Alternative splinting approach for proximal interphalangeal joint flexion contractures: no-profile static-progressive splinting and cylinder splint combo

A prospective randomised comparative study of dynamic, static progressive and serial static proximal interphalangeal joint extension orthoses

Introduction

Many different types of proximal interphalangeal (PIP) joint extension orthoses exist, yet evidence guiding orthosis choice is largely theoretical. The primary aim of this study was to evaluate the clinical effectiveness of three different PIP joint extension orthoses, over 4 weeks of treatment. Secondly, we aimed to explore the relationship between an abbreviated version of the Weeks test (WT) assessment of joint stiffness, and treatment outcome. Lastly, we wished to better understand participants' satisfaction with orthotic treatment.

Methods

Using a randomised comparative study design, 61 participants were allocated to a serial static, dynamic or static progressive orthosis, 50 had follow-up data. Blinded assessment of function was completed before and after 4 weeks of orthotic intervention and a standardised therapy program. Participants were blinded to alternative groups.

Results

Baseline active PIP extension ranged from 14° to 65°. The average improvement in active PIP extension was -9.1° (95% CI -11.0°, -7.1°). There were no statistically significant differences in outcome between the three orthoses groups. However, a trend was observed with greater improvement in active extension for those in the dynamic Capener (-11.5°) compared to the static progressive belly gutter (-7.3°) or serial cast (-8.7°) groups, with less total end range time required. The abbreviated WT was significantly associated with improvement in active extension (p = 0.001). Participants reported a high degree of satisfaction with their orthosis regardless of type.

Conclusions

No single orthosis demonstrated statistically greater effectiveness, although the dynamic Capener orthosis appeared more efficient. The abbreviated WT is associated with treatment outcome.

Efficacy of orthotic devices for increased active proximal interphalangeal extension joint range of motion: A systematic review

STUDY DESIGN

Systematic review.

INTRODUCTION/PURPOSE OF THE STUDY

To determine the efficacy of orthotic devices for increased active proximal interphalangeal (PIP) joint range of motion and optimal wearing schedule of the devices to guide clinical practice. The secondary purpose is to capture the outcome measures used by the authors. The final purpose was to determine if recent studies addressed patient satisfaction and adherence in the orthotic management of a PIP joint injury.

METHODS

A comprehensive literature search was conducted using the search terms splint, orthotic device, hand orthotic, brace, proximal interphalangeal joint, occupational therapy, and physical therapy using PubMed, CINAHL, MEDLINE, and ProQuest. The following data were extracted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines: background statement, objectives, data sources, study eligibility criteria, participants, and interventions, study appraisal and synthesis methods, results, limitations, conclusions, and implications of key findings.

RESULTS

Best results were achieved when the PIP orthoses were worn for a longer duration especially for the treatment of extension deficits.

DISCUSSION

Studies that provided a wearing schedule of a minimum of 6 hours obtained the greatest improvements in extension deficits of the PIP joint.

CONCLUSION

Recommended orthotic dosage to treat PIP joint injury is at least 6 hours a day for 8-17 weeks.

Orthotic management of fixed flexion deformity of the proximal interphalangeal joint following traumatic injury: A systematic review

Background/objective

Fixed flexion deformity of the proximal interphalangeal joint can commonly occur following a traumatic injury impacting on hand function and occupational performance. Numerous interventions have been proposed for fixed flexion deformity resolution. This paper investigates the efficacy of static or dynamic orthoses in reducing fixed flexion deformity contracture following traumatic proximal interphalangeal joint injury.

Methods

A multi-database search of three databases (CINAHL, EMBASE, MEDLINE) was conducted. Data extracted for each study were design, patient descriptions, degree of fixed flexion deformity pre- and post-orthoses, and prescribed interventions and exercise programmes.

Results

The search yielded 643 studies, of which eight met the inclusion criteria. Studies used heterogeneous methodologies investigating various orthotic interventions. Meta-analysis or pooling of results was not possible. Dissimilar orthotic wear regimes were noted in all studies and an alternative clinical significance outcome was found.

Conclusion

More research is required to support clinical reasoning in orthotic choice for fixed flexion deformity of the proximal interphalangeal joint post-traumatic injury.

Isoforce: A new outrigger system for static progressive orthotic interventions of the proximal interphalangeal joint with constant force transmission-Results of a biomechanical study

STUDY DESIGN

Bench research-biomechanical study.

INTRODUCTION

Static progressive orthotic devices are efficient in treating contractures. However, current outriggers are unable to keep force transmission and the force application angle (FAA) constant.

PURPOSE OF THE STUDY

To evaluate the biomechanical performance of the Isoforce outrigger, a novel extension orthosis.

METHODS

A hand model was used to measure the required force at the outrigger and FAA, while simulating resolution of different contracture angles. We also tested feasibility in a small patient series.

RESULTS

The force required with the Isoforce device never exceeded 2.4 N, and the FAA did not change more than 6°. Corresponding figures for the reference devices exceeded 16 N and 20°. The 7 patients testing the Isoforce extension device showed an extension deficit that decreased from 40° at baseline to 25° at 6 weeks. They rated the device as very comfortable to wear.

CONCLUSIONS

Isoforce maintains constant force transmission and FAA throughout the full range of motion, promotes the lengthening of contracted structures, and is comfortable to wear.

LEVEL OF EVIDENCE

Not applicable.

Effects of serial casting in the treatment of flexion contractures of proximal interphalangeal joints in patients with rheumatoid arthritis and juvenile idiopathic arthritis: A retrospective study

AIM

To analyze the effects of serial casting (SC) in the treatment of proximal interphalangeal (PIP) joint flexion contractures in patients with rheumatoid arthritis and juvenile idiopathic arthritis.

STUDY DESIGN

Retrospective case-series.

METHODS

The data of 18 patients treated with SC were obtained from their patient records. The angular changes in the finger joints were analyzed and compared statistically using t-tests.

RESULTS

A total of 49 fingers were serially casted with plaster of Paris over a 14-year period. The SC resulted in significant (26.8°; p < 0.001) reduction in the PIP joint extension loss. Small, but statistically significant, losses in flexion were associated with these gains. (p < 0.001). Angular changes were also observed in the other finger joints. The magnitude of the initial extension loss was the only factor to explain the amount of motion gained (p < 0.001; R2 = 0.38).

CONCLUSION

SC is an effective method to correct flexion contractures in PIP joints in selected patients with arthritis. The gain is partially related to the magnitude of initial extension loss.

Extension orthoses and the stiff proximal interphalangeal joint following hand trauma: A review of current clinical practice in the Australian context

Introduction

Extension orthoses are frequently prescribed by hand therapists to treat fixed flexion deformity of the proximal interphalangeal joint. A wide variety of proximal interphalangeal joint extension orthoses exist, but there is limited research evidence to guide implementation in clinical practice. Consequently, effective management of fixed flexion deformity of the PIP joint remains a challenge.

Method

An electronic survey was distributed to members of the Australian Hand Therapy Association. The survey included two case scenarios, (including a fixed flexion deformity of 30° and 55°) and participants were asked to identify their preferred orthosis for each case. Responses to closed questions were analyzed descriptively. Thematic analysis for open-ended questions was completed by two experienced hand therapists.

Results

One hundred ninety-five therapists completed the electronic survey. Handmade capener (21.7%), pre-fabricated capener (22.2%), and static finger troughs (21.1%) were the preferred orthoses for treatment of contractures of 30°. Serial casts (60.9%) were the preferred choice for a contracture of 55°. Key themes influencing choice of orthosis reflected an evidence-based practice approach to clinical reasoning that combined use of available evidence with therapists’ experience and the needs of the patient. Therapists’ interpretation and application of research differed according to their unique situation.

Conclusion

Orthotic prescription is a multifaceted process that combines therapists’ interpretation of evidence with their experience and the needs of the patient. Further research is needed to evaluate and clarify current theories that are used to guide intervention.

Experiences with pins and rubber band traction in the treatment of proximal interphalangeal joint contracture

BACKGROUND

Proximal interphalangeal joint (PIPJ) contracture is a difficult problem to treat regardless of etiology. Although numerous interventions have been recommended, published results are mediocre at best.

OBJECTIVE

The authors describe their experience and results of using a modification of pins and rubber band traction (PRBT) - applying a dynamic extension apparatus to a contracted PIPJ using the constant traction force in a stretched rubber (elastic) band.

METHOD

A retrospective review of patients treated with this method was performed, and the results are presented. The technique itself is described, and clinical photographs illustrate the method.

RESULTS

Mean PIPJ flexion contracture before PRBT was 82° (range 60° to 110°). The full correction of eight contracted PIPJs in seven patients was achieved, in a mean of 17.8 days (range 14 to 31 days). At one month postremoval of PRBT, the mean PIPJ flexion contracture was 22.8° (range 0° to 46°).

DISCUSSION

The method is compared with previously described methods of PIPJ contracture correction, whether surgical or splinting; the latter may be static, dynamic or a combination of the two. The results of previously published studies are discussed and compared with the method described.

CONCLUSION

The present method is a powerful and effective simplification of a previously described method of correcting PIPJ contractures. This technique is simple, 'low-tech' and can be applied under local anesthetic; the authors believe it offers a useful adjunct to surgical release.

Experiences with pins and rubber band traction in the treatment of proximal interphalangeal joint contracture

Background

Proximal interphalangeal joint (PIPJ) contracture is a difficult problem to treat regardless of etiology. Although numerous interventions have been recommended, published results are mediocre at best.

Objective

The authors describe their experience and results of using a modification of pins and rubber band traction (PRBT) – applying a dynamic extension apparatus to a contracted PIPJ using the constant traction force in a stretched rubber (elastic) band.

Method

A retrospective review of patients treated with this method was performed, and the results are presented. The technique itself is described, and clinical photographs illustrate the method.

Results

Mean PIPJ flexion contracture before PRBT was 82° (range 60° to 110°). The full correction of eight contracted PIPJs in seven patients was achieved, in a mean of 17.8 days (range 14 to 31 days). At one month postremoval of PRBT, the mean PIPJ flexion contracture was 22.8° (range 0° to 46°).

Discussion

The method is compared with previously described methods of PIPJ contracture correction, whether surgical or splinting; the latter may be static, dynamic or a combination of the two. The results of previously published studies are discussed and compared with the method described.

Conclusion

The present method is a powerful and effective simplification of a previously described method of correcting PIPJ contractures. This technique is simple, ‘low-tech’ and can be applied under local anesthetic; the authors believe it offers a useful adjunct to surgical release.

Treatment of proximal interphalangeal joint flexion contracture: combined static and dynamic orthotic intervention compared with other therapy intervention: a randomized controlled trial

PURPOSE

To test the effectiveness of static and dynamic orthoses using them as an exclusive treatment for proximal interphalangeal (PIP) joint flexion contracture compared with other hand therapy conservative treatments described in the literature.

METHODS

60 patients who used orthoses were compared with a control group that received other hand therapy treatments. Clinical assessments were measured before the experiment and 3 months after and included active PIP joint extension and function.

RESULTS

A significant improvement in the extension active range of motion at the PIP joint in the second measurement was found in both groups, but it was significantly greater in the experimental group. Improvement in function (Disabilities of the Arm, Shoulder, and Hand score) between the first and second assessment was similar in the control and experimental groups.

CONCLUSIONS

Using night progressive static and daily dynamic orthoses as an exclusive treatment during the proliferative phase led to significant improvements in the PIP joint active extension, but the improvement did not correlate with increased function as perceived by the patient.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic I.

Management of the stiff finger: evidence and outcomes

The term "stiff finger" refers to a reduction in the range of motion in the finger. Prevention of stiff fingers by judicious mobilization of the joints is prudent to avoid more complicated treatment after established stiffness occurs. Static progressive and dynamic splints are considered effective non-operative interventions to treat stiff fingers. Capsulotomy and collateral ligament release and other soft tissue release of the MCP and PIP joint are also discussed in this article. Future outcomes research is vital to assessing the effectiveness of these surgical procedures and guiding postoperative treatments.

Effectiveness of bracing in the treatment of nonosseous restriction of elbow mobility: a systematic review and meta-analysis of 13 studies

BACKGROUND

Restriction of elbow mobility is a very frequent complaint after trauma or surgery. The objective of this study was to assess and compare the effectiveness of dynamic, static, or static-progressive bracing in patients with elbow stiffness of traumatic or postoperative origin and without evidence of ossification. For the purpose of this study, effectiveness was measured as the increase in total range of motion, as well as extension and flexion.

MATERIALS AND METHODS

We performed a systematic search of the keywords "elbow AND (stiffness OR stiff) AND (brace OR splint OR conservative)" in the online databases PubMed, EMBASE, CINAHL (Cumulative Index to Nursing and Allied Health Literature), and the Cochrane Library. We included all clinical studies using dynamic or static bracing in patients with elbow stiffness. Eligible outcomes were changes in total range of motion, flexion, and extension; sustainability of results; and complications.

RESULTS

We included 13 eligible studies, providing data on 14 treated groups in 247 patients. The mean age of these patients was 34.5 ± 10.4 years, and female patients comprised 46% ± 12%. The mean duration from the incident to the start of brace treatment was 6.9 ± 5.1 months. The mean improvement in range of motion during the course of treatment was 38.4° ± 8.9° (95% confidence interval, 39.5°-41.8°).

CONCLUSIONS

The current evidence strongly supports the use of static-progressive stretching 3 times 30 minutes per day in each direction as a first line of treatment in patients with post-traumatic and postsurgical elbow stiffness. If this treatment fails or if reasons for stiffness other than soft-tissue incompliance are identified, further surgical interventions should be considered.

A novel splint for proximal interphalangeal joint contractures: a case report

Proximal interphalangeal (PIP) joint contractures are notoriously difficult to treat. Best results are obtained with early mobilization and splinting, though a high level of adherence is critical for a good outcome. A new roll-on splint that aims to increase motion with minimal difficulty was used. The patient described here with moderate PIP joint contractures (30°-60°) was treated successfully using this splint. The splint design and therapy protocol are described. The patient was treated for 12 weeks with good adherence to therapy and splinting. Total active motion increased by 87% in the index finger and 108% in the ring finger. Grip, pinch, and tip-pinch strengths increased. The Disabilities of the Arm, Shoulder and Hand score improved from 26.7% to 2.5%. At 3 months, the patient returned to work. Though this case illustrates some of the advantages and disadvantages of the new splint, further study is necessary to evaluate the splint and compare it with other existing forms of treatment for PIP joint contractures.