# 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.