Dynamic Splinting the Stiff Hand: Improving Evidence to Optimize Clinical Outcomes

Celeste Glasgow (2011). Dynamic Splinting the Stiff Hand: Improving Evidence to Optimize Clinical Outcomes PhD Thesis, School of Health and Rehabilitation Sciences, The University of Queensland.

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Author Celeste Glasgow
Thesis Title Dynamic Splinting the Stiff Hand: Improving Evidence to Optimize Clinical Outcomes
School, Centre or Institute School of Health and Rehabilitation Sciences
Institution The University of Queensland
Publication date 2011-05
Thesis type PhD Thesis
Supervisor Associate Professor Jenny Fleming, Dr Leigh Tooth
Total pages 230
Total colour pages 56
Total black and white pages 174
Subjects 11 Medical and Health Sciences
Abstract/Summary ABSTRACT Mobilizing splinting is a common treatment employed by hand therapists to improve range of motion (ROM) in the stiff hand following trauma. A moderate level of evidence exists to support the use of mobilizing splinting to manage joint stiffness in the hand compared to alternative treatment techniques (e.g., joint mobilization, continuous passive motion, casting motion to mobilize stiffness and exercise). Despite this however, little is known about parameters that may affect the effectiveness of splinting treatment. Many factors are believed to influence outcome with splinting (e.g., pre-treatment joint stiffness, time since injury, age, diagnosis) yet there is limited research evidence to justify the relative importance of these variables. In particular, an evaluation of pre-treatment joint stiffness is commonly used by clinicians to determine whether or not a patient will benefit from splinting and if so, what type of splint is required. Three different forms of mobilizing splint may be used by hand therapists to manage joint stiffness including serial static splints, dynamic splints and static progressive splints. While therapists may frequently choose one type of splint in preference to another in a given clinical situation, there is no research evidence to support the superiority of any single splint type. Following a detailed review of the literature and careful consideration of splint biomechanics in combination with joint stiffness theory, it was concluded that dynamic splints were potentially able to target both the viscous and elastic components of joint stiffness more effectively in the fibroplastic, and maturation phases of tissue repair. It is these later two stages of tissue repair that are linked with the development of joint stiffness and contracture. Consequently dynamic splints were chosen for investigation in this study. The overall aim of this thesis was to improve the evidence behind the use of dynamic splinting in order to assist clinical reasoning in the management of the stiff hand. Specific thesis aims included; 1) to identify a reliable and valid measure of joint stiffness in order to accurately assess the relationship between pre-treatment stiffness and dynamic splinting outcome, 2) to investigate the relationship between 11 key clinical variables (including joint stiffness) and outcome following 8 weeks of dynamic splinting, 3) to examine the long term relationship between splint duration and the extent of contracture resolution in order to develop general guidelines for clinicians regarding average timeframes for splinting, 4) to identify the point of plateau with splinting treatment, and 5) to determine whether a daily total end range time (TERT) of 12-16 hours leads to greater contracture resolution compared to 6-12 hours per day over 8 weeks of treatment. Several different studies were conducted as part of this thesis. First, a prospective correlational study was used to examine the reliability and validity of the End Feel and Torque Angle Curve (TAC) techniques for evaluating pre-treatment joint stiffness. Following baseline evaluation and preconditioning using 20 minutes of heat and stretch, End Feel (i.e., springy or non-springy) was assessed and three TAC measurements (in degrees) were taken by two raters. Therapist order for measurement was alternated. Data from 24 participants (38 joints) were analysed and it was demonstrated that the TAC technique had adequate reliability (ICC 2, 2 = .80) and validity (F [2, 35] = 7.9, p = 0.001). In contrast the End Feel technique demonstrated only poor to moderate inter- rater reliability. A second prospective correlational study was used to evaluate the reliability and validity of a modification of the Weeks Test method of assessing joint stiffness. Twenty-seven participants were recruited sequentially from a private community hand clinic. Active range of motion (AROM) was taken cold and then re-assessed after 30 minutes of heat and stretch. The change in AROM over 30 minutes was used as the estimate of joint stiffness. Testing was repeated several days later. High test–retest reliability was demonstrated (ICC 2, 1 = 0.78). The modified Weeks Test showed only weak associations with the TAC and End Feel assessments of joint stiffness indicating a lack of convergent validity with these measures. This suggests that the modified Weeks Test examines a different aspect of joint stiffness to that of the TAC and End Feel techniques. The third and major study component identified clinical predictors of contracture resolution after 8 weeks of dynamic splinting using a prospective cohort design. Fifty-two participants with 63 stiff metacarpophalangeal (MCP) and proximal interphalangeal (PIP) joints were recruited from a private community hand clinic. Six participants (7 joints) dropped out of the main cohort study leaving a final sample of 46 participants (56 joints). As the majority (85.7%) were PIP joints,a subset of PIP joints was examined separately in addition to the combined sample of PIP and MCP joints. Active, passive and torque ROM were assessed at baseline and after 8 weeks of splinting by an independent assessor. Predictor variables examined included; age, type of deficit (flexion, extension), diagnosis, gender, joint type, mechanism of injury, splint type, pre-treatment joint stiffness (End Feel, TAC, modified Weeks Ttest), splint wear time (TERT), time since injury, and insurance status. Findings indicated that the best predictors of improvement in AROM and passive ROM (PROM) included; the modified Weeks Test assessment of joint stiffness, type of deficit, time since injury and diagnosis. For every degree of change in AROM using the modified Weeks Test, AROM after 8 weeks of splinting improved 1.09 (SE 0.2) degrees in the full sample of MCP and PIP joints and 1.02 (SE 0.2) degrees in the PIP subset. In the PIP subset, time since injury of less than 8 weeks predicted better contracture resolution compared to joints that were greater than 12 weeks post injury. Greater improvement in PROM was seen in those splinted to regain flexion compared to extension. The fourth study explored the long term relationship between progress with contracture resolution and duration of dynamic splinting, in the stiff PIP joint. Using a subset of 41 participants from the main predictive study cohort, progress with dynamic splinting treatment was studied over time. Both PIP flexion and extension deficits were included in the sample. Splinting outcome was assessed as change in AROM and torque ROM (TROM). The relationship between contracture resolution and duration of treatment was examined using Joinpoint analysis while controlling for baseline ROM, pre treatment joint stiffness, time since injury, and diagnosis. It was found that duration of treatment with dynamic splinting was strongly associated with the extent of contracture resolution, with ROM continuing to improve over several months of treatment. Greater gains in ROM in a shorter period of time were observed when flexion rather than extension splinting, despite participants in the flexion group averaging less daily TERT (6.7 versus 10.5 hours per day). Participants using flexion splints made most of their gains in AROM in the first 12 weeks of treatment reaching a plateau with splinting at this time. In contrast, slow improvement in extension range was observed to continue beyond 4 months of treatment. It was concluded that longer duration of treatment and greater daily TERT may be needed when splinting for extension rather than flexion. Additionally, further research was required to evaluate response to extension splinting treatment over a longer period of time (> 4months). The fifth and final study component used a subset of 22 participants (with extension deficits of the PIP joint) from the main cohort study in order to examine daily TERT. Three participants dropped out of this TERT study leaving 19 participants (19 joints). Participants were randomly allocated to the use of a capener splint for 6-12 or 12-16 hours a day. Progress was evaluated after 8 weeks of treatment using change in AROM and TROM in order to determine the optimal daily splinting regimen. No statistically significant difference was found between groups in progress observed. A high degree of group crossover resulted in similar average daily TERT and may have accounted for the lack of a significant difference. The majority of participants in the 12-16 hour group (78%) wore their splint for less than 12 hours per day indicating that it may not be feasible for patients to use their splint for more than 12 hours per day. By combining the new evidence produced from this series of studies, it is possible to make several recommendations for prescription of splint wearing regimens in clinical practice. Firstly, the modified Weeks Test was identified as the most useful measure of pre-treatment joint stiffness in the hand demonstrating high reliability and a strong relationship with outcome in splinting. Further research with this technique is needed to examine the accuracy with which it may predict contracture resolution. Diagnosis is also an important predictor of splinting outcome with the poorest progress observed in the intra-articular fracture and soft tissue injury groups. Time since injury is also critical and early intervention with dynamic splinting (<8-12 weeks) is important to maximise potential gain. Flexion deficits of the PIP joint may recover more quickly than extension deficits with less required daily TERT (e.g., 6-8 hours per day). Three months of splinting may be adequate to maximise gains in functional AROM with flexion deficits. Slower progress is to be expected when splinting to improve extension and longer daily TERT will be required. In many cases it may be necessary to continue the use of extension splinting for greater than 4 months before progress will plateau. Most patients will find it difficult to wear splints for greater than 12 hours per day. Limitations of this thesis include the small sample sizes for each of the studies, attrition of participants in the splint duration study, and group crossover in the daily TERT study. Due to these limitations and the exploratory nature of this research, further studies are needed to replicate and extend upon these findings.
Keyword Dynamic Splinting, Joint Stiffness, Joint Contracture, Hand Trauma, ROM
Additional Notes As per original submission no changes were necessary hence the thesis is exactly the same

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Created: Mon, 12 Mar 2012, 21:21:48 EST by Mrs Celeste Glasgow on behalf of Library - Information Access Service