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Hindawi Publishing CorporationStroke Research and reatmentVolume , Article ID ,pageshttp://dx.doi.org/.//

Research ArticleLong-Term Use of a Static Hand-Wrist Orthosis inChronic Stroke Patients: A Pilot Study

Aukje Andringa, Ingrid van de Port, and Jan-Willem Meijer

Revant Rehabilitation Centre Breda, Brabantlaan , JW Breda, Te Netherlands

Correspondence should be addressed to Aukje Andringa; a.andringa@revant.nl

Received December ; Revised January ; Accepted January

Academic Editor: Valery Feigin

Copyright Aukje Andringa et al. Tis is an open access article distributed under the Creative Commons AttributionLicense,which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Background. Long-term splinting, using static orthoses to prevent contractures, is widely accepted in stroke patients with paresis othe upper limb. A number o stroke patients complain about increased pain andspasticity, which leads to the nonuse o the orthosisanda risk o developing a clenched st. Objectives. Evaluating long-term use o static hand-wrist orthoses andexperienced comortin chronic stroke patients.Methods. Eleven stroke patients who were advised to use a static orthosis or at least one year ago wereincluded. Semistructured telephone interviews were conducted to explore the long-term use and experienced comort with theorthosis. Data were analyzed using descriptive statistics.Results. Afer at least one year, seven patients still wore the orthosis or theprescribed hours per day. wo patients were unable to wear the orthosis hours per day, due to poor comort. wo patients stoppedusing the orthosis because o an increase in spasticity or pain. Conclusions. Tese pilot data suggest that a number o stroke patients

cannot tolerate a static orthosis over a long-term period because o discomort. Without appropriate treatment opportunities, thesepatients willremain atrisk o developing a clenchedst and willexperience problemswith daily activities and hygiene maintenance.

1. Introduction

O all stroke survivors, more than hal experience impair-ments o the upper limb in the chronic phase, includingloss o strength and dexterity, spasticity, muscle contracture,pain, and edema []. Patients with a more severe paresishave a higher risk o developing spasticity [] and musclecontractures o the wrist and nger exor muscles []. Without appropriate spasticity treatment or contracture

prevention, patients are at risk o developing a clenched st,a hand which is deormed into a st by shortening o exormuscles o the ngers and sof tissue []. Te abnormalposition o the hemiplegic hand and wrist due to spasticityand muscle contractures may interere with daily activitiesand hygiene maintenance, both negatively inuencing thequality o lie [].

Different approaches are used to inhibit spasticity, preventcontractures, reduce pain and edema, or improve hygienemaintenance o the hand in stroke patients with a nonunc-tional spastic upper limb. However, there is no consensusabout the most effective treatment []. A commonly usedand widely accepted intervention is prolonged splintingusing

static orthoses[]. wo reviews on the effect o upperlimb splinting afer stroke have been published [,]. Bothreviews showed no effect o static orthoses on upper limbunction, range o motion, and pain afer an interventionperiod less than weeks. However, conclusions shouldbe interpreted with caution because o the lack o highquality randomised controlled trials. Tere is a considerableheterogeneity o included study designs, clinical aims, andorthosis wearing protocols, materials, and regimes. In addi-

tion, all published studies ocused on the short-term effecto splinting with splinting periods no longer than weeks.Despite controversies concerning splinting o the hemiplegicupper limb, static orthoses continue to be advised in clinicalpractice.

When used in clinical practice, a considerable amount ostroke patients complain about increased pain and spasticitysince the use o the static orthosis [, ]. Due to discomort,the orthosis cannot be worn or the advised hours per daywhich leads to nonuse in chronic stroke patients and withthat increases the risk o developing clenched sts with whichpatients may experience problems with daily activities andhygiene maintenance.

http://dx.doi.org/10.1155/2013/546093http://dx.doi.org/10.1155/2013/546093

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F : Example o a preabricated static hand-wrist orthosis.

Given our experiences in clinical practice, the purposeo this pilot study is to describe the long-term use ostatic hand-wrist orthoses and the experienced comort owearing the orthosis in chronic stroke patients in orderto acquire preliminary data to urther study the treatmento this specic patient population. We hypothesize that, in

a number o the chronic stroke patients with upper limbimpairments, discomortincreased pain, and spasticityis the reason or not wearing a static hand-wrist orthosisor the advised hours per day. Te secondary aim is todescribe the sel-reported complaints beoreand since the useo the static orthosis to evaluate the effect o the use o theorthosis in chronic stroke patients. Additionally, the use ocointerventions or the impaired upper limb is investigated.

2. Methods

In this pilot study, semistructured interviews were used toexplore the long-term use (i.e., more than one year) o thestatic orthosis in chronic stroke patients, and the experiencedcomort with the static orthosis in chronic stroke patients(Figure ). A selection o stroke patients, who received astatic orthosis rom the Orthopaedic Centre OIM BrabantBreda, Te Netherlands, was taken rom the database. Allstroke patients who were advised to use a static orthosisat least one year ago and were independently living in thecommunity were included. Patients were excluded whencorrect contact details were missing or when patients diedin the study period. I patients were unable to communicateby telephone, inormation was obtained rom the primarycaregiver. Inormed consent was obtained prior to eachinterview.

Patients were asked about current use, comort o theorthosis, reasons or wearing the orthosis, sel-reportedcomplaints in the hemiplegic upper limb, including spas-ticity, hygiene maintenance, pain, and edema, and appliedcointerventions. Answers to all twelve questions were scoredcategorically except the complaints scores. Complaints scoreswere graded rom (no complaints) to (majorcomplaints).Te telephone interviews were carried out by a physicaltherapist who was not directly involved in the patientstreatment.

Descriptive statistics were used to analyze the resultso the semistructured telephone interviews. Nonparametricanalyses were applied to evaluate sel-reported effect o the

orthosis by comparing the data o complaints beore andsince the use o the static orthosis using a Wilcoxons signedrank test. Statistical analysis was perormed using SPSS ..Statistical signicance was set at the % level.

3. Results

.. Study Population. A total o patients, diagnosed withstroke, received a static hand-wrist orthosis at the Ortho-paedic Centre OIM Brabant Breda, Te Netherlands,betweenJanuary , to October , . Participants were ret-rospectively recruited rom the database at October , .Nineteen stroke patients matched our inclusion criteria andwere invited or the study. Eight patients could not beinterviewed, since three died between receiving the staticorthosis and data collection, and ve could not be reached bytelephone. Data o eleven patients ( emale, male, medianage years, range years) was collected. One interviewwas conducted with a caregiver. All patients were in chronic

stage afer stroke (median months poststroke, range months) and were advised to use the static orthosis or atleast one year ago.

.. Long-erm Use o the Orthosis. As shown in able , aferat least one year rom receiving the static orthosis, threepatients still wear the orthosis during night time, with differ-ent experienced comort. Four patients wore the orthosis orat least hours per day, all with good experienced comort.wo patients were unable to wear the orthosis prescribed hours per day, due to poor comort. wo patients stoppedusing the orthosis,one because o an increase o spasticity andthe other because o an increase in pain.

.. Sel-Reported Complaints in the Hemiplegic Upper Limb.Te main reasons reported or wearing the orthosis werereducing spasticity (/), improving opening o the hand(/), and improving hygiene maintenance o the hand (/)(see able ). None o the patients wore the orthosis to reduceedema. Te complaints score since the use o the orthosisshowed a decreasing trend; however differences betweencomplaints in the hemiplegic upper limb beore and since theuse o the orthosis were not signicant ( < 0.05).

.. Cointerventions. en patients reported cointerventionsor their upper limb impairments o whom eight were

still using the static orthosis(able ). Six patients receivedregular physical therapy sessions, six patients perormed dailyhome exercises, and two patients used spasticity medication(Botulinum toxin or Bacloen). Only one patient did not useany other orm o intervention or the impaired upper limb.

4. Discussion

In this pilot study, we investigated the long-term use oa static hand-wrist orthosis in chronic stroke patients. Othe interviewed stroke patients, two stopped wearing theorthosis because o discomort and two could not endurethe orthosis or the prescribed wearing time o at least

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: Orthosis wearing time, experienced comort, and the reported cointerventions in addition to the use o the orthosis.

Patient Wearing time per hours Day/night use Reported comort Cointer vention

hours Day Poor Handmaster

> hours Night Poor None

hours (nonuse) Very poor Medication, home exercises

>

hours Night Poor Physical therapy hours Day Very poor Physical therapy, home exercises

> hours Day Good Physical therapy, home exercises

> hours Day Good Home exercises

hours (nonuse) Poor Home exercises

> hours Day Good Physical therapy

> hours Day Good Medication, physical therapy, home exercises

> hours Night Good Physical therapy

: Sel-reported complaints in the hemiplegic upper limb.

Reasons or wearing a static orthosis Complaints beore orthosis use Complaints since use orthosis

Median (range) () Median (range) ()Spasticity / () . ()

Hygiene maintenance / () ()

Pain / () ()

Edema /

Opening hand / . () . ()

hours per day. Tese ndings support our hypothesis that asubstantial number o patients who are at risk o developingcontractures in the upper limb, that is, our o the eleven,are not able to endure a static orthosis or the prescribed hours because o discomort. Concluding that these chronicstroke patients do not receive the appropriate interventionto prevent contractures. O the seven patients who usedthe orthosis as prescribed, that is, at least hours, two stillcomplained o discomort. Without appropriate contractureprevention, these patients will develop contractures in theupper limb which can lead to problems during daily activitiesand hygiene maintenance, both negatively inuencing thequality o lie.

Te experienced discomort can be a result o the staticcharacteristics o the orthosis. Te position o the orthosissets the wrist in a xed position. However, the level o spastic-ityvaries during daytime resultingin different positionso the

wrist.Witha higher level o spasticity o the muscles, the wristtends to ex. In contrast, a lower muscle tone can lead to lessexion, or even extension, o the wrist. Te chosen position othestatic orthosis is seldomadequate to managethese varyinglevels o spasticity and changing ranges o wrist mobility.When spasticity increases, the hand and ngerswill try to exin the rigid orthosis which causes pain and discomort. Forstroke patients with varying levels o spasticity in the upperlimb, a static orthosis with a xed position o the wrist canlead to problems tolerating the orthosis.

aking this into account, an orthosis or the preventiono contractures in the spastic upper limb needs to allowhigher levels o spasticity and exion o the wrist. A dynamic

orthosis using the low-load and prolonged stretch principle,with a hinge which allows the wrist to ex during higherlevels o spasticity, might be more appropriate or these strokepatients.

In our study, most patients use the orthosis because ospasticity in the upper limb, to prevent contractures or to pre-serve the ability to open the hand or hygiene maintenance.Patients in our study did not report a signicant differenceo the complaints concerning spasticity, contracture, or painbeore and since the use o the static orthosis, although thecomplaints tendedto decrease in thissmall sample size group.Previous studies on the short-term effect o the static orthosisindicate that stretch does not have clinically important imme-diate or short-term effect on joint mobility[]. Tere is evi-dence indicating that static orthoses show no effect on upperlimb unction, range o motion at the wrist, ngers, or thumb,nor pain [, ]. Despite the lack o studies o long-term

effect, physicians and patients still believe that splinting is anappropriate intervention or contracture prevention. Becausecontractures develop slowly, studies about the effect o splint-ing need to ocus on long-term use o at least six months. Allprevious studies ocused on an increased joint mobility o thewrist as an effect o the static orthosis. In our opinion main-taining the range o motion o the wrist is already a positiveeffect o an intervention aiming to prevent contractures.

In conclusion, a static orthosis can be a useul preventiono contractures or a selection o the stroke patients whocan tolerate this low-cost orthosis. However, there is a groupo chronic stroke patients which is not able to endure astatic orthosis and which needs another intervention or

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the prevention o contractures in the upper limb. In thisgroup, stepped care can be used; when static orthoses are notendured, another intervention has to be applied, or example,dynamic orthosis.

.. Limitations o the Study. Although explorative, this study

offers insight into the long-term use o a static orthosis inchronic stroke patients and the patients experiences with it.Despite the preliminary character o this study, the presenteddata are the rst about long-term use o the static orthosisand experienced comort. Patients had to recall scores ocomplaints beore the use o the static orthosis which couldhave been inuenced by recall bias. aking this into account,in combination with the small sample size, the results aboutthe sel-reported complaints o static splinting should behandled with care and should be conrmed in larger studies.

.. Further Research. Further studies are important to iden-tiy the stroke patients who are able to tolerate the staticorthosis and patients who will need other interventions toprevent the development o contractures. For these specicstroke patients who are not able to tolerate the commonlyused static orthosis, it will be relevant to study the effect oalternative interventions, or example, dynamic orthoses.

5. Conclusion

Tese pilot data show that a number o chronic strokepatientscannot tolerate a static orthosis or at least hours per dayduring a long-term period o at least oneyear. Without appro-priate treatment opportunities, these patients will remain

at risk o developing a clenched st and will experienceproblems with daily activities and hygiene maintenance. It is,thereore, worthwhile to nd other interventions which canbe endured by these stroke patients.

Conflict of Interests

Te authors declare that they have no conict o interests.

Acknowledgments

Te authors offer a special thanks to Daisy van Grinsven andIneke Koolhaas or their valuable participation in this study.

Te pilot study was nancially supported by the RevantInnovatieonds.

References

[] J. G. Broeks, G. J. Lankhorst, K. Rumping, and A. J. H. Prevo,Te long-term outcome o arm unction afer stroke: results oa ollow-up study,Disability and Rehabilitation, vol. , no. ,pp. , .

[] H. Nakayama, H. S. Jorgensen, H. O. Raaschou, and . S. Olsen,Recovery o upper extremity unction in stroke patients: theCopenhagen Stroke Study, Archives o Physical Medicine andRehabilitation, vol. , no. , pp. , .

[] H. Nakayama, H. S. Jorgensen, H. O. Raaschou, and . S. Olsen,Compensation in recovery o upper extremity unction aferstroke: the Copenhagen stroke study, Archives o PhysicalMedicine and Rehabilitation, vol. , no. , pp. , .

[] P. P. Urban, . Wol, M. Uebele et al., Occurence and clinicalpredictors o spasticity afer ischemic stroke, Stroke, vol., no., pp. , .

[] K. H. Kong, K. S. G. Chua, and J.Lee, Symptomatic upper limbspasticity in patients with chronic stroke attending a rehabilita-tionclinic: requency, clinical correlates and predictors,Journalo Rehabilitation Medicine, vol. , no. , pp. , .

[] S. Malhotra, A. D. Pandyan, S. Rosewilliam, C. Roffe, and H.Hermens, Spasticity and contractures at the wrist afer stroke:time course o development and their association with unc-tional recovery o the upper limb, Clinical Rehabilitation, vol., no. , pp. , .

[] A. D. Pandyan, M. Cameron, J. Powell, D. J. Stott, and M. H.Granat, Contratures in the post-stroke wrist: a pilot study oits time course o development and its association with upperlimb recovery, Clinical Rehabilitation, vol. , no. , pp. ,

.[] I. C. M. Heijnen, R. J. P. Franken, B. J. W. Bevaart, and J. W. G.

Meijer, Long-term outcome o supercialis-to-proundus ten-don transer in patients with clenched st due to spastichemiplegia, Disability and Rehabilitation, vol. , no. , pp., .

[] M. Franceschini, F. La Porta, M. Agosti, and M. Massucci, Ishealth-related-quality o lie o stroke patients inuenced byneurological impairments at one year afer stroke?EuropeanJournal o Physical and Rehabilitation Medicine, vol. , no. ,pp. , .

[] D. S. Nichols-Larsen, P. C. Clark, A. Zeringue, A. Greenspan,and S. Blanton, Factors inuencing stroke survivors quality olie during subacute recovery,Stroke, vol. , no. , pp.

, .[] U. Sveen, E. Bautz-Holter, K. M. Sdring, . B. Wyller, and K.

Laake, Association between impairments, sel-care ability andsocialactivities year afer stroke, Disability and Rehabilitation,vol. , no. , pp. , .

[] S. E. Farmer and M. James, Contractures in orthopaedic andneurological conditions: a review o causes and treatment,Disability and Rehabilitation, vol. , no. , pp. , .

[] D. B. Cherry, Review o physical therapy alternatives or reduc-ing muscle contracture, PhysicalTerapy, vol., no. , pp. , .

[] P. W. Duncan, R. Zorowitz, B. Bates et al., Managemento adultstroke rehabilitation care: a clinical practice guideline,Stroke,

vol. , no. , pp. ee, .[] E. L. Miller, L. Murray, L. Richards et al., Comprehensive over-

view o nursing and interdisciplinary rehabilitation care o thestroke patient: a scientic statement rom the American heartassociation,Stroke, vol. , no. , pp. , .

[] R. P. S. Van Peppen, H. J. M. Hendriks, N. L. U. Van Meeteren,P. J. M. Helders, and G. Kwakkel, Te development o a clinicalpractice stroke guideline or physiotherapist in Te Netherland:a systematic review o available evidence,Disability and Reha-bilitation, vol. , no. , pp. , .

[] E.A.M.Franke,Ed., CommissieCVA-Revalidatie. Rehabilitationafer a stroke, guidelines and recommendations or health careproessionals, Dutch Heart Foundation, Den Haag, Te Nether-lands, .

8/12/2019 SRT2013-546093

5/5

Stroke Research and reatment

[] N. A. Lannin and R. D. Herbert, Is hand splinting effective oradults ollowing stroke? A systematic review and methodolog-ical critique o published research,Clinical Rehabilitation, vol., no. , pp. , .

[] S. F. yson and R. M. Kent, Te effect o upper limb orthoticsafer stroke: a systematic review, NeuroRehabilitation, vol. ,no. , pp. , .

[] P. A. Feldman, Upper extremity casting and splinting, inTePractical Management o Spasticity in Children and Adults,M.B.Glenn and J. Whyte, Eds., pp. , Lea&Febiger, Philadel-phia, Pa, USA, .

[] A. J. urton and E. Britton, A pilot randomized controlled trialo a daily muscle stretch regime to prevent contractures in thearm afer stroke,Clinical Rehabilitation, vol. , no. , pp. , .

[] O. M. Katalinic, L. A. Harvey, R. D. Herbert, A. M. Moseley, N.A. Lannin, and K. Schurr, Stretch or thetreatmentand preven-tion o contractures,Cochrane Database o Systematic Reviews,vol. , Article ID CD, .

[] S. F. yson and R. M. Kent, Orthotic devices afer stroke and

other non-progressive brain lesions, Cochrane Database o Sys-tematic Reviews, no. , Article ID CD, .