Effect of Hand Splinting: Isn’t Temporality Crucial?

Incidence, Time Course and Predictors of Impairments Relating to Caring for the Profoundly Affected arm After Stroke: A Systematic Review

BACKGROUND AND PURPOSE

A significant number of stroke survivors will not recover the use of their affected arm. A proportion will experience pain, stiffness and difficulty with basic care activities. The purpose of the review was to identify predictors of difficulty caring for the profoundly affected arm and establish the incidence and time-course of the related impairments of pain, spasticity and contracture.

METHOD

Data sources: Databases (PubMED, MEDLINE, AMED, EMBASE, CINAHL and the Cochrane Controlled Trials Register) were searched from inception to December 2013. Additional studies were identified from citation tracking.

REVIEW METHODS

Independent reviewers used pre-defined criteria to identify eligible studies. Quality assessment and risk of bias were assessed using the McMasters Assessment Tool. A narrative evidence synthesis was performed.

RESULTS

Thirty-nine articles reporting 34 studies were included. No studies formally measured difficulty caring for the arm, but related impairments were common. Incidence of spasticity in those with weakness ranged from 33% to 78%, shoulder pain affected 22% to 90% and contracture was present in at least 50%. Spasticity and pain appear within 1 week of stroke, and contracture within two weeks. Impairments continued to develop over at least 3-6 months. The most frequent predictors of spasticity and contracture were weakness and reduced motor control, and the risk of pain is most commonly predicted by reduced sensation, shoulder subluxation, weakness and stroke severity.

DISCUSSION

There is no published evidence on predicting the likelihood of difficulty caring for the arm following stroke. However, the related impairments of spasticity, pain and contracture are common. Given the time-course of development, clinicians may need not only to intervene early but also be prepared to act over a longer time period. Further research is needed to examine difficulty caring for the arm and the relationship with associated impairments to enable researchers and clinicians to develop targeted interventions. © 2015 The Authors. Physiotheraphy Research International Published by John Wiley & Sons Ltd.

Inpatient occupational therapists hand-splinting practice for clients with stroke: A cross-sectional survey from Ireland

Introduction:

Hand splinting after stroke is a common practice despite inadequate evidence. This warrants a better understanding of the therapists’ splinting practice, to develop clinically meaningful treatment options.

Aims:

The study examined the nature and prevalence of the factors associated with therapists’ hand splinting practice and their perceived splinting efficacy.

Settings and Design:

A cross-sectional national survey of hand-splinting practice among inpatient occupational therapists (OTs) in Ireland.

Materials and Methods:

Sixty-two therapists participated in this national survey.

Statistical analysis used

A number of factors were analyzed to explore their relationship with therapists’ perception of splint efficacy using Spearman's rank order correlation.

Results:

53(85.5%) out of 62 survey respondents prescribed splints to their clients at the time of taking the survey. To reduce spasticity, to correct contractures and thus increase range of motion (ROM) were the commonly used splinting goals. These were the goals that were significantly associated with the therapists’ splinting efficacy too.

Conclusions:

Hand-splint prescription following stroke was found to be a common practice among OTs who perceive splints to be quite effective. A custom-made, volar forearm-based wrist-hand splint is the preferred splint among therapists to achieve a number of clinical aims such as improving ROM, stretching soft tissue contractures and reducing spasticity in the upper extremity. A wide variety of splinting regimens is currently practiced, reflecting the lack of a universally accepted and comprehensive practice guideline to regulate therapy. Methodologically valid clinical trials evaluating the efficacy of therapist-preferred splints in achieving their favored outcomes are needed. Development of common, universally accepted therapeutic guidelines based on comprehensive scientific review of such studies is thus needed.

[Immunomodulation by inducing tolerance to E-selectin and adult neurogenesis after stroke]

Neuroblasts in the subventricular zone proliferate markedly after stroke, and migrate to the site of injury along with blood vessels. However, a large fraction of stroke-generated neuroblasts die shortly after being born, because of local inflammation. E-selectin is specifically expressed on endothelial cells, but only when the endothelium activates. Since endothelial activation occurs after stroke, E-selectin can serve as an immunologic tolerization antigen that can focus immunomodulation to regions of the vascular tree. Intranasal instillation of recombinant E-selectin will induce mucosal tolerance to that antigen with the generation of E-selectin-specific regulatory T cells (Tregs). Tregs may protect newly-generated neuroblasts from ischemic damage through 'bystander suppression' in which immunomodulatory cytokines such as TGF-β and IL-10 are released locally. In this series of experiments, we have shown that after E-selectin tolerization in permanent middle cerebral artery occlusion (pMCAO) rats Tregs transmigrate to the peri-infarct region of ischemic brain, TNF expression in the local neurovascular niche is reduced, and the survival of newly generated neuroblasts or neurons in the peri-infarct region is increased. Under these conditions, an improvement in sensorimotor function after pMCAO also occurs. E-selectin-specific Tregs can modulate the efficacy of adult neurogenesis after ischemia and promote repair after brain injury.