
There have been a few controlled studies examining
clinical effectiveness.
Malcus Johnson et al’s (1992) small, 18-month
follow-up study of seven people with RA identified
that the orthoses reduced nocturnal but not day
time pain and MCPJ ulnar deviation continued unabated
with splint use. Callinan and Mathiowetz’s
(1996) investigation (n  39) demonstrated that for
two types of resting orthosis (soft fabric and hard
thermoplastic), there were significant reductions in
overall pain levels when these orthoses were worn
at night for a month. Hand function and morning
stiffness were no different over time when wearing

Figure 2 Static resting orthosis.



the splint. The majority of the study sample preferred
the soft splints.
Janssen et al’s (1990), 12-month, randomized,
controlled trial of 29 patients reported a statistically
significant reduction in hand joint swelling and a
decrease in pain and tenderness scores when these
splints were worn. There were improvements in
grip strength but not hand function. These findings
are difficult to interpret when changes in disease
activity nor baseline values of outcomes were considered
in the analysis.
Adams et al (2008) randomised controlled trial
recruited (n  116) controlled for baseline outcome
value as well as disease activity at baseline
in analysis. There were no significant differences in
handgrip strength, self-report hand function using
the Michigan Hand Outcomes questionnaire and
MCPJ ulnar deviation by groups over 12 months
follow-up. There was some evidence to indicate that
early morning stiffness increased with splint wear
(Adams et al 2006).
There is little evidence from longitudinal fully
powered studies to indicate that these splints can
impact on hand function and deformity, there is
some evidence to suggest that hand pain may be
improved.


FINGER SWAN NECK ORTHOSIS



These small finger based splints apply a three-point
force around the PIPJ to prevent PIPJ hyperextension
and subsequent distal interphalangeal joint
(DIPJ) flexion present in swan necking of the fingers.
They are small functional orthoses that permit
full PIP joint flexion but prevent hyperextension.
They aim to decrease digital pain, correct or prevent
swan necking in the digits and improve hand function
(Zijlstra et al 2002).
These splints can be custom made using thermoplastic
material or silver. Silver custom made
options (Fig. 12.3) are more costly but have been
reported as more durable than the thermoplastic
alternatives, they are also more popular gaining
higher adherence levels than thermoplastic alternatives
(Macleod & Adams 2002, Macleod et al 2003).
There have only been three reported studies of
clinical effectiveness. Ter Schegget and Knipping
(2000) demonstrated in a crossover study of 18 individuals
there was pain relief when worn but this
did not reach statistically significant levels. There
were significant improvements in digital stability


Figure 3 Silver ring swan neck orthoses.



and DIPJ extension. Zijlstra et al’s (2002) small longitudinal
study of 15 people with RA (using 48 ring
orthoses) over a 12 month period demonstrated that
these orthoses improved functional dexterity levels
to statistically significant levels. These results were
confirmed by their later study (Zijlstra et al 2004).
Conversely, they were seen to have no effect on selfreported
hand function, grip strength or hand pain
(Zijlstra et al 2002, 2004).


THUMB SPLINTS




In CMCJ basal joint osteoarthrtis thumb splints are
used for relief of thumb pain, weakness, contracture
and improvement of function (Wajon & Ada 2005).
Thumb splints may immobilise just the CMCJ: short
opponens type (Fig. 12.4) or combine CMCJ with
distal radio carpal joint immobilisation: long type
(Fig. 12.5).
There have been no published studies that
have compared splinting to no splint intervention.
Studies that have examined both short and long
type of splints in one study have reported no difference
between the outcome of the splints. Weiss
et al’s, (2000) short, 2-week cross-over study, examined
26 hands using short and long splints. They
reported that both types of splint appear to reduce
subluxation of the first CMCJ. Pinch strength was
not improved over 2 weeks of splinting, however
patients reported anecdotally that they gained some
pain relief on wear. Short splints were preferred to
long. Soft neoprene splints are preferred to rigid

Figure 4 CMCJ short opponens type splint.




Figure 5 CMCJ and distal radio carpal immobilisation
(long type) splint.



thermoplastic splints and patients prefer the soft
splints for daily and long-term use. The beneficial
effects have been seen to be amplified with the soft
type of thumb splint (Weiss et al 2004).
Patients report preference for soft splints (Buurke
et al 1999). In their cross-over study ten female
patients were recruited and wore three types of
manufactured splints (supple elastic, elastic and
semi rigid material), over a period of 12 weeks.
There was no difference in pain and pinch scores
between the orthoses.
Wajon and Ada’s (2005) randomised trial (n  40)
compared a short opponens type splint and a pinch
exercise regime with a thumb strap splint and an
abduction exercise regime over a 6 week period.
Comparison of change scores over the 6 week
follow-up assessments by a blinded assessor demonstrated
no difference in outcome by groups for
reported pain at rest, pinch grip strength and levels
of hand function.
Swigart et al’s retrospective study (1999) examined
the effects of thumb splinting on 130 thumbs
with varying stages of CMCJ osteoarthritis (OA).
Some patients received surgical intervention but
patients were excluded if they had been treated
with exercise or steroid injections. Long thumb
splints were reviewed after a maximum of 4 weeks
wear. In milder forms of OA, 76% of patients benefited
from some symptomatic improvement and in
more severe cases of OA, 54% benefited. These benefits
were maintained over 6 months.
Evidence that static thumb splinting may delay
or prevent the need for surgical intervention has

also been supported by Berggren et al’s seven year
follow-up study (Berggren et al 2001). The provision
of occupational therapy including aids and equipment,
joint protection advice and thumb splinting
reduced the number of individuals requiring thumb
joint surgery by 65% over a 7 year period (Berggren
et al 2001).
Static thumb orthoses have been reported as
being effective in long-term relief of OA symptoms
when used alongside a single corticosteroid
injection (Day et al 2004). A single corticosteroid
injection combined with 3 weeks static splinting
produced long-term relief from the symptoms of
OA in stage I OA (n  30 thumbs). Although individuals
with later stage OA (stage IV) reported less
benefit, 40% of participants received symptomatic
improvement that was considered sufficient and
sustained irrespective of their stage.


CONCLUSION



Static orthoses continue to be enthusiastically
endorsed by therapists (Henderson & McMillan
2002). During an era when drug developments continue
to assist with more effective control of disease
activity and synovitis, continued research is needed
into the most appropriate types of orthosis to recommend.
The challenge is to provide objective evidence
as to whether the continued use of orthoses
is indicated for people with arthritis and if so which
designs are the most effective and at which stage of
the disease process.




Rheumatology Evidence-Based Practice for Physiotherapists and Occupational Therapists 

Edited by Krysia Dziedzic PhD, MCSP and Alison Hammond PhD, MSc, BSc(Hons), DipCOT, FCOT
2010, © Elsevier Ltd. ISBN 978-0-443-06934-5
























































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