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?
While there’s anecdotal evidence and a few older A non-randomised study is any quantitative study estimating the effectiveness of an intervention (harm or benefit) that does not use randomisation to allocate people to comparison groups. 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 A trial in which the people taking part are randomly divided into groups. A group (the intervention group) is given the intervention being tested (for example a drug, surgery, or exercise) and compared with a group which does not receive the intervention (the control group). (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 An investigation of a healthcare problem. There are different types of studies used to answer research questions, for example randomised controlled trials or observational studies. 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 An investigation of a healthcare problem. There are different types of studies used to answer research questions, for example randomised controlled trials or observational studies. 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 In systematic reviews we search for and summarize studies that answer a specific research question (e.g. is paracetamol effective and safe for treating back pain?). The studies are identified, assessed, and summarized by using a systematic and predefined approach. They inform recommendations for healthcare and research. (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 Something done with the aim of improving health or relieving suffering. For example, medicines, surgery, psychological and physical therapies, diet and exercise changes. is used for up to seven months (no An investigation of a healthcare problem. There are different types of studies used to answer research questions, for example randomised controlled trials or observational studies. 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 Clinical significance is the practical importance of an effect (e.g. a reduction in symptoms); whether it has a real genuine, palpable, noticeable effect on daily life. It is not the same as statistical significance. For instance, showing that a drug lowered the heart rate by an average of 1 beat per minute would not be clinically significant, as it is unlikely to be a big enough effect to be important to patients and healthcare providers. 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 The extent to which an intervention (for example a drug, surgery, or exercise), produces a beneficial result under ideal conditions. and splint prescription pattern after stroke (Adrienne, 2011). The An investigation of a healthcare problem. There are different types of studies used to answer research questions, for example randomised controlled trials or observational studies. 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 An investigation of a healthcare problem. There are different types of studies used to answer research questions, for example randomised controlled trials or observational studies., 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 are measures of health (for example quality of life, pain, blood sugar levels) that can be used to assess the effectiveness and safety of a treatment or other intervention (for example a drug, surgery, or exercise). In research, the outcomes considered most important are ‘primary outcomes’ and those considered less important are ‘secondary outcomes’..
So what does this mean for therapists?
I 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 Something done with the aim of improving health or relieving suffering. For example, medicines, surgery, psychological and physical therapies, diet and exercise changes. 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 A way of expressing the chance of an event taking place, expressed as the number of events divided by the total number of observations or people. It can be stated as ‘the chance of falling were one in four’ (1/4 = 25%). This measure is good no matter the incidence of events i.e. common or infrequent. of falling into patterns of Something done with the aim of improving health or relieving suffering. For example, medicines, surgery, psychological and physical therapies, diet and exercise changes. 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 In systematic reviews we search for and summarize studies that answer a specific research question (e.g. is paracetamol effective and safe for treating back pain?). The studies are identified, assessed, and summarized by using a systematic and predefined approach. They inform recommendations for healthcare and research. 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: http://www.sign.ac.uk/guidelines/fulltext/118/index.html
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