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Three Part Question

In [infants under 3 months old with Erb’s Palsy] does [wrist/ hand splinting] [improve active range of movement]?

Clinical Scenario

An infant under 3 months with Erb’s Palsy is referred to occupational therapy for hand splints. You wonder if splinting is a useful intervention to improve joint range of movement (ROM) for this client group.

Search Strategy

Searches were conducted by a librarian at Central Manchester University Hospitals NHS Foundation Trust. These included AMED, CINAHL, BNI, MEDLINE and EMBASE from 1995 - 2012. Date of search: July 2012. The search was limited to articles written in English and only those relating to infants or children (children added as limited data). The Cochrane library was also searched.
AMED
[CHILD] AND
[SPINAL DISEASE OR PARALYSIS OR BRACHIAL PLEXUS OR erb*.ti,ab OR NERVOUS SYSTEM DISEASE] AND
[SPLINTS OR BRACING OR CASTING OR ORTHOTIC DEVICES] AND [ARM]

CINAHL
[BRACHIAL PLEXUS NEUROPATHIES] OR [Erbs AND Pals*] AND
[SPLINTS OR CASTS OR Brac*]

EMBASE
[BRACHIAL PLEXUS OR BRACHIAL PLEXUS INJURY OR BRACHIAL PLEXUS NEUROPATHY] AND BIRTH INJURY AND
[SPLINT OR PLASTER CAST OR BRACE]

MEDLINE
[BRACHIAL PLEXUS NEUROPATHIES OR BRACHIAL PLEXUS OR PERIPHERAL NERVOUS SYSTEM DISEASES] AND BIRTH INJURIES AND
[SPLINTS OR CASTS OR BRACES]

Search Outcome

Four relevant articles (systematic review, retrospective study and two literature reviews) were found and are summarised in the table. None of these articles were purely about hand/ wrist splinting, they only mentioned that some clinicians have used splinting as part of conservative management. The systematic review concluded that there was no synthesised evidence of splinting’s effectiveness as part of conservative management. Other articles were not relevant to our question.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Bialocerkowski et al 2005 Australia	Infants and Children	Systematic review NICE Level of evidence 2++ (into effectiveness of conservative management with children with Erb’s Palsy)	All studies lacked clear description of what constituted conservative management. Splinting was one of components considered to be part of conservative management alongside passive exercise, ‘gentle regular exercises’, ‘active and passive movement’, dynamic traction and home exercise programme. Only Eng et al (see below) mentioned splinting out of the eight studies that were reviewed. There was no synthesised evidence of splinting’s effectiveness as part of conservative management. A definition of what conservative management constitutes has not been made. There has been no comparison of effectiveness of conservative management with a control group.	Conservative management was variable. Only 1 of 8 articles (Eng et al, see below) mentioned splinting. This was ranked low on the hierarchy of evidence and no randomised controlled trials were found.	All studies lacked clear description of what constituted conservative management which limits replication in the clinical setting. The only reliable outcome measure for this patient group noted in the article is the Active Movement Scale, which was not used in Eng et al or any other study. Measures that were used did not have evidence of validity and reliability. Only less severely affected infants received conservative management (others received surgery) which made it difficult to conclude the effectiveness of this management within a general population. Study’s descriptions of the treatment were often brief and lacked information. Most studies were undertaken by physicians or surgeons, with little involvement from therapists (who would have had a significant role in the conservative management of these patients).
Eng et al 1996 USA	186 infants/ children (over 50% seen in 0-1month) (85% within 0-3months) All patients first seen under 15months of age	Retrospective study NICE Level of evidence 3	This paper reviewed the outcomes with patients who have been conservatively managed. Conservative management comprised of a study of shoulder stabilisation, gentle passive range of movement exercises, massage and sensory feedback, weight bearing, active movement and if indicated splinting of elbow and/or (if not a ‘mild’ case) wrist extension splint, with the thumb in opposition and to be worn for 3-4 hours at a time.	In a retrospective review of 191 sets of patient notes from 1981-1993. 186 children in study. Grouped into 5 categories to classify by severity of impairment. Assessed initially and at follow up. There was high correlation between the ‘impairment rating’ initially and on follow up, suggesting little change. When using McNemar’s test of symmetry, 72% of patient’s scores didn’t change, 31 patient improved by 1 grade, 2 improved by 2 grades and 8 patients deteriorated 1 grade.	Not all patients were splinted in the study (all but ‘mild’ cases were splinted) and splinting was not assessed in isolation ‘Mild cases’ were not defined. There was no control group. Compares initial and follow up exams, but does not say how long after the initial assessment the follow up exam was completed.
Ho ES 2010 Canada	Children 0-18 years	Literature review and opinion	Noted that there is poor literature on wrist splinting of children for Erb’s Palsy, but that wrist splints were used with adults. Noted that in Ramos and Zell (Ramos LE, Zell JP (2000) Rehabilitation programme for children with brachial plexus and peripheral nerve injury. Seminars in Paediatric Neurology (7) 52-7) a static wrist splint for children with Erb’s Palsy who had a weak wrist and lacked finger extension was suggested. Found no papers with expert opinion (level 5) level of evidence to support this. Recommended the use of clinical reasoning to justify a rationale for splinting or not splinting. Considerations included avoiding restriction of movement where there may be nerve recovery, avoiding loss of range of movement where there is permanent damage and consideration of the impact of considering the effect of splinting on sensation, grasps and weight bearing. Noted that some infants had full recovery within 1 month from birth. Noted that clinical guidelines were needed in the use of splinting.	No results: only literature review	Not a study Only notes that other therapists have splinted the wrist of this patient group. Not specific to under three months
Piatt JH 2004 USA	Infants and Children	Literature review. Not referenced or excluded in systematic review.	Noted that a wrist splint may be fabricated by the therapist to maintain wrist extension; however, it provided no justification, reference or evidence for this.	No results: literature review only	Not a study Only told us that other therapists have used wrist splinting in this patient group. Not specific to under three months

Comment(s)

As noted in Bialocerkowski et al (2005) physiotherapists and occupational therapists play a significant role in the management of these children and documentation and publishing of outcome provided is required to justify treatment.

Clinical Bottom Line

There is no published evidence that splinting is or is not effective for infants with Erb’s Palsy to improve active range of movement. There is need for further research of efficacy of wrist splinting in this patient group.

References

1. Bialocerkowski A, Kurlowicz K, Vladusic S, Grimmer K Effectiveness of primary conservative management for infants with obstetric brachial plexus palsy International Journal of Evidence Based Healthcare 2005; 27-44
2. Eng GA, Binder H, Getson P, O’Donnell R Obstetrical Brachial Plexus Palsy: Outcome with Conservative Management. Muscle &Nerve 1996; 884-891
3. Ho ES Developmental and biomechanical considerations in the provision of wrist orthoses in children with obstetrical brachial plexus palsy. Hand Therapy 2010; p94-99
4. Piatt JH Birth injuries of The Brachial Plexus Pediatric Clinics of North America 2004; 421-440
5. National Institute for Clinical Excellence NICE Guideline Development Methods: Reviewing and grading the evidence National Institute for Clinical Excellence 2004, updated 2005