# Upper Limb Orthotics/Orthotic Treatment of Post-Stroke Spasticity in the Distal Upper Limb
## Case Scenario

At age 46 the patient, a male, suffered a right-brain haemorrhagic stroke. Two month post-stroke the patient, due to his age, has recovered more function of the stroke-affected side than expected but currently still has hemiparesis with mild spasticity distally in his left upper limb. The haemorrhagic stroke was caused by thinning of blood vessels due to his use of prescribed medication to treat the rheumatoid arthritis (RA) he experiences in his right hand and right hip joint. The RA affected joints include the carpal metacarpal, metacarpal-phalangeal as well as his proximal and distal inter-phalangeal joints and of course, his right hip joint.
As it is too uncomfortable and painful to use his right hand for long periods, the patient is required to use his stroke-affected left hand to grip his walking aid and enable ambulation independent of family members and allied health staff. Whilst it is understood stroke-survivors tend to use their sound side to grip walking aids it remains a case-by-case decision. It was deemed by the allied health rehabilitation team that the patient should be capable of using his quad-base walking aid with his stroke affected upper limb. The patient presently receives Botulinum toxin treatment to prevent and reduce muscular spasticity however, in further attempt to maintain function of his left hand the patient has been recommended by his general practitioner to use an upper limb orthosis.
For the purposes of this study, focus will be placed on the upper limb orthotic component rather than the lower limb orthotic components of the case scenario.

## Literature-based Information
### Evidence

Haemorrhagic strokes involve bleeding within or around the brain. This bleeding leads to necrosis of the brain tissue of that area due to a lack of sufficient oxygen delivered to the cells. Depending on the area of infarction, stroke survivors can experience various forms of disabilities, ranging from cognitive issues such as difficulty processing thoughts, to physiological issues such as difficulty swallowing.
In severe cases, stroke survivors experience hemiplegia – the paralysis of muscles on the stroke-affected side. Conversely, in less severe cases, stroke survivors experience the milder form of hemiplegia, hemiparesis – weakness of the muscles on the stroke-affected side. A common problem associated with hemiplegia and hemiparesis is hypertonia of the muscles in both the upper and lower limbs of the stroke-affected side. Hypertonia can cause spasticity, a condition of muscle tightness or in severe cases contracture, the permanent shortening of muscles.
For this particular case study however, only the upper limb and more specifically the patient’s distal upper limb will be addressed with relation to treatment using upper limb orthotics. In the patient’s case, there is mild spasticity in muscles of the left forearm and hand. That is, tighteness in his wrist and finger flexor musclescausing reduction in extensibility at the wrist, metacarpal-phalangeal, proximal inter-phalangeal and distal inter-phalangeal joints.

### Orthotic Treatment Options

Although it is controversial as to whether orthotic treatment is effective in reduction of muscular contracture in post-stroke patients, it is anticipated that in conjunction with the Botulinum treatment the patient receives, prescription of an orthotic device will aid in preservation of hand function.
Post-stroke, there are various orthotic treatment options available with intent to reduce spasticity and prevent contracture of muscles. In relation to the distal upper limb, orthotic devices are often applied to areas of the wrist and hand, thus are termed wrist-hand orthoses or splints. From as early as 1968 in a study led by Chariat, custom-made volar and dorsal splints have been available as treatment options. In more recent studies, more focus has been placed upon volar splinting. This is seen research conducted by Pizzi, Carlucci, Falsini, Verdesca and Grippo (2005) where subjects were instructed to wear a static volar splint, described as being reflex-inhibitory, for ninety minutes per day, across a three-month period. Similarly, in a four-week comparison study by Lannin, Cusick, McCluskey and Herbert (2007), the static palmar splint was evaluated in addition to an extension splint, with subjects being required to donn the devices overnight for approximately twelve hours per day.
In recent years studies, such as that by Hoffman and Blakey (2011) along with that by Kim et al. (2013), have placed interest on dynamic splinting of the upper limb. Dynamic devices maintain the hand in a neutral position but have mechanical attachments that allow patients to flex their fingers in a grasp and release motion. This exercises the wrist and finger flexors that would otherwise remain inactive in a static device. Kim et al’s (2013) modification of a dynamic splint saw the use of what was described as a ‘hand-stretcher’, which physically expanded muscles of fingers and thumbs for ten minutes, twice daily for four weeks. Maintaining the idea of a custom-orthosis Watson, Crosby, and Matthews’s (2007) experimental trial prescribed a tailor-made Lycra orthosis to their case study subject across an eighteen-week period. Conversely, research by Hoffman and Blakey (2011) strayed from the usual custom splint. Instead Hoffman and Blakey (2011) reviewed off-the-shelf function dynamic orthoses manufactured by the Saebo brand, describing the efficacy of three available products: the SaeboFlex, SaeboReach and SaeboStretch. In an earlier study, Farrell, Hoffman, Snyder, Giuliani and Bohannon (2007) also followed the usage of a Saebo product – the Saeboflex, in their experimental trial of its use for six hours daily, across five days.
The lengths of the studies and hours subjects were required to wear their devices have been mentioned throughout this section as they both provide a guide as to what would be appropriate time frames to set for patients. The variation of time frames seen in the studies indicate that, in a similar way, the orthotic treatment options provided to patients must also have specified time of use for it to be effective. That is, a prescribed device can be to be worn for a few months or years, and nightly or only during rest periods, depending on a patient’s condition and what is required for them to be able to achieve their goals given their condition.

### Comparison of Orthotic Treatment Options

In Feldman’s (1990) early work on casting and splint the upper extremities, it was suggested that wearing a splint for extended periods could encourage learned disuse of the muscles the splint encompasses. Later on, Lannin, Horsley, Herbert, McCluskey and Cusick ‘s research (2003) concluded the use of a palmar splint overnight did produce positive results but none that were clinically significant with beneficial effects for adult patients with acquired brain injuries. Yet another study, led by Pizzi et al. (2005), claimed the use of a volar static splint was said to have significantly increased the wrist’s passive range of motion. Nonetheless, this was later on refuted by Lannin et al. (2007), whom argued splinting of the wrist and hand, in both neutral and extended position overnight did not have any significant results and recommended their use to be discontinued. Their study showed that in comparison to their control group who received physical rehabilitation, the use of a neutral palmar splint increased wrist extensibility by an average of 1.4° however, the use of an extension splint reduced wrist extensibility by an average of 1.3°.
On the other hand, Kim et al.’s (2013)study showed modification of a dynamic splinting device into a ‘stretching device’ relieved spasticity of the hand in stroke patients with chronic hemiparesis. Research into the tailor-made Lycra orthosis by Watson et al. (2007) also retrieved positive results of improvement in their subject’s active range of motion and upper limb function. Similarly, review of the SaeboFlex orthosis in Farrell et al.’s (2007) experimental trial resulted in improvement of wrist extension and reduction of muscle tone. Nonetheless results from the same studied showed that neither wrist flexion or movements of the fingers improved through use of the SaeboFlex orthosis. Whilst the study on Saebo, products by Hoffman and Blakey (2011) was not a comparative one like other studies of dynamic orthoses, it was still suggested that the SaeboFlex, SaeboReach and SaeboStretch devices respectively allowed motions of grasp, release and prevention of contracture.
It is understood that there are treatment options other than orthotic devices that can be prescribed to a stroke patient to aid in maintaining and regaining function of their upper limb. Some of these include: rehabilitation in such forms as occupational therapy or Botulinum toxin injection treatments. In the former, patients can be retaught gripping, grasping and stretching to exercise the wrist and finger flexor muscles whereas in the latter, injections can be made to deactivate particular muscles which reduces hypertonia and hence spasticity of the patient’s limb. Like the orthotic devices, these treatment options on their own each have their merits and demerits. With that logic in mind, a combination of treatment options relevant to the patient’s needs may result in optimal outcomes, in regard to what the treatment process is aimed to be able to achieve.
In accordance to the idea mentioned above, Lai, Francisco and Willis (2009) conducted a study investigating the effectiveness of a combination of treatments: Botulinum toxin type-A injections, manual (occupational) therapy in addition to dynamic splinting. Botulinum toxin type-A injections and occupational therapy were found in the experimental trial to be efficacious. In conjunction to that, dynamic splinting proved beneficial in maintenance and gain of the subject’s range of motion. This reinforces that for optimal treatment outcomes, prescription of a combination of treatment options incorporated to complement each other’s functions would be more ideal than prescription of a singular treatment option alone – whether that be Botulinum toxin treatment, dynamic or static splinting.
With reference to the particular case study outlined, the ideal prescription for the patient would be a dynamic splinting device for the left hand, to be used in conjunction with his current Botulinum toxin treatment. The device should be worn as much as possible on a daily basis with exception of removal for hygiene care of the device and the area the device encompasses. In addition to this, the patient should attend regular occupational therapy sessions, in which he would be taught to preserve hand range of motion through consistent stretching and maintenance of gripping and grasping actions.

## Functional Aims and Goals

As per the prescription described above, the orthotic device recommended for the patient is a dynamic one similar to that used in the study by Lai et al. (2009). The device would hold the patient’s wrist in a comfortable fixed extended position of less than 45° with fingers in a fixed semi-flexed position but also allow actions of gripping and grasping motions (flexion) at the metacarpal-phalangeal, proximal and distal inter-phalangeal joints. The extended position at the wrist joint is to oppose the spasticity muscles across the joint – associated with post-stroke hemiplegia – that often pulls the wrist into a flexed position. Likewise, spasticity of the long intrinsic finger flexors would cause flexion of the patient’s fingers, hence holding the fingers in semi-flexion is intended to oppose the natural tendency for the fingers to flex and thereby also maintain the range of motion the joints are capable of. Should flexibility and the client's tolerance increase through treatment, the orthotic device being made from low temperature thermoplastic can be re-heated to position the client's joints in further extension, countering the spasticity Through positioning the patient’s wrist and hand in the described method, it is hoped the device would oppose the patient’s hemiplegia-associated muscle spasticity, whilst at the same time, allowing him to grip his walking aid and enable independent ambulation.

## Design

While the recommended was described above as a dynamic one where the client’s wrist is held in a comfortable fixed extended position of less than 45° and the fingers in a semi-flexed position, limitations of the materials available for the device’s manufacture was an issue. Thus a static orthotic device holding the client’s hand in the position described above was designed instead, which can be worn at night or during rest periods in which the client does not require to use his left hand for gripping or grasping objects.
Had the dynamic device been manufactured it would have resembled a wrist hand thumb spica with the distal trimline proximal to the distal palmar crease to allow flexion at the metacarpal-phalangeal as well as inter-phalangeal joints. Individual rigs for each finger would have also been added so as to hold the client’s hand in a comfortable extended position, countering the tendency of spastic muscles in stroke survivors to contract and flex, but enable allow gripping and grasping motions when required. A diagram of this dynamic device can be seen in Figure 1.
The static orthotic device designed can be seen in Figure 2a and 2b . The device opposes the tendency for spastic muscles of stroke survivors to contract and flex. It does so through application of 3-point force systems at certain joints including that of the wrist, metacarpal-phalangeal, proximal and distal interphalangeal joints. These can be seen in the force diagrams of Figures 3a, 3b and 3c. Forces applied to the dorsal surface of the wrist and hand are done so by the suspending straps whereas forces to the palmar or volar surface of the hand are done so by the low temperature thermoplastic the device itself is made from.
| Figure 2a. Static orthotic device – sagittal medial view | Figure 2b. Static orthotic device – coronal superior view | Figure 3a. Force diagram – sagittal medial view | Figure 3b. Force diagram – transverse view | Figure 3c. Force diagram – coronal anterior view |
With regard to materials, the static orthotic device is to be made from low temperature thermoplastic to enable easy moulding and modification, thus creating a more custom fit to the client. The proximal trimline sits about 3cm away from the cubital fossa and elbow to avoid causing damage to the sensitive and allow comfortable flexion at the joint, respectively. Distally, the trimline ends at the distal end of the thumb for the thumb segment and distal to the longest digit of the lateral four digits. To secure the device to the client, Velcro straps are located as close as possible to the proximal trimline, at the wrist joint, over the area that is between the proximal and distal interphalangeal joints of the lateral four digits and over the interphalangeal joint of the thumb for the thumb segment.

## Manufacturing Process

Required materials: texta, flexible material (i.e. Chux), low temperature thermoplastic, shears, water, heat pan, scissors, Velcro adhesive eye pieces, Velcro non-adhesive hook pieces
* Using a texta, a basic template was drawn onto a flexible material – as the low temperature thermoplastic (LTT) is a flexible material, this gave indication as to whether the traced template was a suitable size to create the device for the client. See Figure 4.
* The flexible material was checked against the client to confirm the fit
* The template was then traced onto LTT and cut using shears
* In a heat pan, water was water heated and the cut LTT was placed into the pan to be heated. See Figure 5.
* The client was left hand and wrist were positioned accordingly, ready for moulding of LTT
* When the LTT became more flexible, it was removed from the heat pan and dried, to remove the excess water before moulding to the client
* It was checked if the LTT was too hot on client's skin before moulding it to their wrist and hand
* Once moulded, position was held until the LTT began to cool and hold shape on its own. See Figure 6.
* The device was then removed from the client and excess LTT was cut off. Reheating in the heat pan was done where necessary if the LTT was too hard to cut.
* Four adhesive eye Velcro pieces were cut with scissors - 1 for the volar surface of the thumb, 1 for the lateral 4 digits, 1 for the posterior surface of the wrist and 1 for the proximal trimline
* Four non-adhesive hook Velcro pieces were cut with scissors – each one long enough to meet the eye Velcro pieces circumferentially
* The adhesive eye Velcro pieces were attached to the appropriate areas. See Figure 7.
* The non-adhesive hook Velcro pieces were then attached to their counterparts
* Excess Velcro wasa trimmed off where needed
* The device was then fitted to the client and to ensure there was no discomfort.
The final device appeared as seen in Figure 8.
| Figure 4. Basic template for LTT on a flexible material | Figure 5. Heating of LTT in heat pan with hot water | Figure 6. Moulding of LTT to client with wrist and hand held in position | Figure 7. Attachment of adhesive eye pieces of Velcro | Figure 8. Final device on the left hand in coronal superior view, sagittal medial view, coronal posterior, sagittal lateral view, respectively |

## Critique of Fit

As outlined in the case scenario, the client is a male aged 46 who suffered a right brain stroke, rendering him left side hemiparetic. In addition to hemiparesis of his left side, the client also experiences spasticity in muscles of his left upper limb. Due to severe RA in his right upper limb causing discomfort when being used for long periods, the client is required to use his left upper limb to grip his walking aid and independently ambulate.
The client simply wishes to be able to independently ambulate short distances, for instance, around the house and to local stores from a closely parked vehicle. Thus the original dynamic device mentioned in the Design section was aimed to work in conjunction with the Botulinum toxin injection treatment the client already receives, and help him regain function of his left hand by countering the existing post-stroke spasticity.
Because the original dynamic device could not be manufactured due to the shortage of materials available, the secondary static resting/night orthotic device was then recommended instead. The secondary static device was still aimed to counter the client’s post-stroke spasticity however, was only to be worn in resting periods, including nighttime.
To counter the post-stroke spasticity in the client’s left upper limb, the static device as per suggestion in research by Lannin et al. (2003), as well as Seneviratne (2007), holds wrist and hand in comfortable extension. Also in accordance with Lannin et al. (2003), the client’s fingers are held in a semi-flexed position. This is hoped to prevent the spastic muscles of the mentioned areas from pulling the client’s upper limb into the contracted clawed position often seen in stroke survivors.
The device manufactured for the client using the above Manufacturing Process, is well suspended both proximally and distally due to the straps and the malleability of the LTT when heated. The LTT was easily moulded to the client when heated and hence conformed to the contours of the client’s wrist and hand, as seen in Figure 9. With regard to the positioning, the device holds the client’s fingers in the appropriate semi-flexed position however there is only slight extension of the wrist and hand (see Figure 10).
| Figure 9. Contouring within the static device | Figure 10. Wrist, hand and fingers positioned by static device |
If the static device were to be re-manufactured, the thumb piece would be adjusted when the LTT is heated up to ensure there is not excess plastic once the LTT cooled down (see Figure 11). The position of the thumb strap would thus be more appropriate and better hold the client’s thumb in place (see Figure 11).
Cosmetically, preventing the LTT from sticking to itself, would have ensured there were no rough areas within the device (see Figure 12). The rough area is both a cosmetic and health concern as the area appears uneven in comparison to the rest of the device and can also feel coarse against the client’s bare hands and can cause small scratches or abrasions. Also in relation to aspects that could cause discomfort for the client is the trimlines, while most of it is flared away from the client’s limb, proximally there are areas that could have been further smoothed to remove the jagged edges (see Figure 13).
The two proximal straps suspending the client’s forearm are well positioned (see Figure 14) however, the distal strap suspending the client’s medial four fingers can be positioned more proximal (see Figure 15) to better hold the fingers in place and distribute forces as per the 3-point force systems seen in the Design section.
| Figure 11. Static device with excess LTT at thumb piece and thumb piece strap positioning | Figure 12. Rough area on static device from LTT sticking to itself | Figure 13. Jagged edges on trimline | Figure 14. Proximal straps at the upper forearm and the wrist (left to right, respectively) | Figure 15. Distal strap at the hand |
As mentioned, the static device that was manufactured was a secondary design due to limitations of materials to manufacture the original dynamic device that was designed. The static device created was made so with the correct materials however, if the dynamic device were to be made instead, there is little difference between the two aside from trimline positions and the rigs that would be put in place. Should the dynamic device have been manufactured instead, it would as per Figure 1 have still been made with LTT contoured to the client, but would have trimlines proximal to the distal palmar crease and proximal to the interphalangeal joint of the thumb. The rigs attached to the dynamic device would have been made from a felt material and been attached with Velcro pieces on the client’s palm and suspended by clear fishing wire like cords (this can be seen in the design of Figure 1).

## Outcome Measures

Given the device’s trimlines and that it was prescribed as a static orthosis for rest periods, outcome measures were applied before and after use of the device over an extended amount of time. In addition to assessment of range of motion at the wrist and phalangeal joints before and after use of the device, it was decided that the Patient-Specific Functional Scale (PSFS) by Stratford, Gill, Westaway and Binkley (1995), would also be appropriate to obtain outcome measures. A sample of this can be found at the following link: http://www.worksafe.vic.gov.au/__data/assets/pdf_file/0019/10963/patient_specific.pdf
The PSFS by Stratford and colleagues (1995) consists of an initial assessment and several follow-up assessments depending on the amount of time the patient was cooperating with the associated health professional. In the initial assessment, the client selects certain activities they have difficulty accomplishing and subjectively scores these using the Patient-Specific Activity Scoring Scheme (PSASS) of 1-10 where 1 indicates an inability to perform the activity and 10 indicates the ability to perform the activity at the same level as before the injury. The total score is found by dividing the sum of the activity scores with the number of activities. The score can then be assessed using the scale given where an average score of difference 2 or more points demonstrates a significant change, and a single activity score difference of 3 or more, indicates a significant change.
In the initial assessment, it was found that the client had limited range of motion at his wrist and phalangeal joints – where the wrist and phalangeal joints were prone to adopt a flexed position. The client’s wrist extension capabilities were assessed in the initial assessment and in the follow-up session. Results from the initial assessment showed the client could only actively extend 20°, however assessment in the follow-up session showed the client was able to actively extend up to 65°. The increased difference in the client’s ability to extend at his wrist suggests treatment has had impact on the client’s functionality. It is however, difficult to differentiate whether the orthotic device alone created the difference or whether the Botulinum toxin injection treatment in conjunction with the physical therapy the client receives also had impact on his increased range of motion capabilities.
| Activity | Initial | Follow-up | Difference |
| Opening fist | 1 | 8 | 7 |
| Gripping walking aid | 2 | 8 | 6 |
| Cutting food | 1 | 7 | 6 |
| Opening jars | 3 | 6 | 3 |
| Donning and doffing of orthotic device | 6 | 8 | 2 |
| Average Scores | 2.6 | 7.4 | 4.8 |
Results from the PSFS also showed significant positive increases where tasks initially scored on the lower end of the PSASS were then scored at the higher end of the scale in the follow-up session. This can be seen in the table below.
With the exception of the fifth task – donning and doffing the orthotic device, the scoring differences indicate significant change in the client’s functionality levels. It should be noted however, that the opposite unaffected upper limb carries out most of the donning and doffing of the orthotic device. As mentioned earlier, it is also difficult to distinguish whether the use of the device alone has created the improvement in the client’s functionality or whether it was a combination of the client’s Botulinum toxin injection treatment, physical therapy as well as the use of the orthosis that produced the effect.

## Referral Letter

Addressed To:
Mrs. P. Handerson – Occupational Therapist, St Vincent's Community Rehabilitation Centre Northcote
92 Dennis Street, Northcote VIC, 3070
Dear Mrs. Handerson,
Firstly, thank you for accepting this client referral. I hope that by working together collaboratively, we can achieve positive treatment outcomes, improving QOL for the client.
The client, Mr. Justin Chen, is a 46y.o. male who suffered a right-brain hemorrhagic stroke 2/12 ago. Mr. Chen experiences RA in his sound right UL which causes severe pain and discomfort, rendering it difficult for him to grip his walking aid (a single point stick - SPS) to independently ambulate. Thus, other allied health professionals and I, are attempting to treat his spastic stroke-affected left upper limb with intention to allow simple grip and grasp motions. This will be useful in enabling Mr. Chen to hold his SPS and facilitate independent ambulation.
At the time of treatment commencement with me, Mr. Chen was undergoing Botulinum toxin injection treatment to control the spasticity in his left UL. Mr. Chen is currently still undergoing this treatment, however, your professional opinion as to whether this should continue will be valuable.
In addition to the Botulinum toxin injection treatment, Mr. Chen is also seeing a physiotherapist on a weekly basis to maintain ROM at his shoulder and elbow joint. From what I understand, there has been little done with regards to treatment of the wrist and hand, since Mr. Chen’s discharge from our care inpatient care at St. George’s Health Services in Kew.
With regards to treatment received from me, Mr. Chen has been prescribed with a custom resting/night static orthosis holding his wrist in slight comfortable extension, and hand and fingers in a slightly flexed position as per evidence in existing peer reviewed literature by Lannin and colleagues (2003, 2007). The device is to be worn in resting periods, as well as nighttime. Initially a dynamic orthotic device was to be made, and this remains the ideal treatment however due to limitations of materials available, the static device has been prescribed instead. It is hoped that when materials become available, a dynamic device can be manufactured for Mr. Chen to progress into.
At this point, I hope that with your expertise in hand therapy, you will be able to aid Mr. Chen in maintaining ROM and flexibility at joints of his wrist and hand. Your treatment, in conjunction with the Botulinum toxin treatment injections, physiotherapy and donning of the orthotic device, will hopefully enable grip and grasp motions to allow Mr. Chen to hold his SPS and facilitate independent ambulation.
I look forward to hearing your opinions and treatment plans.
Thank you and kind regards,
Ms. M.T. Ly,
Orthotist, St. George’s Health Services in Kew.

## Search Strategy

Most resources found were recent, relevant and provided valuable insight to the topics they addressed however, there were some resources found that were still relevant despite being published over a decade ago. It was also found that references noted within journal articles were a valuable source to draw information from and expand research as well as understanding of the topic. In some cases, certain journal articles found had promising abstracts outlining the topic interest but required payment for access, which limited information that may have been valuable to the case study.
Search Strategy Terms and Quantity of Results Retrieved
| Terms used | MedLine | CINAHL | Cochrane |
| Haemorrhagic and stroke and post-stroke | 38 | 11 | 8 |
| Splint* and stroke and spastic* | 19 | 35 | 13 |
| Orthos* and stroke and spastic* | 37 | 43 | 6 |
| Splint* and stroke and contracture | 7 | 14 | 10 |
| Orthos* and stroke and contracture | 10 | 6 | 1 |
| Cerebrovascular accident and orthos* | 15 | 6 | 10 |
| CVA and orthos* | 8 | 11 | 0 |
| Cerebrovascular accident and splint* | 2 | 0 | 4 |
| CVA and splint* | 1 | 1 | 0 |
'*' Indicates trunction to expand search results