Upper Limb Orthotics/Splinting Wrist Contracture after Stroke

The patient is a 42 year old male who suffered from a stroke whilst at home. He is otherwise very healthy and fit. He plays basketball regularly, training once and playing once a week. He has the Australian Basketball Masters coming up in 4 months. He is an accountant and uses computers for majority of tasks and needs finger dexterity. The patient is now suffering from contracture and spasticity of the wrist and digits of the right upper limb. He would like to be able to return to work, playing basketball and complete self-care activities.



Evidence
Wilson et al. (1999) state that with an ever increasing aging population, stroke ranks as one of the leading causes of long term disability. A hemiplegic stroke affects one side of the body, which in the case of the client is the right side affected. Strokes prove to be detrimental to the side they affect, causing lasting complications, as well as complications that can be healed if treated appropriately. Immediately after a stroke, up to 80% of survivors will suffer from upper limb problems, and persisting problems from 30-75% of said survivors. Upper limb recovery rates are around 30% but can be as low as 5% regaining full limb function, therefore immediate treatment is crucial (Adey-Wakeling, Z., & Crotty. M., 2013).

An individual with this type of brain injury will typically have effective movement on their unilateral side in their shoulder, complete elbow flexion, supination and wrist extension. Elbow extension will be limited – possible with gravity but not against any form of resistance, finger or thumb movement is impeded. The individual will have the ability to extend their wrist, which moves the index finger and thumb into a tenodesis grasp. The patient is currently developing a unilateral wrist contracture, which would limit or reduce the patient’s wrist extension ROM, and force the hand into constant wrist flexion (Kirshblum, Priebe, Ho, Scelza, Chiodo & Wuermser, 2007).

A contracture occurs when non stretchy fiber-like tissues replace the normal stretchy tissues in the skin, affecting the range of motion of the limb affected (MedLine Plus, 2012). Muscle contracture affects forearm flexors and extensors, biceps brachii, flexors of the digits and flexor carpi radialis and ulnaris. During healing after injury, scar tissue contracts and this may produce deformity. In the case of neuromuscular disease, the view that it is only muscular imbalance or spasticity (affecting approximately 20% of stroke sufferers) at a joint which causes contracture has been modified since changes in the soft tissues have now been recognised.

Orthotic treatment options
The primary goal of the orthotic intervention is to reduce wrist contracture and bring the hand back into the functional position of 10-30 degrees of extension, with the fingers and thumb freely movable (Lannin, Horsley, Herbert, McCluskey & Cusick, 2003). With the wrist in this position, the fingers naturally form a tenodesis grasp. (Kirshblum et al, 2007). This grasp creates slight pressure between the thumb and index finger, allowing small or light objects to be held and manipulated. With the wrist in slight extension, functional tasks will be much easier to perform such as using a manual wheelchair, placing objects in hands and carrying objects in the supinated position on wrists. To achieve this goal, the patient will be fitting with a splint to hold the affected wrist in the functional position to give as much function as possible.

Many studies have suggested that static volar splints keeping the wrist in functional resting position of 30 degrees extension, thumb in adduction and interphalangeal joints in 45 degrees flexion will prove most effective worn at least 90 minutes per day. Pizzi et al (2005) demonstrated that a custom volar splint worn for 2-3 hours a day for up to 3 months improved wrist PROM (Pizzi, A., Carlucci, G., Falsini, C., Verdesca, S., & Grippo, A., 2005). There were statistically significant increases in wrist PROM. Basaran et al. suggest that splinting has biomechanical benefits constituting stretch-associated changes in muscle and connective tissue, and neurophysiological benefits involve reduction of spasticity by inhibiting the reflexive contraction of muscles (Basaran, A., Emre, U., Karadayut, K.I., Balbaloglu, O., & Bulmus, N., 2012).

As shown in the image above, the position of the arm in the splint is to keep the arm in the most functional position possible whilst reducing the affects of contracture of the muscles and maintaining a passive range of motion (ROM) in patients with upper motor neuron lesions, burns, and contractures (MedScape, 2013). The only flaw with this splint in the image above is that the wrist is not in 30 extension, though in the splint required for reducing muscle contracture, that is mandatory. It is achieved by using a three point force system to alleviate pain and tension in certain areas. One point of force is on the proximal volar side of the splint, the second is on the dorsal distal end of the forearm and the third point is the palmar surface of the hand. It is also imperative that the length of time the splint is used in compliance with the literature, being over a month’s continual use. Engin et al took out a study for the practical use of a volar static splint worn an hour before activities were undertaken to see the effectiveness of doing everyday tasks. After the initial assessment, these were evaluated on the second, fourth and sixth month. After the third and fourth assessment they showed improvements in the L test and the TUG test.

Comparison of orthotic treatment options
Neurological contractures can often be reduced gradually through repeated stretch over days, weeks or months depending on the severity (Katalinic, Harvey & Herbert, 2011). For this reason the adjunct therapy I suggest is physiotherapy. Weppler (2012) suggests that stretching can have both immediate and short term effects, however to have a long term impact on the contractures, stretching should be performed on a regular basis for an extended period of time. A physiotherapist would be able to passively stretch the patient’s wrists, as well as prescribe take home exercises for the patient to perform regularly to assist in improving wrist range of motion and contracture reduction.

There are a few different interventions suggested by the current literature to treat contracture of the upper limb post-stroke; some methods to be used in conjunction with other treatments, for example a splint with Botoxulin injections, or in other cases surgery is recommended. There are also differences of opinion as to what kind of splint should be used; instead of the volar static splint, a Dynamic Splint. One study proved the dynamic splint to be very effective in on patients with unresolved upper limb contracture, with the patients using the Dynasplint system nightly for months gaining 52 degrees of elbow extension. Its effectiveness beckons from its use of the same biomechanical principle as low-load, prolonged duration stretching to increase the total time at end of range of motion, which is widely accepted amongst the current literature (Lai, J.M., Jones, M., & Willis, F.B., 2008). Nuismer, et al treated 18 contractures by stretching orthoses (9 Dynasplint, 8 Ultraflex and 1 turnbuckle) for a mean of 6.47 hours per day (1 to 12). Only two patients showed no improvement, with the remainder making gains of between 6° and 66° in range of movement after three months, showing both the benefits of a splint and stretching.

The search strategy used was through reviewing and losing the following electronic databases: CINAHL, Cochrane and Medline to find journal articles on the effect of splinting for wrist contracture post-stroke. In particular, I was searching for systematic and literature reviews and large scaled randomized controlled trials. After thorough research, it is my clinical prescription to provide this client with a volar static splint along with the provision of physical therapy and stretching. Through the research, it shows significant improvement of wrist range of motion, decreasing the effects of both muscle contracture and spasticity after a stroke.

Functional Aims and Goals
The functional aim of the device is to immobilise the wrist and fingers to oppose the contracture as a result of the stroke. The prescription of this device is supported in accordance to the literature to reduce muscle contracture after stroke (Lannin, Horsley, Herbert, McCluskey & Cusick, 2003). A volar static splint was prescribed to restrict the movements of the wrist, thumb and the interphalangeal (IPJ) and metacarpalphalangeal joints (MCPJ) joints of the fingers.

Specifically, the splint holds the wrist in 30 degrees extension and slight ulnar deviation, the thumb in opposition and adduction and the IPJ and MCPJ in slight flexion. In doing so, it will allow the wrist to reach its full range of motion, which otherwise would not have been possible as the contracture was causing the wrist to sit in flexion, which is not the most functional position. With the fingers in only slight flexion, it extends the fingers out from their fully flexed position forced on by the contracture.

The material of choice is the LTT compared to using a POP cast. The functional goals for both materials are identical with both encouraging immobilization to restrict movement, though the LTT is more aesthetically pleasing, lightweight and provides more comfort than that of the plaster cast. It balances effectiveness and comfort, without compromising function.

Design
The preferred wrist hand orthosis (WHO) prescribed is a volar static splint made from low temperature thermoplastic (LTT), whereby the splint covers the volar side of the forearm. The splint is designed to counteract the contracture experienced as a side effect of the stroke. For the arm to remain functional, the arm is manipulated as follows:

•	Wrist is slightly ulnar deviated (10°)

•	Wrist is in extension (20°-30°)

•	Thumb is opposed and adducted

•	IPJ and MCPJ in flexion (45°)

Technical drawings:

As shown on the right is the template of the clients arm, drawn leaving room on the sides to wrap around half the circumference of the arm and the thumb fully extended to allow for the thumb to be cuffed by the orthosis.



Force systems:

Trimlines:

(a)	The splint begins two fingers length distal to the elbow on the proximal forearm on the volar surface.

(b)	It wraps around the arm to just slightly more than half the circumference of the forearm.

(c)	It covers the palmar surface of the thumb also wrapping around half the circumference of the thumb and reaching slightly longer than the thumb.

(d)	It cups the palmar surface of the hand with the digits in their flexed position, and extends slightly longer than the fingers to keep them supported and not allow over extension due to the contracture.



Manufacturing process
https://www.youtube.com/watch?v=qp5QXp2Usbg

The fabrication process of the LTT splint is as follows:

1. Draw design and then cut the template and check to see if it fits the client 2. Trace onto thermoplastic, cut it out & submerge into warm water

3. Whilst the LTT is heating up, put clients arm into position as stated above

4. Remove the LTT and pat dry to remove excess water

5. Mould the thermoplastic to the clients wrist ensuring the correct position is maintained

6. Once it has set, remove and neaten the edges where necessary by submerging the edges in the water, making sure there are no sharp bits and all trimlines are met

7. 5 straps are needed to apply pressure at the following positions: • proximal trimline of the orthosis (thick strap) • proximal to the wrist joint (thick strap) • between MCP and IP joint of the thumb (thin strap) • between MCP and PIP joints of the 4 digits (thin strap) • between DIP and IP joints of the 4 digits (thin strap)

8. To attach the straps to the splint, the position where the strap needs to go is heated for a second as well as the bottom surface of the small Velcro piece and simply just place it    in position and it will adhere.

9. This process is then repeated on the other side where the strap is attached through heating the rough side and the position on the splint for a second and placing it on top.

10. Process repeated for all 5 straps.

The fabrication process of the POP cast is as follows:

1. Mark anatomical landmarks on arm

2. Put sleeve on arm whilst cutting a whole for the thumb

3. Measure plaster of paris from two finger width distal to the elbow, to slightly longer than the tips of the fingers

4. Make 6 layers of that length and place in cold water

5. Position the wrist in 30 degrees extension, slight ulnar deviation, the thumb in opposition and adduction and fingers in slight extension

6. Place the plaster on the palmar surface of the hand and arm wrapping around the arm to just over half the circumference of the arm

7. Keep the arm in this position until the plaster dries

Critique of fit
The patient is a 42 year old male who suffered from a stroke whilst at home. He is otherwise very healthy and fit. He plays basketball regularly, training once and playing once a week. He has the Australian Basketball Masters coming up in 4 months. He is an accountant and uses computers for majority of tasks and needs finger dexterity. The patient is now suffering from contracture and spasticity of the wrist and digits of the right upper limb. He would like to be able to return to work, playing basketball and complete self-care activities.

On presentation, the client reported pain in his right arm, specifically at the joints of the wrist and fingers where the contracture is prominent. The contracture has also reduced his able to function normally, especially being able to type at work with the function of the fingers significantly reduced. His goal is to be able to get back to work and be able to play basketball again without too much interference from the contracture. The client’s left arm had full ROM, whereas the right arm had slightly less ROM than desired. In the wrist joint, there is over-flexion with the muscles contracting, which is resulting in the wrist not being able to get into its full ROM actively. Considering the results of the clinical assessment, a likely diagnosis is muscle contracture of the right wrist and fingers.

The goal of orthotic management is to provide immobilisation for the wrist to counteract the muscle contracture. Muscle contracture following a stroke presents with the affected limb in excessive flexion of the wrist and fingers and radial deviation. In order to achieve these goals, an orthotic prescription has been developed to oppose the nature of the contracture, by extending the wrist, deviating the wrist in the opposite direction (ulnar deviated), keeping the thumb and fingers in a functioning position whilst also opposing the over-flexion.

The chosen WHO is a volar static splint with the wrist in 30 degrees of extension, slight 10 degrees of ulnar deviation, thumb in opposition & adduction, and 45 degrees flexion of the ICJ and MCPJ. With the three point force system, there is one point of force is on the proximal volar side of the splint, the second is on the dorsal distal end of the forearm and the third point is the palmar surface of the hand.

As seen in the 4th image, the thumb is slightly too opposed and the MCPJ are slightly over-flexed, leaving little room on the palmar surface for a clinically functional position. With the opening not as wide as it should have been, the functionality is diminished. To correct this, I would take more time on the hand area in the manufacturing process to get it in the optimal position. I could use a cylindrical device in the palm to ensure it holds the shape and forms in the most functional position.

The device has a few imperfections in the appearance of the device. Whilst in the manufacturing process, I had some permanent marker on my hands that transferred onto the LTT. There are also a few pen marks on the lateral border of the trimlines that were not able to be removed. If the task were repeated, I would be more careful to keep the appearance of the device as professional as possible. It was also a little unstable on the palmar surface of the hand, so I added another layer of LTT for reinforcement.

The device is the right fit for the client in terms of length, positioning of trimlines and force systems. It is comfortable for the client with only one area that needs to be improved on. As seen in the 2nd and 5th image, the lateral trimline of forearm slightly digs into the clients’ arm resulting in slight bulging, which could potentially cause pain, discomfort and ulcering. To alleviate this problem, I could do a slight flaring of the trimline, to allow the soft smooth surface of the device to palpate the skin, rather than the straight edge.

The device meets the orthotic goal of immobilisation, but lacks slightly in the area of functionality, especially in the hand due to the fit of the fingers being slightly too flexed. This will not completely oppose the contracture of the fingers, which is the goal of the device, but could be easily fixed with slight modification.

Outcome measures
The purpose of the device is to keep the arm immobilised to prevent further contracture, so an outcome measure would be to assess how much normal function the patient now has after the stroke. It can't be compared to prior to the stroke because his function was normal, so there will be no improvement, but what can be assessed is his physical recovery and ability to complete ADLs. This can be done through the DASH (Dash score = {(sum of n responses)-1}x25, n=number of completed responses) or quickDASH questionnaire which is a general upper limb function test with good reliability.

The clients ROM can be measured; active, resisted and passive; to see if/how much the ROM improves from just post-stroke, to further along the recovery period, along with a grip strength test to see if muscle mass and strength is affected. Due to the contracture, we would expect to see a loss of ROM in the wrist, particularly in the ability to extend the wrist as the wrist is in the extreme forced flexion. Finger dexterity will also be affected, which would greatly affect the score on the DASH questionnaire as that would affect numerous ADLs.

Muscle grading would be tested, as the client may have lost muscle tone and strength, with a score of 0 to 5 in his capability to move his arm and wrist against gravity and some resistance. With increasing resistance, I would look out for signs of pain being exerted and decreased congruence between the bones and muscles.

Referral Letter
Referral was made to a physiotherapist to help with ROM and regaining strength of the wrist and fingers.

It was addressed to: Ms. N Reynolds - Physiotherapist, The Physiotherapy Clinic, Extension Court, GREENVALE MELBOURNE, VIC 3059

Dear Ms Reynolds,

Thank you for accepting my referral for my client today. My client is a 42 male who plays competitive basketball and works as an accountant. He has recently suffered from a hemiplegic stroke and as a result, affected the right side of his body. In particular, he now has muscle contracture of the right upper limb, mainly affecting his wrist and fingers. It has put his wrist and fingers into a forced flexion position making it functionally unsound. I have fitted him with a LTT volar static splint keeping his wrist in 30 degrees extension and slightly ulnar deviated, his thumb in opposition and adduction and his fingers in 45 degrees flexion, allowing him to be in the most functional position whilst the immobilisation is counteracting the contracture. The splint should be worn as long as possible to get the best results. The adjunct therapy I would recommend is stretching of the soft tissues (active and passive movements) and physiotherapy on a weekly basis. As he is a competitive basketballer, he is keen to get back into training for his upcoming Masters tournament so I believe with your help his wrist and finger dexterity and mobility benefit immensely. Many thanks,

Rebecca Guglielmino

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