Palmar resting splints for Stroke patients
Date First Published:
May 14, 2010
Last Updated:
July 9, 2010
Report by:
Claire Hannam and Sarah Hemes, Physiotherapist and Occupational Therapist (MRI)
Three-Part Question:
In [ adult Stroke patients with spasticity in forearm flexor muscles], is a [palmar resting splint] effective in [maintaining muscle length]?
Clinical Scenario:
A 60 year old man is admitted to the stroke unit following a stroke. He has increased tone in the forearm flexors, causing malalignment of the wrist into flexion. You passively realign the wrist and facilitate activity during therapy sessions. You wonder if you should also provide a palmar resting splint to maintain the muscle length.
Search Strategy:
Medline on the world wide web.
Repeated in Cinahl, EMBASE, AMED
Repeated in Cinahl, EMBASE, AMED
Search Details:
[exp stroke OR brain damage] AND [exp splints] AND [exp muscle spasticity]. Limit to human adult and English.
Exp [hand] OR [hand deformities] AND [stroke] OR [brain damage] AND [splints].
Exp [paralysis/paresis] AND [splints].
Exp [hand] OR [hand deformities] AND [stroke] OR [brain damage] AND [splints].
Exp [paralysis/paresis] AND [splints].
Outcome:
Altogether 8 articles were found, 7 which were relevant to the study question. 2 of these were included in the Systematic Review.
Relevant Paper(s):
| Study Title | Patient Group | Study type (level of evidence) | Outcomes | Key results | Study Weaknesses |
|---|---|---|---|---|---|
| Effects of splinting on wrist contracture after stroke; A RCT Lannin N.A, PhD, Cusick A, PhD, McCluskey A, PhD, Herbert R.D, PhD 2007 Australia | 63 stroke rehab in-patients, less than 8 weeks post stroke. | RCT | Disability of the Arm, Shoulder and Hand Outcome Measure | No significant outcome | Participants not blinded to the trial. |
| Tardieu Scale for Spasticity | Splinting did not reduce spasticity | ||||
| Motor Assessment Scale | No significant outcome | ||||
| A standardised torque device to measure muscle extensibility | Splinting had no effect on loss of R.O.M | ||||
| Application of a Volar Static Splint in Poststroke Spasticity of the Upper Limb. Pizzi A, MD, Giovanna C, MD, Catuscia F, MD, Verdesca S, MD, Grippo A, MD. 2005 Italy | 40 patients with hemiplegia and upper limb spasticity, that had occurred at least 4 months before | Pretest-posttest trial | Modified Ashworth scale | Reduction of elbow spasticity | Not a randomised controlled trial therefore unable to show clear effectiveness of splinting. |
| Passive elbow and wrist R.O.M | Significant improvement | ||||
| Visual Analogue Scale | Reduced wrist pain | ||||
| Spasms | Reduced spasms | ||||
| Comfort and time of splint applications | Well tolerated | ||||
| A randomised controlled pilot study to obtain the best estimate of the size of the effect of a thermoplastic resting splint on spasticity in the stroke-affected wrist and fingers. Sheehan JL, Winzeler-Mercay U, Mudie MH 2006 Australia | 14 stroke patients with no functional use of hand and a clinically detectable spasticity (Grade 2-3 measured by Ashworth Scale) | RCT pilot study | A computerised torque device to measure resistance at wrist | 5 weeks of splinting was effective in decreasing rate of change in resistance in wrist and finger flexors. | Short period of splinting compared to no splinting. Short time difference between long term group and short term group. Small sample group. |
| Is hand splinting effective for adults following stroke? A systematic review and methodological critique of published research. Lannin NA, Herbert RD 2003 Australia | 19 studies. | Systematic review and methodological critique of published research. | Fugi-Meyer assessment | Inflatable arm splinting makes no difference to hand function. | Evidence from the studies were generally weak, with small sample sizes used and low methodological quality. 1 medium quality and 1 high quality study out of the 19 reviewed. |
| Passive ROM | Thermoplastic splints made no difference to contracture formation in wrist and finger flexors. | ||||
| Changes of reflex size in upper limbs using wrist splint in hemiplegic patients. Ushiba J; Masakado Y; Komune Y; Muraoka Y; Chino N; Tomita Y 2004 Japan | 17 stroke patients more than 3 months post stroke. | Chnages of reflex size in upper limbs using wrist splint in hemiplegic patients. | Dunnetts Test | Reduced reflex size in spastic muscle group and increase reflex size in the flaccid muscle group. | Small sample size, condensed further by using a mixture of high and low tone patients. |
| Biceps Tendon jerk reflex | Tendon jerk reflex reduced in 45% of spastic limbs. |
Author Commentary:
There is only one current RCT on the effectiveness of splinting in stroke which found no improvement in muscle length. However, a RCT pilot study contradicted this and stated that wearing a splint for 5 weeks actually reduced the rate of muscle shortening in wrist and finger flexors. The Systematic Review, which pre-dated these RCT's, concluded that there was insufficient evidence to either support or refute the effectiveness of hand splinting in stroke. Of the remaining articles, one found improvement in elbow and wrist ROM which would suggest an improvement in muscle length, and the final article showed that muscle tone could be improved from the wearing of a splint therefore suggesting that muscle length could be maintained.
Bottom Line:
Based on the current best evidence, there is some evidence to support splinting as an effective tool in maintaining muscle length in forearm flexors poststroke. However, the studies are on a very small scale and therefore further, in-depth research is needed on this topic.
Level of Evidence:
Level 3: Small numbers of small studies or great heterogeneity or very different population
References:
- Lannin N.A, PhD, Cusick A, PhD, McCluskey A, PhD, Herbert R.D, PhD. Effects of splinting on wrist contracture after stroke; A RCT
- Pizzi A, MD, Giovanna C, MD, Catuscia F, MD, Verdesca S, MD, Grippo A, MD.. Application of a Volar Static Splint in Poststroke Spasticity of the Upper Limb.
- Sheehan JL, Winzeler-Mercay U, Mudie MH. A randomised controlled pilot study to obtain the best estimate of the size of the effect of a thermoplastic resting splint on spasticity in the stroke-affected wrist and fingers.
- Lannin NA, Herbert RD. Is hand splinting effective for adults following stroke? A systematic review and methodological critique of published research.
- Ushiba J; Masakado Y; Komune Y; Muraoka Y; Chino N; Tomita Y. Changes of reflex size in upper limbs using wrist splint in hemiplegic patients.