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Q Does overnight splinting of the wrist prevent contracture after stroke? Is splinting in an extended position more effective than splinting in a neutral position?
randomised controlled trial.
blinded (outcome assessor).
Follow up period:
9 inpatient rehabilitation and stroke units in Sydney, Australia.
63 patients ⩾18 years of age (mean age 71 y, 52% women) who had had a stroke in the previous 8 weeks (mean 4 wks), no active wrist extension, and sufficient cognitive and hearing function to participate in the trial.
neutral splint (0–10° extension) (n = 21), extension splint (comfortable end of range position [>45°] with the metacarpophalangeal and interphalangeal joints extended) (n = 21), or no splint (n = 21). Patients in the 2 splint groups wore the custom made, static, palmar mitt splints for ⩽12 hours/night for 4 weeks. All patients received usual rehabilitation, except that stretches of the wrist or long finger flexor muscle were not performed.
angle of wrist extension under standardised torque applied by a specially designed and validated device (mean of 3 photographed recordings), upper limb function (3 items of the Motor Assessment Scale), spasticity (Tardieu scale), and self reported disability and pain (Disabilities of the Arm, Shoulder, and Hand [DASH] Outcome Measure).
Patient follow up:
98% (94% for wrist extension at 6 weeks) (intention to treat analysis).
The overall mean loss of range of motion at 6 weeks was 17°. Groups did not differ for angle of wrist extension (table), upper limb function, spasticity, disability, or pain at 4 or 6 weeks.
Overnight splinting of the wrist for 4 weeks in either a neutral or extended position did not prevent contracture after stroke.
Lannin et al investigated the overnight use of hand splints after stroke. The study was initiated because of a lack of high quality evidence to support or refute the use of hand splints to prevent contractures in clinical settings.1,2 Despite this uncertainty about efficacy, hand splints are widely used by occupational therapists and physical therapists in North America.
Lannin et al concluded that 4 week splinting in either a neutral or extended position did not reduce contractures and that wrist splints should not be used routinely after stroke. The trial was well designed in terms of randomisation, blinding of the outcome assessor, and follow up. Each group had only 21 participants, and the confidence intervals of the between-group differences were wide, although sufficient to indicate that clinically significant benefit from splinting in an extended position was unlikely.
Rehabilitation therapists will probably not change their use of splints based on this single study. In fact, most therapists would argue that the use of splints to prevent contractures after stroke is determined on an individual patient basis. Splints are usually combined with other therapies such as botox injections and stretch exercises of the wrist and long finger flexor muscles; the latter were not performed with study participants, and this is a possible limitation of this study.
The trial by Lannin et al was directed toward rehabilitation therapists and not necessarily toward other professionals who coordinate stroke rehabilitation, namely nurses. However, nurses are members of interdisciplinary rehabilitation teams2 and routinely apply or remove wrist splints, assist patients who are prescribed splints, and provide patient education. Such a trial affects nursing practice in relation to interprofessional team decision making regarding patient rehabilitation progression and ultimate discharge planning.
For correspondence: Dr N A Lannin, Royal Rehabilitation Centre, Sydney, New South Wales, Australia.
Source of funding: no external funding.
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