Early Implementation of an Orthosis for the Hemiplegic Upper Extremity

PURPOSE: The wrist-hand orthosis is one of the most commonly used interventions to address stroke-induced upper-extremity deficits. Among the high-quality literature, the evidence on orthoses is conflicting. The majority of studies evaluated the impact of orthosis use to prevent contractures without regard for the proposed contracture timeline, early initiation within 3 wk (Malhotra, Pandyan, Rosewilliam, Roffe, & Hermens, 2011), and all the joints at high risk for contracture formation (fingers, wrist, elbow and shoulder). In this study we aim to assess the feasibility of a novel orthosis initiated early poststroke that includes the shoulder, elbow, wrist, and fingers for stroke-induced unilateral hemiplegia.

DESIGN: This study is a prospective feasibility study using a mixed-methods repeated-measure cohort design. Participants were ages 18–85 yr with acute stroke-induced hemiplegia of the upper extremity. Individuals were in Stage 1 of motor recovery according to the Chedoke–McMaster Stroke Assessment (the Chedoke).

METHOD: Enrolled participants were fitted with an orthosis that included the shoulder, elbow, wrist, and fingers. Targeted time frame for orthosis fabrication and implementation was 5 days poststroke and no later than 14 days. In the hospital, orthosis wear was 4 hr continuously daily and all night; following transfer to a rehabilitation center, the wear schedule was only at night. Outcomes of interest included goniometer measures of the shoulder, elbow, wrist, and fingers for range of motion, a visual analog scale (VAS) for pain, and the Chedoke for level of impairment. Each outcome measure was assessed at baseline and 1, 2, and 3 mo. For nonparametric data, a Wilcoxon signed-rank test assessed participants’ level of impairment according to the Chedoke and pain levels determined by the VAS. A related-samples t test was indicated for goniometric data to assess for contracture risk.

RESULTS: Eleven participants were recruited (enrollment fraction of 73% of those eligible). All participants tolerated the orthosis according to the wear schedule in the hospital. One participant was excluded secondary to not continuing to meet the study inclusion criteria. On average, the orthosis was applied within 8 days poststroke. Wilcoxon signed-rank tests revealed no significant difference in pain from baseline to 1 mo (Z = –.954, p = .340) and no significant difference in impairment of the hand (Z = –1.342, p = .180) and arm (Z = –1.414, p = .157) from baseline to 1 mo.

DISCUSSION: Due to the feasibility study design, the study was not powered to determine efficacy, as the goal was to assess feasibility of the protocol and orthosis to ensure the methodology is achievable in an acute care hospital setting. The intervention has been found to be feasible with strengths and limitations. We completed the 1-mo assessment with 100% of the participants. Participant retention after the 1-mo follow-up was difficult (3-mo retention = 40%), preventing further inferential analysis. We were unable to determine if the orthosis impacted participants’ contracture formation, upper-extremity function, or upper-extremity pain. A randomized controlled trial with a larger sample size is indicated to determine the efficacy of the innovative orthoses for stroke patients with hemiplegia.

IMPACT STATEMENT: Implications of this study are to address an identified gap in care and the literature for stroke patients, establish the standard of care for an occupational therapy poststroke program in the acute care setting, and improve functional outcomes for patients with a severe stroke.

References

Adrienne, C., & Mannigandan, C. (2011). Inpatient occupational therapists hand-splinting practice for clients with stroke: A cross-sectional survey from Ireland. Journal of Neurosciences in Rural Practice, 2, 141–149. https://doi.org/10.4103/0976-3147.83579

Lannin, N., Cusnick, A., McCluskey, A., & Herbert, R. (2006). Effects of splinting on wrist contracture after stroke: A randomized controlled trial. Stroke, 38, 111–116. https://doi.org/10.1161/01.STR.0000251722.77088.12

Malhotra, S., Pandyan, A. D., Rosewilliam, S., Roffe, C., & Hermens, H. (2011). Spasticity and contractures at the wrist after stroke: Time course of development and their association with functional recovery of the upper limb. Clinical Rehabilitation, 25, 184–191. https://doi.org/10.1177/0269215510381620

Pizzi, A., Carlucci, G., Falsini, C., Verdesca, S., & Grippo, A. (2005). Application of a volar static splint in poststroke spasticity of the upper limb. Archives of Physical Medicine and Rehabilitation, 86, 1855–1859. https://doi.org/10.1016/j.apmr.2005.03.032