Splinting the hand in the functional position after brain impairment: a randomized, controlled trial.

OBJECTIVE To evaluate the effects of 4 weeks of hand splinting on the length of finger and wrist flexor muscles, hand function, and pain in people with acquired brain impairment. DESIGN Randomized, assessor-blinded trial. SETTING Rehabilitation center in Australia. PARTICIPANTS Twenty-eight adults with acquired brain impairment, all within 6 months of the first injury. There was 1 withdrawal. INTERVENTIONS Subjects in both experimental (n=17) and control (n=11) groups participated in routine therapy-motor training for upper-limb use and upper-limb stretches-5 days a week. The experimental group also wore an immobilizing hand splint in the functional position (10 degrees -30 degrees wrist extension) for a maximum of 12 hours each night for the duration of the 4-week intervention period. MAIN OUTCOME MEASURES The length of the wrist and extrinsic finger flexor muscles was evaluated by measuring the torque-controlled range of wrist extension with the fingers extended. Functional hand use was evaluated with the Motor Assessment Scale. Pain was evaluated with a visual analog scale. RESULTS The effects of splinting were statistically nonsignificant and clinically unimportant. At follow-up, estimates of treatment effects slightly favored the control group: range of motion at the wrist favored controls by 2 degrees (95% confidence interval [CI], -7.2 degrees to 3.2 degrees ), function favored controls by 0.2 points (95% CI, -2.7 to 2.3), and pain favored the experimental group by 1cm (95% CI, -4.6 to 2.2). CONCLUSIONS An overnight splint-wearing regimen with the affected hand in the functional position does not produce clinically beneficial effects in adults with acquired brain impairment.

[1]  J. Wilton,et al.  Hand splinting : principles of design and fabrication , 1997 .

[2]  N J O'Dwyer,et al.  Reflex hyperexcitability and muscle contracture in relation to spastic hypertonia , 1996, Current opinion in neurology.

[3]  P. Williams.  Use of intermittent stretch in the prevention of serial sarcomere loss in immobilised muscle. , 1990, Annals of the rheumatic diseases.

[4]  G. Gillen.  Stroke Rehabilitation: A Function-Based Approach , 1998 .

[5]  Maureen E. Neistadt.  Stroke Rehabilitation: A Function-Based Approach , 2000 .

[6]  D. Goldspink,et al.  The influence of immobilization and stretch on protein turnover of rat skeletal muscle. , 1977, The Journal of physiology.

[7]  G. Goldspink,et al.  Changes in sarcomere length and physiological properties in immobilized muscle. , 1978, Journal of anatomy.

[8]  K J Ottenbacher,et al.  Why rehabilitation research does not work (as well as we think it should) , 1995, Archives of physical medicine and rehabilitation.

[9]  David Moher,et al.  The CONSORT statement: Revised recommendations for improving the quality of reports of parallel-group randomized trials (Reprinted from JAMA 2001;285:1987-1991) , 2001 .

[10]  G. Yarkony,et al.  Contractures A Major Complication of Craniocerebral Trauma , 1987, Clinical orthopaedics and related research.

[11]  R. Shepherd,et al.  Task-related training improves performance of seated reaching tasks after stroke. A randomized controlled trial. , 1997, Stroke.

[12]  B. Tiplady,et al.  Validity and sensitivity of visual analogue scales in young and older healthy subjects. , 1998, Age and ageing.

[13]  J. Whyte,et al.  The Practical Management of Spasticity in Children and Adults , 1990 .

[14]  F. Mackey,et al.  Motor assessment scale scores as a measure of rehabilitation outcome following stroke. , 1992, The Australian journal of physiotherapy.

[15]  S. Sahrmann,et al.  Review of length-associated changes in muscle. Experimental evidence and clinical implications. , 1982, Physical therapy.

[16]  J. Poole,et al.  Motor assessment scale for stroke patients: concurrent validity and interrater reliability. , 1988, Archives of physical medicine and rehabilitation.

[17]  G. Goldspink,et al.  The importance of stretch and contractile activity in the prevention of connective tissue accumulation in muscle. , 1988, Journal of anatomy.

[18]  Patricia McKenney Moulton.  A Motor Relearning Programme for Stroke (2nd ed.) , 1989 .

[19]  Lorraine Williams Pedretti,et al.  Occupational Therapy: Practice Skills for Physical Dysfunction , 1985 .

[20]  J. Carr,et al.  Neurological Rehabilitation: Optimizing Motor Performance , 2003 .

[21]  Theodore I. King.  Plaster splinting as a means of reducing elbow flexor spasticity: a case study. , 1982, The American journal of occupational therapy : official publication of the American Occupational Therapy Association.

[22]  E. Ohnhaus,et al.  Methodological problems in the measurement of pain: A comparison between the verbal rating scale and the visual analogue scale , 1975, PAIN.

[23]  S. Braver,et al.  The measurement of clinical pain intensity: a comparison of six methods , 1986, Pain.

[24]  N B Lincoln,et al.  Randomized, controlled trial to evaluate increased intensity of physiotherapy treatment of arm function after stroke. , 1999, Stroke.

[25]  A comparison of volar and dorsal splinting of the hemiplegic hand. , 1968 .

[26]  P. Armitage,et al.  Statistical methods in medical research. , 1972 .

[27]  J. Ghajar.  Traumatic brain injury , 2000, The Lancet.

[28]  P. Williams.  Effect of intermittent stretch on immobilised muscle. , 1988, Annals of the rheumatic diseases.

[29]  P. Neilson,et al.  Spasticity and muscle contracture following stroke. , 1996, Brain : a journal of neurology.

[30]  C. Chapman,et al.  Pain measurement: an overview , 1985, Pain.

[31]  R. Young,et al.  Spasticity, disordered motor control , 1980 .

[32]  A comparison of volar and dorsal splinting of the hemiplegic hand. , 1968, The American journal of occupational therapy : official publication of the American Occupational Therapy Association.

[33]  S. Pocock,et al.  Clinical Trials: A Practical Approach , 1984 .

[34]  J. J. McPherson.  Objective evaluation of a splint designed to reduce hypertonicity. , 1981, The American journal of occupational therapy : official publication of the American Occupational Therapy Association.

[35]  L. Harvey,et al.  Test-retest reliability of a procedure for measuring extensibility of the extrinsic finger flexor muscles. , 1994, Journal of hand therapy : official journal of the American Society of Hand Therapists.

[36]  N. Kaplan.  Effect of splinting on reflex inhibition and sensorimotor stimulation in treatment of spasticity. , 1962, Archives of physical medicine and rehabilitation.

[37]  J. Carr,et al.  Investigation of a new motor assessment scale for stroke patients. , 1985, Physical therapy.

[38]  J M Lachin,et al.  Statistical considerations in the intent-to-treat principle. , 2000, Controlled clinical trials.

[39]  C. A. Trombly,et al.  Occupational Therapy for Physical Dysfunction , 1989 .

[40]  J. Lehmann,et al.  Spasticity: quantitative measurements as a basis for assessing effectiveness of therapeutic intervention. , 1989, Archives of physical medicine and rehabilitation.

[41]  P. Flett.  Rehabilitation of spasticity and related problems in childhood cerebral palsy , 2003, Journal of paediatrics and child health.

[42]  H Rodgers,et al.  A review of the properties and limitations of the Ashworth and modified Ashworth Scales as measures of spasticity , 1999, Clinical rehabilitation.

[43]  S. Casswell,et al.  What is meant by intention to treat analysis? Survey of published randomised controlled trials , 1999 .

[44]  R. Balnave,et al.  The effect of position of immobilisation on resting length, resting stiffness, and weight of the soleus muscle of the rabbit , 1993, Journal of orthopaedic research : official publication of the Orthopaedic Research Society.

[45]  L. Ada,et al.  Spasticity: Research Findings and Implications for Intervention , 1995 .

[46]  D Moher,et al.  The CONSORT statement: revised recommendations for improving the quality of reports of parallel-group randomized trials. , 2001, Annals of internal medicine.

[47]  M. Donohue,et al.  A survey of rationales for and against hand splinting in hemiplegia. , 1981, The American journal of occupational therapy : official publication of the American Occupational Therapy Association.

[48]  E. Faragher,et al.  The unreliability of clinical measures of muscle tone: implications for stroke therapy. , 2000, Age and ageing.