Static splinting after stroke: are therapists overlooking the evidence?

Guest blogger Danny Minkow, who is studying for an MSc in Occupational Therapy, invites other students and therapists to consider the problem of continuing use of therapies which lack evidence to support them or have been shown to be ineffective, and explores this in relation to the current evidence for splinting and stretching as stroke rehabilitation interventions.

Occupational therapy as a field is striving to be known for being “science driven and evidence based”. I’m currently in my 3rd semester pursuing a Master of Science in Occupational Therapy at Brenau University and I feel proud to be in an OT program that answers this call. During my first semester, I took a course called Evidence Based Practice. Thanks to my exceptional instructors, I felt this was one of the most important courses I’ve ever taken in school…ever! Now that I’ve started my field work and I’m learning more about different interventions, I’ve made a habit of ‘asking for the evidence’. However, I’ve discovered that many common interventions have little or poor evidence to justify their widespread use. So I’d like to take this opportunity to reach out to other students and therapists, and to explore an example about arm and hand splinting and stretching for stroke rehabilitation. These interventions are still in use to prevent or treat contractures after stroke, but is there good evidence to support this practice?

So does splinting help with contractures?

old booksWhile there’s anecdotal evidence and a few older non-randomized studies that suggest stretching from static splinting is effective for preventing and treating contractures, when subjected to more rigorous testing, positive results simply have not materialized. For example, a randomized controlled trial (RCT) involving 63 post stroke patients studied the effects of either neutral static splint or extended static splint worn overnight for 4 weeks, as compared to a control group wearing no splint (Lannin, 2007). The study found that splinting the wrist in either the neutral or extended wrist position for 4 weeks did not reduce wrist contracture after stroke. Citing the above RCT, the Scottish Intercollegiate Guidelines Network (SIGN) guideline on stroke management and rehabilitation says that splinting is not recommended for improving upper limb function or for reducing spasticity in the wrist and finger flexors following stroke. Other medical stroke guidelines that were written before this study say that splinting should be “considered” while acknowledging that the evidence was poor.

A few years later, the same RCT was included in a Cochrane systematic review (Katalinic, 2010), along with 34 other studies, with 1,391 participants. This review went even further and investigated if stretching, whether it was administered from splints, manual stretching, or even positioning programs, help prevent or treated contractures caused by several neurological conditions (stroke, traumatic brain injury, spinal cord injury, and cerebral palsy) as well as non-neurological conditions.

The authors concluded that there is moderate to high quality evidence to show that there is little or no effect of stretching/splinting on joint mobility, if this treatment is used for up to seven months (no study explored the use of stretch for longer periods). The effects of stretch on quality of life and activity limitation haven’t been well investigated, but in the few studies where this was evaluated there was no benefit from stretching. Stretch did not decrease pain or spasticity and was found to cause an immediate increase in pain in people with neurological conditions.

Since the Cochrane review was published, we can add another RCT (Basaran, 2012). This time, in 2012, a group of 39 patients post-stroke were divided into dorsal splint, volar hand splint, and a control group (no splint). The results were in line with the Cochrane Review’s and again failed to demonstrate any clinically significant differences in spasticity or in wrist passive range of motion of both the volar and dorsal splint groups.

Ok, so what?

Well, despite this evidence, static hand splints are still used by occupational therapists (OTs) to treat patients post-stroke. In 2011, a fascinating cross-sectional survey of hand-splinting practice among inpatient OTs in Ireland examined the perceived hand splinting efficacy and splint prescription pattern after stroke (Adrienne, 2011). The study found almost two-thirds of the respondents, 38 (61.3%) out of 62 OTs surveyed, believe splinting to be effective or very effective for rehabilitation after a stroke. Now granted, that’s a relatively small study, but it seems that OTs perceive hand splints to be effective and continue to prescribe splints regularly to their clients, despite inadequate evidence to support their continued use. All this comes at a time when healthcare systems are trying to reduce their costs while improving patient care. Reducing the use of less efficient interventions would help lower costs and improve outcomes.

So what does this mean for therapists?

man with laptopI may have oversimplified the full picture of stretching and splinting for spasticity and contractures after stroke, as splints can be used for many reasons. It just seems that static splinting to prevent or treat contractures shouldn’t be one of these reasons.

The most important message here is that a treatment is in use which can be painful for patients and offer them no benefit in the short term, while the long-term effects are unknown. Similar examples can be found in other areas of healthcare too. It’s a reminder that we therapists must frequently review the best available evidence to see if it supports our interventions. Perhaps we are all at risk of falling into patterns of treatment that could even develop into a discipline’s “tradition” of practice. Sure, we could blame outdated medical guidelines based on much weaker evidence, but we shouldn’t be afraid to challenge health science’s guidelines or status quo with the best available evidence.

What do you think? Do you know of other widely used interventions that are not as effective as people believe? What can we do to encourage better use of available evidence?



Lannin, N. A., Cusick, A., McCluskey, A., & Herbert, R. D. (2007). Effects of Splinting on Wrist Contracture After Stroke A Randomized Controlled Trial. Stroke, 38(1), 111–116. doi:10.1161/01.STR.0000251722.77088.12

Katalinic OM, Harvey LA, Herbert RD, Moseley AM, Lannin NA, Schurr K. Stretch for the treatment and prevention of contractures. Cochrane Database of Systematic Reviews 2010, Issue 9. Art. No.: CD007455. DOI: 10.1002/14651858.CD007455.pub2.

Scottish Intercollegiate Guidelines Network (SIGN). Management of patients with stroke: rehabilitation, prevention and management of complications, and discharge planning. Edinburgh: SIGN; 2010. (SIGN publication no. 118). [cited June 2010]. Available from URL:

Basaran, A., Emre, U., Karadavut, K. I., Balbaloglu, O., & Bulmus, N. (2012). Hand splinting for poststroke spasticity: a randomized controlled trial. Topics in Stroke Rehabilitation, 19(4), 329–337. doi:10.1310/tsr1904-329

Adrienne, C., & Manigandan, 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(2), 141–149. doi:10.4103/0976-3147.83579

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Danny Minkow

About Danny Minkow

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Danny Minkow has a Masters of Science in Occupational Therapy from Brenau University. He is currently working as an Acute Care/ Inpatient OT at the Veterans Affairs Medical Center in Atlanta, Georgia. Danny is a veteran of U.S. Air Force and also has a History degree from The University of Florida. Danny has great interest in stroke research, the Cochrane Collaboration, and translating evidence based medicine into practice. Follow him on Twitter @DannyMinkow

12 Comments on this post

  1. It is always nice and healthy to think aboutour daily practice. Although many reviews do not show evidence based results regarding splinting , some studies shows improvement or maintenance of range of motion, normalization of muscular activity, comfort and better positioning during daily activities or sleep,according to the goals, design and wear regimens of the splint and how the clientes understand it’s value and meaning. Is ouro work to develop more high quality studies to show and validate this practice that has been used for so many therapists and a long ago.

    denise / Reply
  2. Hey Danny, thanks for your work. We can definitely all strive for more evidenced based daily interventions. We have seen some research in the past few years in the effectiveness of dynamic splinting post stroke, including much done with the saebo brand splints. Resting hand splints are often used post stroke for a flaccid extremity to try to prevent damage to the hand and give a chance for tone to recover. Having the splint may not improve function in that case but is preventing unintentional injury when used with positioning recommendations. Additionally, while active stretching can be painful, a splint should not be painful to wear. If it is, it shouldn’t be worn. Again, thanks for your research, it’s a part of good clinical reasoning!

    Cheryl / Reply
  3. Forty two years ago we focused on evidence in M.O.T. school and also in my high school and college biology classes. While it is very important to keep up with studies and evidence, ours is equally a field of art – the art of evaluating evidence as well as individuals. Also, I am concerned that many today see lack of evidence as proof it doesn’t work rather than need for more studies. I do not think today’s focus on the latest study, especially since most are so short and the average post stroke patient has many years of hygiene and function to deal with; so as in most good, double blind studies, this topic also sparks the need for longer term studies, comparison of different types of splints and wearing periods, level of severity, secondary effects such as protection, and predicting which clients will use it for longer . I agree with you that if the client is only to use if for a few months,, there is little benefit. Keep up your admirable concern for using the best procedures to give our clients their lives back.

    Sandra Otto / Reply
  4. Thanks for sharing. It is always nice to share recommendations you think may be helpful when putting down the established therapy. Thanks!

    Katie / Reply
  5. I am a physiotherapist with 15 years experience in treating stroke patients. Splinting is used by physiotherapists. I have found it not to be helpful and infact bad. Patients are happy to wear it because it can support positioning without spending much effort. It also reduces the workload for the therapist. Sadly, despite repeatedly proving that it is not beneficial, after so many years of existence of the profession haven’t we found better means to improve contracture than using splints and rest their hand and fingers in peace? Everywhere we see this. This shows how poorly we are trained in understanding biological system and/or we close our eyes and believe it is so. Over and above this those of us who claim it is beneficial cannot perform an RCT but tell ‘am seeing benefit’ so it is good and just write 4 lines claiming ineffective treatments to be so beneficial, art, tradition etc. We are happy in changing all aspects of our life as modern, but when it comes to patient care follow age old tradition, additionally creating wrong beliefs among patients that resting in peace will help in not worsening.
    Whole world is suffering because of lifestyle disorders and human body improves by being active. muscle length increases by being active.

    Vasanthan / Reply
    • So what do you prescribe for post stroke patients in a nursing home with limited resources

      COTA / (in reply to Vasanthan) Reply
      • The reason for looking at evidence is NOT to move with individual prescription. So, if some treatment starts to work, evidence will surface. Its important to keep looking for it. ‘it’ means the effect sizes with beneficial mcid from high quality RCT.

        Vasanthan / (in reply to COTA) Reply
  6. I have always use static splints post stroke, my aim is to for positioning, to prevent muscle, tendon and soft tissue shortening which may arise from prolong flexed wrist and digital joints as a result of stroke. From the evidence sampled in my practice it really helps, I also know that splinting will not help improve function, reduce spasticity but it can help reduce pain, maintain range of motion, comforts
    and positiom

    Alfred / Reply
  7. Some colleagues of mine and I were having a discussions similar to this topic just other day.
    We have a pt who one OT wrote a contracture prevention goal with the use of splints, however the pt remains flaccid, limited interaction and participation who we are able to position well without splinting, I feel at this time there is no need to add a device to both the pt’s daily routine or the nursing staff who would have to manage the splint.
    For contractures I do use some splinting to help optimize positioning for joint protection and especially in hands where the finger nails are digging into the palm to help prevent additional issues because of the contracture. Like any good treatment should be it depends on all the factors for the individual so sometimes I like the use of splints, sometimes I don’t. experience in the population you are working with definitely helps you look at evidence differently than just reading it from the journal. Research and efficacy are extremely important to help the pt with to best treatments but they need to be the best intervention for that person at that time also.

    Sara Jo / Reply
    • I also usually try to engage pt, in other ROM programs or functional activities to promote improved muscle function to restore what functional use I can prior to utilizing any splinting in the long term. I do like to use some UE splints as tools to help the pt progress, much like using reachers and sock aids and walkers as opposed to just placing a splint and that be the only thing addressing an issue

      Sara Jo / (in reply to Sara Jo) Reply
  8. I am a post-stroke patient. I no longer use the hand-wrist splint provided by the rehab hospital over 2 years ago. It is difficult to put on with one hand. It holds my thumb in an unnatural position and the metal edge irritates the side of my palm. HOWEVER, I am looking at devices to wear while sleeping to hold my fingers in a comfortable position, ease contracture, and especially prevent fingernails from digging into my palm. This seems to be an intermittent problem, but a little comfort would be nice.

    Teri Davis / Reply
  9. I am a 9.5 year post-stroke patient and I disagree with this article. I have always worn a splint at night only and my husband does stretches for me about 4 times a week. While I have never regained movement, my hand has gone from a fist so tight that my nails dug into my palm and it could only be opened with a great deal of work to a hand that rests either in a very loose fist to mostly opened and relaxed. This has helped improve my actual quality of life because; 1, it is so much more comfortable and 2, since I can close it but not open it, being looser allows me to do things like get it around smaller jars to hold them so I can open or hold them. So, even though it is mostly paralyzed, I can still make use of it to a useful degree…it also allows me to have it do things such as hold a handle on a bowl while using a hand mixer with my other hand and folding clothes. In being able to use it for these things has allowed me to regain some strength in it as well. I will never give up my nighttime splinting because I know first hand how much it helps. It may not seem like much to an OT but as a patient, I know I would not be nearly as productive. That being said, there is a big difference in hand splints…most do not work at all because the spasticity pulls the hand right out of the straps. I think every patient is different and what works for one may not work for the other because the level of spasticity varies so much. The other options they gave me were botox and muscle relaxers. I won’t ever try botox(poison) and for a while tried muscle relaxers which worked great for the first month and then they kept increasing the dose to the point of addiction(which they never told me that it was addictive) and it never worked well after that first month anyway. A study this short proves absolutely nothing.

    deb / Reply

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