resting splint research splint provision charlie laver

1c J Mellson,A Hammond, C Laver 2010

Resting Splint Survey:

NW COTSS-Rheumatology

Group

Jo Mellson1, Alison Hammond1 Charlie Laver2

Centre for Health, Sport & Rehabilitation Research, University of Salford1

ICATS, Pennine MSK Partnership2

2

Background

Agenda item at NW COTSS (April 2009)

to discuss: Midline or pronation? Benefits

of pressure gloves?

Survey questions submitted by members

to include in survey

Decision by the group to investigate current

practice due to unclear evidence base


Aim of the study

Investigate current practice amongst COT-SS Rheumatology OT members related to provision of NRS in RA:

rationale for splint provision in early and established RA;

differing splint designs used and rationale for these;

wearing regimens recommended ;

patient instructions regarding splint wear and care;

methods used by OTs to assess for splint provision and evaluate effectiveness;

and rationale for use of compression gloves as an alternative to RS.


MethodPotential content generated at COTSS-R meeting;

additional items submitted; literature.review

Draft questionnaire v 1 developed

Reviewed at COTSS-R meeting;

additional items recommended

Draft questionnaire v 2

Reviewed by COTSS-R members; revisions recommended

Final version

University ethics approval

E-mailed/ mailed to 35 NW Rheumatology OTs


Analysis

Quantitative:

– descriptive medians and inter-quartile ranges

Qualitative:

– content analysis (Burnard 1991)

– Thematic analysis or

– Frequency counts (as applicable).


Questionnaire: six sections

1. Resting splint provision

2. Resting splint design

3. Wearing regimens and splint instructions

4. Splint evaluation

5. Compression gloves

6. Final comments


Response Rate

24/ 35 OTs replied (69%)

79% of respondents made splints

Respondents (n=19)

Majority of sample Band 7 OT’s

Years splinting experience: 14.95 (SD

8.09)

Years experience in Rheumatology: 14.00

(SD 8.42)


Resting Splint (RS)

service provisionEarly RA:

13/19 when stable on DMARDs

On average 25% of patients receive RS (IQR 10-35%)

On average 3 splints provided per month (IQR 1-5)

Established RA

On average 22.5% of patients receive RS (IQR 13.75-32.50%)

On average 3 splints provided per month (IQR 2-5.25)


Importance of RS aims in early and established

rheumatoid arthritis (median: IQR) (n=19).

1=low; 5 = high importance Early RA

(< 2 years)

Established

RA(> 2 years)

Decrease pain at night 5 (5-5) 5 (5-5)

Rest/ immobilise weakened joint structures

to decrease local inflammation

5 (4-5) 5 (4-5)

Correctly position joints in which

deformities have already begun to develop

4 (2-5) 4 (3-5)

Minimise joint contractures 3 (2-4) 4 (3-4)

Minimise risk of deformity development (eg

MCPJ subluxation)

3 (2-4) 3 (2-4)

Decrease pain during the day 3 (2-4) 3 (1-3)

Increase joint stability 2 (1-4) 2 (1-4)

Improve hand function during the day 2 (1-3) 2 (1-3)


Symptoms/issues influencing decision to provide NRS in early

and established rheumatoid arthritis (n=19).

1=low; 5 = high importance Early RA

(< 2 years)

Established

RA(> 2 years)

High levels of night pain 5 (5-5) 5 (5-5)

“Clawing” or strong finger flexion at night 5 (5-5) 5 (5-5)

Maintaining a comfortable hand position at

night/ at rest

5 (4-5) 5 (4-5)

Joint swelling 4 (3-5) 4 (3-5)

Joint changes (eg early deformity

development)

4 (3-5) 4 (3-4)

At patient request as had splint previously 3 (3-5) 4 (3-5)

High levels of day pain 3 (2-4) 3 (2-4)

Presence of pins and needles 3 (2-3) 3 (2-3)

Early morning stiffness in the hands 2 (1-4) 3 (1-4)

Limited range of movement 2 (1-3) 2 (1-3)


Symptoms/ problems assessedFree text responses: Total

assessing (n)

Standardised

method eg (n)

Pain 12 10 (VAS)

Range of movement 11 4 (goniometer )

Joint swelling 9 4 (ring sizer, tape

measure)

Impact of hand problems (on ADL, work or

leisure)

8 4

Sensation 8 0

Hand function 7 5 (DASH)

Grip/pinch strength 7 5 (Jamar, bulb

dynamometer)

Deformities 6 0

Patient’s attitudes to splints 4 0

Skin colour/ changes 3 0

Hand chart/assessment sheet 4

Stiffness; hand dominance; sleep disturbance 2


Reasons for non-prescription of RS

1. Psychological: (15/19)

2. Physical

3. Practical

4. Cognitive impairment

5. Recent medication changes/

steroid injections

14

Splint patterns: 2. thumbs up 8/136/13 used both designs (1 & 2)

16

Example pattern 1 splints:

pronation


Resting splint positioning7 splinted in one position only; 12 used a 2nd

position at times:

Wrist position (n):

Pronation

Midline

Between pro /mid

8

10

1

Wrist extension ° (median (IQR) 20 (15-25)

MCPJ flexion (median (IQR) 40 (30 – 46.25)

PIPJ flexion (median (IQR) 20 (11.5 – 30)

DIPJ flexion (median (IQR) 5 (0 – 11.25)

Thumb position:

Palmar abduction (n)

Extension/radial abduction (n)

Between abduction/ extension (n)

10

4

5


Rationale for positioning

“Functional / Resting position”

Comfortable mid-range

Not pulling more on extensors or flexors

Well-tolerated

Promotes sleep in fatigued patients

Minimises stress on joints and structures

Protects structures and minimises

deformity.

19

Splint material

20

Splint Straps


Short-term splint evaluationNo. Time

(weeks)

Duration

(minutes)

Face to face 14 2(IQR 2– 3.25)

20(IQR 13.5– 27.5)

Telephone 6 2(IQR 2-3)

5(IQR 5-12.5)

None 2


Long-term splint evaluation

10 = long-term review at some stage when

saw patients

Only 4 did regular review (eg annual

review)

9 conducted no long-term review

All 19 asked patients to contact them if

any problems with splint


Time and cost of RSOn average it takes 45 minutes (SD 17.32) to:

assess for, make, fit and give instructions in correct resting splint wear and precautions, excluding teaching hand exercises.

Cost of OT time average Band 7@£32/hr (PSSRU figures 2009): £24

Cost per patient of 1 splint + exercise + short-term review = 75 minutes = £40

Splint costs: average cost £29 per splint

Total cost of providing splint + exercises = £69

resting splint research splint provision charlie laver

Health & Medicine