Elastic Wrist Orthoses

Transcription

1 Elastic Wrist Orthoses Reduction of Pain and Increase in Grip Force for Women with Rheumatoid Arthritis Lrlla Nordenskiold The aim of this study was to investigate effects of elastic wrist orthoses on pain, grip strength, and function. Twenty-two women with seropositive rheumatoid arthritis [mean age, 53 years) registered their pain on a visual analogue scale both with and without orthosis on the wrist of the dominant hand in three standardized activities of daily living (ADL) situations. Grip force at onset of pain was measured on an electronic instrument (Grippit) with three different grips. Pain was decreased by 39%, 42%, and 52% when using an orthosis in the three ADL situations. Anecdotally, the women noted that the splints provided support and decreased pain both in home, at work, and during leisure activities. Orthoses improved grip force at onset of pain by 26%, 22%, and 29 /o. All subjects showed reduced strength /20 /0-250/0) when compared to grip strength in a group of women without rheumatoid arthritis. INTRODUCTION Wrist pain and instability are common problems for people with rheumatoid arthritis (RA). Swanson estimated that 65% of the rheumatic wrists have roentgenographic evidence of arthritis changes [ 11. Clini- This study was supported by grants from the National Association against Rheumatism, Sweden; the Swedish Association of Clccupational Therapists; LIC Ortopedi, Stockholm, Sweden; and the Swedish Medical Research Council (project G Grimby). Ulla Nordenskiold is Head Occupational Therapist at the Departments of Occupational Therapy and Rehabilitation Medicine, Sahlgrenska Hospital, Goteborg, Sweden Address correspondence to Ulla Nordenskiold, Department of Occupational Therapy, Bruna Straket 1, Sahlgrenska Hospital, s Goteborg, Sweden. 158 cally, pain and loss in range of motion from associakd synovitis are present in an even greater percentage. Involvement may be seen early in the course of the disease in the radiocarpal, intercarpal, or radioulnar joints [I]. A coinmon occupational therapy intervention for these problems has been the use of wrist orthoses and assistive devices. The use of these treatment modalities is widespread, although there are few studies on their effectiveness. Feinberg and Brandt followed 50 patients with RA who were fitted with full bilateral wrist and hand resting splints and found that 62% were generally compliant. However, decreased pain was reported by only 25% of the compliant group. No major differences in improved range of motion or stiffness were found between either group [2]. Anderson and Maas tested the hypothesis that splinting would increase grip strength [3]. Ninety-two female subjects with RA were randomly assigned to one of five groups: (I) no splint, (2) a dorsal working splint, (3) a palmar working splint, (4) a gauntlet working splint, or (5) a ready-made fabric splint. No differences in grip strength were found among the five groups for either the dominant or the nondominant hand. Musur studied the influence of wrist stabilization on strength and stated that stabilization with the help of an elastic bandage increases the finger muscle strength to a much greater extent than when plaster is used [4]. This article reports on a study that examined the Submjtted for publication February 15, 1989; accepted July 18, by the Arthritis Health Professions Association /90/$3.50

2 Arthritis Care and Research Elastic Wrist Orthoses 159 Figure 1. Two types of prefabricated elastic wrist orthoses: Camp (Halsingborg, Sweden), with larger thumb opening; and Kehband (Stockholm, Sweden), with more material on the dorsal side. Figure 2. GRIPPIT, the electronic instrument with two extensions for measuring of grip strength (AB Datektor, Goteborg, Sweden). It is equipped with a force transducer and an elbow rest. effects of elastic wrist orthoses on pain, grip strength, and function. METHODS AND MATERIALS Selection of Subjects Twenty-two randomly selected women with seropositive RA, American Rheumatism Association (ARA) functional classes 11 and 111 [5], were recruited from the Rheumatologic Outpatient Clinic at Sahlgrenska Hospital, Goteborg, Sweden. Ages ranged from 30 to 65 years (mean, 53 years). Duration of illness was from 1 to 33 years (mean, 11 years). Subjects were taking only nonsteroidal antiinflammatory drugs (NSAID] and had not received local steroids in the previous 14 days. Eighty-two women without RA, age ranges from 23 to 65 years (mean, 40 years], were selected as a control group. Assessment Procedures Two types of soft volar wrist orthoses were used {Figure 1). Each is made of an elastic fabric with a preshaped aluminum strip on the volar side, holding the wrist in a neutral position. The orthoses were applied so as to immobilize the wrist while allowing full mobility of the metacarpophalangeal (MCP], proximal interphalangeal (PIP], and the distal interphalanged (DIP) joints and the carpometacarpal (CMC) joint of the thumb. The volar support in the palm did not exceed the distal palmar crease [6]. Pain during activities of daily living (ADL) was measured using a 100-mm visual analogue scale (VAS) (where 0 = no pain and 100 = maximum pain 171. Measurements were made before and after application of the splint. In addition, pain was recorded immediately following the completion of three standardized ADL situations: (a) setting a breakfast table for two people (standing and walking], (b) filling a glass with milk from a full carton (sitting], and (c) vacuuming a floor without a rug for 3 min with one hand (walking). The activities were performed using the dominant hand first without an orthosis and then repeated using an orthosis. All subjects were right-hand dominant. Grip force was measured by a newly designed electronic instrument, Grippit (AB TABLE 1 Average Pain Experienced (0-100-mm scale) During Activities of Daily Living Without and With Wrist Orthosis In = 22) Pain Pain Without With a Wrist a Wrist Pain Orthosis Orthosis Difference Setting tireak fast table (20.6) (15.9) (9.21 Filling a glass of milk (26.81 (17.4) (13.8) Vacuuming for min (29.7) (27.4) (16.71 a Data are means with standard deviations in parentheses. P <

3 160 Nordenskiold Vol. 3, No. 3, September 1990 Figure 3. The perceived pain using visual analogue scale without and with an orthosis in three ADL situations. Each mark on the x axis represents each test person. The upper line marks the pain level without orthosis; the lower line marks the pain level with orthosis. The grey field represents the pain relief with the orthosis. were interviewed with standardized questions to assess the effectiveness of the wrist orthoses in home, at work, and during leisure activities. Detektor, Goteborg, Sweden), which measures forces from 0 to 996 N. This device graphically records force exerted by the fingers and palm when the hand is clasped around an elliptical handle (Figure 2*). All measurements were made when pain was first perceived, in order to measure the applicable force without further increasing the pain for the RA subjects. Three type of grips were measured: (a) small grip, which included the MCP, PIP, and DIP joints and all finger flexor muscles; (b) medium grip including all three joints, with less flexion of the MCP joints and the effect of the intrinsic muscles partly eliminated; and (c) large grip involving primarily the two distal joints and the long finger muscles. All subjects were tested while seated with the arm resting on a table. The elbow was flexed 100. Each hand was tested with the three different-sized grip handles. The RA patient group was tested with and without the orthosis. Additionally, the RA patients * For more information about the device pictured in Figure 2, contact the author. Statistical Analyses Pain differences between the ADL test solution without and with orthoses and differences between the grip force without and with orthoses for the RA group were analyzed by Fishers nonparametric permutation test for paired observations [8]. Results of differences between the RA group and the control group were analyzed using the Mann-Whitney I/ test. RESULTS Pain was significantly reduced when the three ADL tasks were performed while the patients wore the splint (Table 1). Pain was reduced by 39% when setting a table, by 42% when filling a glass, and by 52% when vacuuming for 3 min (Figure 3). During the interviews, patients frequently commented that they were less tense when wearing the orthoses. They noted that the splints provided support and decreased pain when the patients performed the following tasks: handling a frying pan, ironing, picking up children, shopping, driving, biking, reading, doing handicrafts, and,gardening. The 14 women who were employed outside their homes reported that activities such typing and handling files and folders were easier with the orthoses. Splints created problems during activities such as doing laundry, dish washing, window washing, skiing, and sailing. Only one

4 Arthritis Care and Research Elastic Wrist Orthoses 161 TABLE 2 TABLE 3 Mean Grip Strength (in N) for Right and Left Hand at Onset of Pain (Standard Deviation in Parentheses) for Women Without RA (Control Group) and for Women With RA Right hand Left hand a P <: Control Group RA Women (n = 82) (n = 22) (62.4) (59.6) (56.2) (57.0) (61.8) (54.4) 70.3' (58.5) (59.8) 64,5a (41.8) 63.7a (49.1) 69.1a (45.5) 62.Sa (32.9) Mean Grip Strength (in N) Without and With Wrist Orthasis at Onset of Pain (Standard Deviation in Parentheses) (n = 22) Right hand Left hand a P < P < P < Without With Orthosis Orthosis Difference 70.3 (58.5) 79.5 (59.8) 64.5 (41.8) 63.7 (49.2) 69.7 (45.6) 62.5 (33.0) 79.4 (49.5) 87.5 (52.9) 78.2 (41.2) 80.0 (47.4) 86.6 (51.7) 72.7 (33.1) 9.0a (14.3) 8.0b (15.7) 13.7' (10.9) 16.3' (14.2) 16.9' (20.5) 10.2c (11.3) woman commented on the negative cosmetic appearance of the splints. The grip strength at the onset of pain for the RA group was -20%-25% of grip strength in the control group (Table 2). When the RA women wore the orthoses, force was increased significantly for all three grip sizes measured in both the right and the left hands (Table 3). The application of wrist splints improved the grip force at onset of pain by 22%-29% in the right hand and by 24Y0-29Y0 in the left hand. The increased grip force did, however, not approximate that of the control group. DISCUSSION These data suggest that application of elastic wrist splints reduces pain during three ADL and also improves grip force at pain onset. These results are consistent with those of Musur [4]. Interestingly, the force at the onset of pain measured with the three sizes of grips (that is, the small, medium, and large) was similar among the RA subjects while a much wider difference was noted among the control group. For example, the control group had 24% less strength with the large grip than with the grip in the right hand' The RA subjects had only 9% less force with the smallversusthe large grip in the right hand. A contributing factor may be the point at which measurements were taken. For the subjects with RA, force was measured at the onset of pain synonymous with maximum strength for people with EM? This question warrants additional study. Another contributing factor is the involvement of the MCP joints in RA. Synovitis, swelling and instability of the joints restrict full gripping ability. Anecdotally, it is interesting to note that without the orthosis six subjects (27%) had to stop vacuuming for 3 min due to pain and that with a wrist orthosis they could complete the task (four with much reduced pain and two with maximum pain). The number of subjects experiencing no pain increased from one without the orthosis to four with the orthosis. The remaining had some degree of pain when performing the activity both with and without the orthosis (Figure 3). In order to further reduce pain and increase the ADL ability in rheumatic people, continued studies should be performed as to the effect of splintiing regimes and provision of assistive devices in actual ADL situations. Nevertheless, the present study suggests that the use of elastic wrist splints by women with RA may assist them in achieving their daily tasks easier and with less pain. The author warmly thanks the 22 women with RA who participated in the practical tasks, as well as to Profs. Gunnar Grimby and Erik Moberg and Dr. Kate Lorig for helpful discussions. The author also thanks Engineers Carl-Axel Wannerskog and Lars-Erik

5 162 Nordenskiold Vol. 3, No. 3, September 1990 Imsson for their cooperation with t.he construction of the grip strength instrument and Viktor Nordenskiold for the illustrations. REFERENCES 1. Swanson A: Pathomechanics of deformities in hand and wrist, Chapter 44. In Hunter JM (ed): Rehabilitation of the Hand. St Louis, CV Mosby, Feinberg J, Brandt KD: Use of resting splints by patients with rheumatoid arthritis. Am J Occup Ther 35: , 198'1 3. Anderson K, Maas F: Immediate effect of working splints in grip strength of arthritis patients. Aust Occup Ther J 34:26-31, Musur M: Methods of assessment and management of the rheumatoid hand at the Institute of Rheumatology, Warsaw, Poland. In Hunter JM, Schneider LH, Mackin EJ, Callahan AD (eds): Rehabilitation of the Hand, 2nd ed. St Louis, CV Mosby, Steinbrocker 0, Traeger CH, Batterman RC: Therapeutic criteria in rheumatoid arthritis. JAMA 140: , Moberg E, Hagerth CG, Nordenskiold U, Svens B, Traneus M: Splinting in Hand Therapy. New York, George Thieme, Huskisson EC: Measurement of pain. Lancet >! , Bradley JV: Distribution: Free Statistical Tests. Englewood, NJ, Prentice-Hall, 1968, pp 76-78