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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
[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].

Search 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)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Lannin N.A, et al 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
Pizzi A et al 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
Sheehan et al 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.
Lannin et al 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.
Ushiba J et al 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.

Comment(s)

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.

Clinical 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

1. Lannin N.A, PhD, Cusick A, PhD, McCluskey A, PhD, Herbert R.D, PhD Effects of splinting on wrist contracture after stroke; A RCT Stroke 2007; 38:111
2. 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. Archives of Physical Medicine and Rehabilitation 2005; 86:1855-9
3. 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. Clinical Rehabilitation 2006; 20 : 1032-1037
4. Lannin NA, Herbert RD Is hand splinting effective for adults following stroke? A systematic review and methodological critique of published research. Clinical Rehabilitation. 2003; 17: 807-816
5. 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. Electromyography and Clinical Neurophysiology 2004; 44, 175-182