Systematic Review of Orthoses for Stroke-Induced Upper-Extremity Deficits

PURPOSE: Between 2010 and 2030, it is projected that the cost of stroke care will increase a staggering 238%, and by 2030, an estimated 3.88% of the U.S. population age >18 yr (approximately 12 million people) will have had a stroke (Ovbiagele et al., 2013). Considering the anticipated future cost and number of stroke patients, there is an urgent need in stroke rehabilitation to ensure that our interventions are reliable, valid, and effective. To further this aim, we are conducting a systematic review of the evidence surrounding use of orthoses in stroke-related upper-extremity (UE) deficits. One of the most commonly used therapeutic interventions for stroke rehabilitation is the orthosis. Currently, there are no universal guidelines to determine initiation, duration, or type of orthosis for stroke patients.

DESIGN AND METHOD: This study is a systematic review. Medical librarians searched MEDLINE, EMBASE, CINAHL, Cochrane Database of Systematic Reviews, Cochrane Controlled Trials Register, Health Technology Assessment Database, Physiotherapy Evidence Database, and OTseeker using subject headings and key words related to UEs, splints, and stroke. Before the medical librarians performed the literature search, the authors published the systematic review protocol on Prospero, an international prospective register of systematic reviews, to prospectively establish methodology with the goal of minimizing bias and offering transparency. The systematic review team included three master’s-level occupational therapy students and two practicing occupational therapists. Covidence software (Melbourne, Australia) was used to screen all the article titles and abstracts.

Inclusion criteria were as follows: (1) English text available; (2) obtained from a peer-reviewed journal; (3) Level I, II, or III evidence as defined by the American Occupational Therapy Association (Tomlin & Borgetto, 2011), and (4) static UE orthosis. A static UE orthosis was defined in the systematic review protocol as a removable device that immobilizes the joints for therapeutic means by applying a prolonged, static stretch to the muscles. Seventeen articles met the inclusion criteria and were appraised using a data extraction form and the MacDermid (1996) quality appraisal scale. Both quality assessment measures, the MacDermid and data extraction form, were practiced with the three occupational therapy students to establish competency and reliability. The piloting process entailed reading three peer-reviewed articles, rating the articles using the MacDermid scale, and completing the data extraction form. Less than 10% variance was achieved in the MacDermid quality appraisal scale to ensure interrater reliability. IBM SPSS Statistics was used to analyze descriptive statistics obtained from the MacDermid ratings and the data extraction form. Effect sizes were calculated for studies with similar dependent variables and were reported for dependent variables found to be significant.

RESULTS: Mean score for the MacDermid (out of 48) was 31.29 (range = 17–43). Wrist flexion, extension, and passive range of motion exhibited medium effect sizes, with more pronounced improvements than the visual analog scale for pain, Fugl–Meyer Assessment, and Motor Assessment Scale.

CONCLUSION: Future studies should aim to use consistent outcome measures while exploring variability in orthosis type and application.

IMPACT STATEMENT: Implications of this study will be to identify gaps in the literature surrounding the use of static upper-extremity orthoses for adults poststroke. As a commonly used therapeutic intervention for stroke rehabilitation in occupational therapy, the research surrounding the efficacy of this intervention must be evaluated.

References

MacDermid, J. C. (1996). Development of a scale for patient rating of wrist pain and disability. Journal of Hand Therapy, 9, 178–183. https://doi.org/10.1016/S0894-1130(96)80076

Ovbiagele, B., Goldstein, L. B., Higashida, R. T., Howard, V. J., Johnston, S. C., Khavjou, O. A., . . . Trogdon, J. G. (2013). Forecasting the future of stroke in the United States: A policy statement from the American Heart Association and American Stroke Association. Stroke, 44, 2361–2375. https://doi.org/10.1161/STR.0b013e31829734f2

Tomlin, G., & Borgetto, B. (2011). Research Pyramid: A new evidence-based practice model for occupational therapy. American Journal of Occupational Therapy, 65, 189–196. https://doi.org/10.5014/ajot.2011.000828