The Effectiveness of Static Hand and Wrist Splints for People with Rheumatoid Arthritis

109 Pages·2016·1.38 MB·English

The Effectiveness of Static Hand and Wrist Splints for
People with Rheumatoid Arthritis:
A Systematic Literature Review

Gemma Mottern

A research project submitted in partial fulfillment of the requirements of the degree
Master of Occupational Therapy
at Otago Polytechnic, Dunedin, New Zealand

29 July, 2013
Abstract

Occupational therapists commonly use static hand splints for patients with rheumatoid
arthritis to improve hand function, prevent deformity, increase grip strength and
relieve joint pain (Henderson & McMillan, 2002), yet the evidence to support this
intervention is limited. A systematic review was conducted to assess the effectiveness
of five different types of static hand and wrist splints for adults with rheumatoid
arthritis. Articles were identified through a computerized search of seven
bibliographic databases from their inception to June 2012. The literature search
procedure was complimented by manually scanning the reference lists of retrieved
articles, searching for grey literature and checking personal reference collections.
Articles were evaluated according to predetermined criteria for inclusion at each of
the title, abstract, and article levels. Included studies were independently scored using
the Structured Effectiveness Quality Evaluation Scale (SEQES) and also graded
according to Sackett’s Levels of Evidence. Fifty-one studies were identified as
potentially relevant. After assessment of relevance and quality, only 18 articles
fulfilled the inclusion criteria. Quality scores on the SEQES ranged from 14 to 46 out
of a possible 48. The current evidence provided varied support for all five types of
static splints. There is strong evidence that wearing a prefabricated wrist extension
splint during certain functional tasks significantly relieves wrist pain after one month
and does not compromise dexterity and grip strength. There was insufficient evidence
to support or refute the role of static resting splints to reduce pain, grip strength or
improve upper limb function. However, participants who wore these splints for one
month preferred to wear soft splints to rigid ones. The one study of thumb splints
provided evidence of statistically significant benefit in pain reduction wearing the
splint for 12 weeks. Indicative findings for evidence that swan neck splints,
boutonnière splints and metacarpal ulnar deviation splints improve hand function were
found. In overview, until more evidence becomes available, an evidence-informed
approach in which occupational therapists use their clinical experience while
integrating all available levels of evidence to meet the patients’ needs and goals is
recommended.

Key words: rheumatoid arthritis, occupational therapy, splinting, hand function

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Acknowledgments

Firstly, I would like to take this opportunity to express my deepest gratitude to
the most important person in my studies, Sian Griffin, supervisor of my master’s
research project, who provided me with all the necessary support, guidance, patience,
constructive feedback and encouragement which are indispensable to the success of
my postgraduate studies.
I would like to extend my sincere thanks to my family members for their
loving support during my study. I must also express my gratitude to my husband,
Michael Mottern, for his continuing encouragement, support and understanding.

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Table of Contents
List of Tables ................................................................................................................... vi
List of Figures ................................................................................................................. vii
Chapter One: Introduction to the Study ............................................................................ 1
Need for a Systematic Literature Review .................................................................. 4
Aims of the Systematic Review ................................................................................. 5
Chapter Two: Pathomechanics of Rheumatoid Deformities in the Hand and Wrist ........ 6
Wrist Deformities ...................................................................................................... 7
Metacarpophalangeal Joint Deformities .................................................................... 8
Swan Neck Deformity ............................................................................................... 9
Boutonniere Deformity ............................................................................................ 10
Deformities of the Rheumatoid Thumb ................................................................... 11
Chapter Three: Static Splints for the Hand and Wrist .................................................... 12
Static Resting Splints ............................................................................................... 12
Wrist Extension Splints ........................................................................................... 13
Finger Splints ........................................................................................................... 13
(1) Splinting for swan neck deformity ........................................................... 13-14
(2) Splinting for boutonniere deformity .............................................................. 15
Metacarpal Ulnar Deviation Splints ................................................................... 16-17
Splinting for the Rheumatoid Thumb ...................................................................... 18
Static Splints and their Principles of Action ............................................................ 19
Chapter Four: Methodology ............................................................................................ 20
What is a Systematic Literature Review? ................................................................ 20
Why is a Systematic Literature Review Needed? .................................................... 21
The Process of a Systematic Review ....................................................................... 22
Framing the research question ............................................................................ 22
Search strategy ............................................................................................... 23-26
Inclusion and exclusion criteria ..................................................................... 26-27
Critical Appraisal/Quality Assessment ............................................................... 29-30
Levels of Evidence................................................................................................... 32
Grades of Recommendation..................................................................................... 33
Chapter Five: Results ...................................................................................................... 34
Search and Selection of Studies .......................................................................... 34-35
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Methodological Quality of the Included Studies ..................................................... 36
Static Resting Splints .......................................................................................... 38-40
Wrist Extension Splints ...................................................................................... 43-47
Finger Splints ........................................................................................................... 52
splinting for swan neck deformity.................................................................. 52-55
splinting for boutonniere deformity .................................................................... 58
Metacarpal Ulnar Deviation Splints ................................................................... 60-61
Thumb Splints ..................................................................................................... 64-65
Chapter Six: Discussion .................................................................................................. 67
Static Resting Splints .......................................................................................... 67-69
Wrist Extension Splints ...................................................................................... 69-70
Finger Splints ........................................................................................................... 71
(1) Swan neck splints ..................................................................................... 71-72
(2) Boutonniere splints ................................................................................... 72-73
Metacarpal Ulnar Deviation Splints ........................................................................ 73
Thumb Splints .......................................................................................................... 74
Limitations of the Study ..................................................................................... 74-75
Limitations of the Current Evidence ................................................................... 75-76
Chapter Seven: Conclusion ............................................................................................. 77
Implications for Practice ..................................................................................... 77-78
Recommendations for Future Research .............................................................. 78-79
References .................................................................................................................. 80-93
Appendix A: Anatomical Structure of the Hand and Wrist ...................................... 94-95
Appendix B: Search Strategies from the Different Databases ........................................ 96
Appendix C: SEQES interpretation guide ............................................................... 97-101
Appendix D: Characteristics of Excluded Studies ........................................................ 102

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List of Tables

Table 1. Rheumatoid Thumb Deformities .................................................................... 11
Table 2. Study Inclusion and Exclusion Criteria .......................................................... 28
Table 3. Structured Effectiveness of Quality Evaluation Scale ................................... 31
Table 4. Sackett’s Level of Evidence Model................................................................ 32
Table 5. Grades of Recommendations and Definitions ................................................ 33
Table 6. Methodological Quality of the 18 Splinting Studies ...................................... 37
Table 7. Summary of Evidence for Static Resting Splints ...................................... 41-42
Table 8. Summary of Evidence for Wrist Extension Splints................................... 48-51
Table 9. Summary of Evidence for Swan Neck Splints .......................................... 56-57
Table 10. Summary of Evidence for Boutonniere Deformity......................................... 59
Table 11. Summary of Evidence for Metacarpal Ulnar Deviation Splints ..................... 63
Table 12. Summary of Evidence for Thumb Splints ...................................................... 66

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List of Figures

Figure 1. Caput ulnar syndrome ....................................................................................... 7
Figure 2. Radiograph of a typical wrist deformity ........................................................... 7
Figure 3. Clinical appearance of ulnar drift deformity .................................................... 8
Figure 4. Radiograph of a classic metacarpal ulnar deviation deformity ........................ 8
Figure 5. Swan neck deformity ........................................................................................ 9
Figure 6. Boutonniere deformity .................................................................................... 10
Figure 7. Static resting splint ......................................................................................... 12
Figure 8. Commercial wrist extension splint ................................................................. 13
Figure 9. Prefabricated thermoplastic splint, Oval-8 design .......................................... 14
Figure 10. Silver ring splint ........................................................................................... 14
Figure 11. Custom thermoplastic splint for swan neck deformity .................................. 14
Figure 12. DS anti-boutonniere splint ............................................................................ 15
Figure 13. Boutonniere prefabricated thermoplastic splint ............................................. 15
Figure 14. Volar based custom boutonniere splint ......................................................... 15
Figure 15. Modified MUD splint, described by Rennie (1996) ...................................... 16
Figure 16. LMB splint, volar hand based design ............................................................ 16
Figure 17. Ulnar drift splint, neoprene (3.2mm) ............................................................. 16
Figure 18. Norco Fabrifoam soft MCP ulnar drift splint ................................................ 17
Figure 19. Wrist-hand-based splint – palmer view ......................................................... 17
Figure 20. Wrist-hand-based splint – dorsal view .......................................................... 17
Figure 21. Thermoplastic short opponens splint ............................................................. 18
Figure 22. Neoprene CMC joint thumb splint ............................................................... 18
Figure 23. Flowchart of the five essential steps in a systematic review ......................... 23
Figure 24. Flowchart of the study selection process in the systematic review ............... 35
Figure 25. MCP-blocking splint, palmer view................................................................ 62
Figure 26. MCP- blocking splint, dorsal view ................................................................ 62
Figure 27. Innovative thumb splint, dorsal view ........................................................... 65

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Chapter One:
Introduction

Hand function disability is common in patients with rheumatoid arthritis (RA)
(Maini & Feldman, 1998). Local inflammation initially causes pain, swelling and a
limited range of movement. Within one year of diagnosis, 50% of individuals with RA
have difficulty with impaired hand function; in particular, finger flexion and pincer
grip (Eberhardt & Fex, 1995). As the disease progresses, approximately, 90% of those
individuals develop specific hand and wrist deformities (Horsten, Ursman, Roorda, van
Schaardenburg, Dekker, & Hoeksma, 2010), and the resultant damage can lead to long
term disability. Static hand and wrist splints have been used in rheumatology for many
years (Rotstein, 1965). They are recommended for helping individuals manage their
arthritis (Adams, 1996), and are a commonly used intervention in occupational
therapy (Henderson & McMillan, 2002). Despite splinting’s widespread use, evidence
in the form of published clinical studies is limited. The aim of this systematic review
was to determine the effectiveness of five types of static hand splints for persons with
RA. This review focuses on the use of splinting for non-surgical treatment, not on the
efficacy of post-operative splinting.
The most prevalent recognizable hand deformities in RA include ulnar
deviation of the metacarpophalangeal joints, the boutonniere deformity, and the swan-
neck deformity. Most individuals will also develop thumb involvement (Terrono,
2001). These deformities can cause significant functional consequences and impact
quality of life (Madenci & Gursoy, 2003). There is also the potential loss of social and
financial independence (Young et al., 1998) and the burden of care on direct (e.g.,
medical care) and indirect costs (e.g., effects on the individual’s ability to work)
(Jantti, Aho, Kaarela, & Kautiainen, 1999; Cooper, 2000). Given the major impact RA
deformities can have on hand function and quality of life (Johnsson & Eberhardt,
2009); occupational therapists are frequently looking for the most effective splints to
alleviate pain, increase joint stability, prevent joint deformity and improve function.
Rheumatoid arthritis is a chronic, systemic, inflammatory condition that
affects approximately 1% of the population worldwide (Taylor, 2007). It occurs twice
as often in woman as in men (Uhlig & Kvien, 2005), with a peak incidence between
45 and 65 years (Lee & Weinblatt, 2001). The course of RA is variable and
unpredictable but for a significant number of patients it is a severe disease resulting in
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persistent joint pain, progressive joint destruction and long-standing disability
(Tehlirian & Bathon, 2008; Wolfe & Zwillich, 1998). The etiology is still not fully
understood but involves a complex interplay of environmental and genetic factors
(Uhlig & Kvien, 2005).
The disease is characterized by symmetrical involvement of the peripheral
joints, in particular, the small joints of the hands and wrists (Scott & Kingsley, 2008).
In a recent study of RA patients attending a rheumatology clinic, hand involvement
occurred in approximately 75% of participants (Oldfield & Felson, 2008). This
finding is supported by Dellhag and Bjelle (1995) who found that 90% of all patients
had wrist, metacarpophalangeal (MCP) joints, and/or proximal phalangeal (PIP) joint
involvement, causing significant pain and impaired hand function.
In the early stages of RA, involvement of the hand and wrist is frequently
described, causing pain and limited range of motion. McQueen and colleagues (1998)
performed a longitudinal, prospective study to investigate the progression of joint
damage in early RA using magnetic resonance imaging (MRI).The results
demonstrated that 40% of people first develop inflammatory symptoms in their finger
joints, then hand and wrist erosions within four months of disease onset. In long-
standing RA the hand joints are involved in up to 85% of patients (Eberhardt,
Rydgren, Pettersson, & Wollheim, 1990) and these deformities can lead to severe
limitations in activities of daily living (e.g., in family life, in working life, and in other
social situations) (Johnson & Eberhardt, 2009).
Rheumatoid arthritis causes synovitis and joint erosions, leading to capsular
distention, ligament laxity, loss of joint motion and imbalance of muscle function
(Boutry et al., 2003). When combined with external forces on the joints (Flatt, 1996),
three hand deformities commonly develop, ulnar drift deformity of the metacarpals,
swan neck deformity and boutonnière deformity (Madenci & Gursoy, 2003). These
deformities develop early in the disease process and their presence is a predictor of
disease severity (Johnsson & Eberhardt, 2009). In a recent study of RA patients
attending a rheumatology clinic, 59% of patients developed one or more hand
deformities after 10 years, with MCP joint deformity the most prevalent (Johnsson &
Eberhardt, 2009). Development of these deformities is correlated with a positive
rheumatoid factor (Johnsson & Eberhardt, 2009), active synovitis, and disease
duration (Madenci & Gursoy, 2003). There is no association with hand dominance
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and more than one deformity can develop in the same hand (Eberhardt, Malcus-
Johnson & Rydgren, 1991).

Splinting
Hand and wrist splints are a common component of occupational therapy
programs for persons with rheumatoid arthritis. Recent literature suggests splinting
has the potential to improve hand function, by attempting to support the proximal
joints, applying counterbalanced force to deforming joints and improving
biomechanical advantage (Prosser & Connolly, 2003). Hand splints have both
biomechanical and biological rationales for their use and action (McClure, Blackburn,
& Dusold, 1994), however evidence to support the clinical effectiveness is still
emerging (Adams, Hammond, & Burridge, 2005). The rationale for the use of wrist
and hand splints in rheumatology has included:
(cid:120) To decrease soft tissue and joint pain (Pagnotta, Korner-Bitensky,
Mazer, Baron, & Wood-Dauphinee, 2005).
(cid:120) To rest/immobilize weakened joint structures and decrease local
inflammation (Jansen, Phiferons, van de velde, & Dijkmans, 1990).
(cid:120) To correctly position joints (Ouellette, 1991).
(cid:120) To increase joint stability (Kjeken, Moller, & Kvien, 1995).
(cid:120) To increase hand function (e.g., grasping or pinching) (Pagnotta et al.,
2005).
(cid:120) To contribute towards self-management strategies in long-term disease
management (Hammond, 1998).
(cid:120) To minimize joint contractures and hand deformities (McClure et al.,
1994).

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