Sarah E. Collier, Julie Jepsen Thomas

Transcription

1 Range of Motion at the Wrist: A Comparison Study of Four Wrist Extension Orthoses and the Free Hand Sarah E. Collier, Julie Jepsen Thomas KEY WORDS hand occupational therapy (treatment) wrist splint OBJECTIVE. This study compared the total wrist range of motion permitted by four different styles of wrist extension orthoses and the free hand. METHOD. Using a repeated-measures, counterbalanced design, 40 healthy female volunteers 20 to 39 years of age shot a basketball while free handed and while wearing each of four wrist extension orthoses: AlignRite; Rolyan D-Ring Long; Rolyan D-Ring Short; and a custom-made, thumb hole design orthosis. The motion at the wrist was measured by an electrogoniometer. RESULTS. No significant differences were found in total wrist motion permitted among the four orthotic conditions. Analyses revealed that the custom-made orthosis allowed significantly less palmar flexion and significantly more dorsiflexion than the three commercially available orthoses. All orthoses significantly restricted wrist movement compared with the free hand. CONCLUSION. The commercially available wrist extension orthoses offered little difference in the amount of restriction they provided. The custom orthosis restricted movement to a different portion of the available range than did the commercial orthoses. Future research should examine how different strapping techniques on custom-made orthoses affect total range of motion permitted at the wrist. Knowledge of patterns of restriction among various styles of orthoses will help therapists to select the most appropriate orthosis for a client s individual needs. Collier, S. E., & Thomas, J. J. (2002). Range of motion at the wrist: A comparison study of four wrist extension orthoses and the free hand. American Journal of Occupational Therapy, 56, Sarah E. Collier, MOT, OTR/L, is Occupational Therapist, Kennedy Donovan Center, New Bedford, Massachusetts. Julie Jepsen Thomas, PhD, OTR/L, FAOTA, is Professor and Chair, Department of Occupational Therapy, School of Allied Health, Medical College of Ohio, 3015 Arlington Avenue, Toledo, Ohio ; jthomas@mco.edu. Occupational therapy plays a major role in the evaluation and treatment of persons with hand and wrist conditions (Linden & Trombly, 1995). Treatment for many problems, such as rheumatoid arthritis, radial nerve deficits, wrist instability, and carpal tunnel syndrome may involve wrist extension orthoses to support or restrict certain movements. The specific goals for orthotic use include preventing deformities, protecting tissues as they heal, and relieving pain during inflammation or after injury (Fess & Kiel, 1998; Kjeken, Moller, & Kvien, 1995; Linden & Trombly, 1995). Clients are most concerned with the loss of function in their daily occupations when given an orthosis to wear (Jansen, Olson, & Hasson, 1997) because mobility and function of the upper extremity may be negatively affected. Studies of wrist extension orthoses have investigated effects on hand speed, hand function, finger dexterity, grip strength, and pain reduction (Biddulph, 1981; Carlson & Trombly, 1983; Nordenskiold, 1990; Pagnotta, Baron, & Korner-Bitensky, 1998; Stern, 1991, 1996; Stern, Sines, & Teague, 1994; Stern, Ytterberg, Krug, & Mahowald, 1996; Stern, Ytterberg, Krug, Mullin, & Mahowald, 1996). Recent studies have focused on muscle recruitment when wearing a wrist extension orthosis (Bulthaup, Cipriani, & Thomas, 1999; Jansen et al., 1997). The amount of physical immobilization or range of motion that occurs with different orthoses has not been studied extensively. Knowledge of degree of immobilization will help therapists to select the proper orthotic for the 180 March/April 2002, Volume 56, Number 2

2 type of condition being treated. Currently, therapists must rely on personal experience when judging the amount of wrist movement that occurs when wearing wrist extension orthoses. The purpose of this study was to compare the wrist range of motion allowed among four different styles of wrist extension orthoses and the free hand. Only Carlson and Trombly (1983) have documented the wrist range of motion allowed by an orthosis. During the most taxing of the Jebsen Hand Function subtests (Jebsen, Taylor, Trieschmann, Trotter, & Howard, 1969), participants used, on average, less than 10 of motion with the orthosis compared with 45 while free handed. Many daily occupations require more extreme wrist movement than occurs during the Jebsen subtests (Ryu, Cooney, Askew, An, & Chao, 1991). In the present study, participants were asked to shoot basketballs, an occupation that requires extreme ranges of wrist dorsiflexion and palmar flexion. Based on findings from Carlson and Trombly, our hypotheses were that (a) total wrist movement, dorsiflexion, and palmar flexion will be less when wearing an orthosis than when free handed and (b) no difference in the amount of total wrist movement, palmar flexion, and dorsiflexion among the orthoses will exist. Method Design The study used a repeated-measures, counterbalanced design. Participants experienced all conditions in one of five orders, thus acting as their own controls. Participants The Institutional Review Board approved the study, and participants gave informed consent before data collection. The participants were a convenience sample of 40 women recruited through printed and verbal announcements at college campuses in northwest Ohio. They were between 20 and 39 years of age (M = 23.9 years, SD = 3.9). Women within a restricted age range were included to decrease the variability associated with gender and effects of aging. Participants were self-reported as right-hand dominant and free from upper-extremity dysfunction. Apparatus and Instruments A Penny and Giles Biometrics Limited Goniometer XM65 1 (electrogoniometer) was used to measure wrist movement. The manufacturer reports test retest reliability to be within 1 and ± 1.5 over 90 from neutral. Before testing each 1 Penny and Giles Biometrics Ltd., Unit 25, Nine Mile Point Industrial Estate, Cwmfelinfach Gwent NP1 7HZ, United Kingdom. participant, the electrogoniometer was calibrated according to manufacturer instructions. Participants wore each of four styles of wrist extension orthoses manufactured by Smith, Nephew & Rolyan 2 (see Figure 1) during the study conditions. The Rolyan D-Ring, in short and long lengths, is made of a 9.5 mm polyester cotton foam covered with nylon tricot. They have hook-and-loop straps and an adjustable aluminum wrist support bar. The long style extends approximately one half and the short style one third of the length of the forearm. The AlignRite wrist orthosis is made of woven cotton-coated rubber fabric with an adjustable aluminum wrist support bar and a wrap-around wrist strap. The researcher measured participants dominant right wrists and metacarpals according to the manufacturers instructions and adjusted the metal stays in each commercial orthosis to position the wrist in 15 to 30 of dorsiflexion. The fourth orthosis was a custom-made Rolyan Thumb Hole wrist extension orthosis. This orthosis was formed from precut patterns of Aquaplast-T (also manufactured by Smith, Nephew & Rolyan) to fit participants right wrists and position the wrist in 15 to 30 of dorsiflexion (Stern, 1991). One-inch-wide hook-and-loop straps were positioned across the dorsum of the hand and just proximal to the ulnar styloid process. A 1 1/2-in.-wide strap was placed at the proximal end of the orthosis as directed by the manufacturer. Each participant shot an official, intermediate-sized basketball into a Huffy ProSport basketball hoop. 3 The hoop was positioned 4 ft above the floor and 6 ft away from the participant. Procedure Participants were randomly assigned to one of five order groups. They donned and adjusted the proper orthosis for the counterbalanced order. The researcher attached the electrogoniometer to the orthosis (or the free hand) with double-sided tape over the third metacarpal and in midline of the dorsal forearm (Carlson & Trombly, 1983). The participants stood on a designated mark on the floor and shot the basketball three times during each orthotic condition (see Figure 2). Participants rested between conditions while the computer was reset and the orthoses were changed for the next condition. Data Analysis The electrogoniometer interfaced with a 200 MHz Gateway Pentium P5-200 desktop computer. 4 Data were 2 Smith, Nephew & Rolyan, Inc., One Quality Drive, PO Box 1005, Germantown, Wisconsin Huffy Sports, N53 W24700, S Corporate Circle, Sussex, Wisconsin Gateway, The American Journal of Occupational Therapy 181

3 Figure 1. Wrist extension orthoses (clockwise from upper left): Rolyan Thumb Hole Wrist Extension, Rolyan D-Ring Long, Rolyan D-Ring Short, Rolyan AlignRite. sampled at 60 Hz for 10 sec per trial with a KPCMCIA- 16At analogue-to-digital acquisition card 5 with Testpoint version 3.2B 6 data acquisition software. The data were smoothed through digital signal processing and a 5-point window (Oppenheim & Schafer, 1975). Data reduction involved identifying the maximum degrees of dorsiflexion and palmar flexion for each trial. The maximum degrees for dorsiflexion for the three trials in each condition were averaged. The same process was done for palmar flexion. The total range of motion was calculated as the difference between the mean amounts of palmar flexion and dorsiflexion for each participant in each condition. The means for dorsiflexion, palmar flexion, and total range of motion were not skewed and were used for all further analyses. Data were analyzed with the Statistical Package for the Social Sciences (SPSS) for Windows version 9.0 (SPSS, 1999). A one-way analysis of variance (ANOVA) found no order effects; therefore, data were combined for each of the five orthotic conditions. Descriptive statistics included mean, standard deviation, minimum, maximum, and range (degrees). Repeated-measures ANOVAs for unbalanced groups were performed at the.05 alpha level with Tukey s honestly significant difference (HSD) post hoc comparisons of the differences in the range of movement provided by orthotic conditions. Because of technical difficulties with the electrogoniometers, trials for 3 participants were not included in the analyses. The omitted trials included one participant s trials of the free hand, another s trials for the custom orthosis, and a third s trials for the Rolyan D-Ring Short orthosis. Results Tables 1 through 3 present the descriptive statistics. The repeated-measures ANOVAs for total range of motion, F(4, 5 Keithly Instruments, Inc., Aurora Road, Cleveland, Ohio Capital Equipment Corp, 900 Middlesex Turnpike, Building 2, Billerica, Massachusetts Figure 2. Participant shooting the basketball while wearing Rolyan D-Ring Long orthosis with electrogoniometer attached. 144) = 331.1, p <.01; palmar flexion F(4, 144) = 160.0, p <.01; and dorsiflexion, F(4, 144) = 270.8, p <.01, revealed overall significant differences between conditions. Tukey s HSD post hoc analyses showed that the free hand condition permitted significantly more total motion than the orthotic conditions but no differences in total motion permitted among the orthotic conditions (see Table 1). Post hoc analyses also revealed that the custom-made orthosis permitted significantly less palmar flexion (see Table 2) and significantly more dorsiflexion (see Table 3) than the three commercial orthoses. Discussion This study compared the range of wrist movement in three commercially available orthoses, a custom-fabricated orthosis, and the free hand while shooting basketballs. As hypothesized, and consistent with Carlson and Trombly s (1983) results, the free hand allowed significantly more mean total movement than each of the four orthoses (98 vs. < 30 ), suggesting that the orthoses accomplish the intended purpose of limiting movement at the wrist joint. We also hypothesized that no difference would be found in the amount of palmar flexion permitted among Table 1. Descriptive Statistics in Degrees for Total Range of Motion in Each Condition Maximum Minimum Total Total Condition n M SD Motion Motion AlignRite Rolyan D-Ring Long Rolyan D-Ring Short Custom Free Hand March/April 2002, Volume 56, Number 2

4 Table 2. Descriptive Statistics in Degrees for Palmar Flexion Component of Movement in Each Condition Extreme of Condition n M SD Palmar Flexion AlignRite a Rolyan D-Ring Long a Rolyan D-Ring Short Custom a Free Hand a These orthoses prevented palmar flexion; therefore, the wrist remained in dorsiflexion by the mean number of degrees indicated. the different orthoses. While moving toward palmar flexion, the three commercial orthoses, on average, allowed the wrist to reach approximately the neutral position, whereas the custom-fabricated orthosis held the wrist, on average, in 14 of dorsiflexion, which was significantly less palmar flexion than the commercial orthoses. With regard to dorsiflexion, the three commercial orthoses did not differ in the average amount of movement permitted (26 31 ). The custom-made orthosis permitted significantly more mean dorsiflexion than the three commercial orthoses (40 ). These findings suggest that the custom-made orthosis is optimal for wrist conditions where palmar flexion should be restricted. On the other hand, the custom-made orthosis permitted significantly more dorsiflexion than the other three orthoses. The strapping configuration recommended by the manufacturer may not provide enough restriction to hold the palm against the orthosis when the extremes of dorsiflexion are used during occupations. If a high degree of restriction of wrist movement is desired, the therapist may need to augment strapping, adjust strap placement, or choose a more restrictive orthotic design. The literature regarding strapping on custom orthoses is inconsistent. The manufacturer and other sources (Fess & Philips, 1987; Lohman, 1996; Wilton, 1997) suggest that strapping be placed proximal to the ulnar styloid process to prevent irritation of the bony prominence. Other sources suggest that a wrist strap positioned too proximally is inefficient and provides inadequate joint control (Malick, 1985; McKee & Morgan, 1998; Schultz-Johnson, 1992). The results of this study suggest that straps positioned according to the manufacturer s instructions, with a strap over the dorsum of the hand and another proximal to the wrist joint, allow the hand to move away from the orthosis, especially into dorsiflexion. Table 3. Descriptive Statistics in Degrees for Dorsiflexion Component of Movement in Each Condition Extreme of Condition n M SD Dorsiflexion AlignRite Rolyan D-Ring Long Rolyan D-Ring Short Custom Free Hand Previous studies have investigated the functional aspects of wearing wrist extension orthoses. The results of this study as well as past research findings regarding grip, dexterity, and comfort can help therapists select an orthosis. This study found little difference in the amount of motion commercial orthoses permit; however, previous research has determined that the Rolyan D-Ring is more comfortable and permits grip strength and hand function similar to the free hand (Stern et al., 1994; Stern, Ytterberg, Krug, Mullin et al., 1996). In addition, the current study found that the length of the Rolyan D-Ring orthoses did not appear to offer more or less wrist immobilization. This study only considered the movements of wrist palmar flexion and dorsiflexion, excluding radial and ulnar deviation that are also important in wrist function. The electrogoniometers had to be attached on top of the orthoses; therefore, measurements may not be indicative of actual wrist movement allowed inside the orthoses. However, the electrogoniometer was placed uniformly among participants and conditions. Variability in the resting position of each orthosis may have been a source of error; however, the same researcher fabricated and fitted all orthoses, and every effort was made to be consistent in measuring wrist angles. The findings are applicable to situations where orthoses are fit according to the manufacturer instructions as they were for this study. This study suggests that placement of straps proximal to the wrist joint on a custom-made orthosis may affect the amount of motion permitted, and a study investigating the effect of different strap configurations is warranted. Conclusion This study compared the range of motion permitted at the wrist by four styles of wrist extension orthoses and the free hand. The orthoses provide significant restriction in wrist movement compared with the free hand. The commercially available wrist extension orthoses offered little difference in the amount of wrist movement they permit, but the custom-made orthosis allowed significantly less palmar flexion and significantly more dorsiflexion than the commercially available orthoses. Because similar amounts of movement are permitted by commercial orthoses, the decision to use a particular orthosis may depend on other factors discussed in the literature, such as hand function, finger dexterity, grip strength, and comfort and client preference. Acknowledgments We thank Martin Rice, PhD, OTR/L, for assistance with the electrogoniometers and Smith, Nephew & Rolyan, Inc., The American Journal of Occupational Therapy 183

5 for providing the orthoses used in the study. This study was completed in partial fulfillment of the first author s requirements for the master of occupational therapy degree. References Biddulph, S. L. (1981). The effect of the Futuro wrist brace in painful conditions of the wrist. South African Medical Journal, 60, Bulthaup, S., Cipriani, D. J., III, & Thomas, J. J. (1999). An electromyography study of wrist extension orthoses and upperextremity function. American Journal of Occupational Therapy, 53, Carlson, J. D., & Trombly, C. A. (1983). The effect of wrist immobilization on performance of the Jebsen Hand Function Test. American Journal of Occupational Therapy, 37, Fess, E. E., & Kiel, J. H. (1998). Neuromuscular treatment: Upper extremity splinting. In M. E. Neistadt & E. B. Crepeau (Eds.), Willard & Spackman s occupational therapy (9th ed., pp ). Philadelphia: Lippincott-Raven. Fess, E. E., & Philips, C. A. (1987). Hand splinting: Principles and methods. St. Louis, MO: Mosby. Jansen, C. W. S., Olson, S. L., & Hasson, S. M. (1997). The effect of use of a wrist orthosis during functional activities on surface electromyography of the wrist extensors in normal subjects. Journal of Hand Therapy, 10, Jebsen, R. H., Taylor, N., Trieschmann, R. B., Trotter, M. J., & Howard, L. A. (1969). An objective and standardized test of hand function. Archives of Physical Medicine and Rehabilitation, 50, Kjeken, I., Moller, G., & Kvien, T. K. (1995). Use of commercially produced elastic wrist orthoses in chronic arthritis: A controlled study. Arthritis Care and Research, 8, Linden, C. A., & Trombly, C. A. (1995). Orthoses: Kinds and purposes. In C. A. Trombly (Ed.), Occupational therapy for physical dysfunction (4th ed., pp ). Baltimore: Williams & Wilkins. Lohman, H. (1996). Wrist cock-up splints (wrist immobilization splints). In B. M. Coppard & H. Lohman (Eds.), Introduction to splinting: A critical-thinking and problem-solving approach (pp ). St. Louis, MO: Mosby. Malick, M. H. (1985). Manual on static hand splinting: New materials and techniques (5th ed.). Pittsburgh,PA: AREN. McKee, P., & Morgan, L. (1998). Orthotics in rehabilitation: Splinting the hand and body (pp ). Philadelphia: F. A. Davis. Nordenskiold, U. (1990). Elastic wrist orthoses: Reduction of pain and increase in grip force for women with rheumatoid arthritis. Arthritis Care and Research, 3, Oppenheim, A. V., & Schafer, R. W. (1975). Digital signal processing. Englewood Cliffs, NJ: Prentice Hall. Pagnotta, A., Baron, M., & Korner-Bitensky, N. (1998). The effect of a static wrist orthosis on hand function in individuals with rheumatoid arthritis. Journal of Rheumatology, 25, Ryu, J., Cooney, W. P., Askew, L. J., An, K.-N., & Chao, E. Y. S. (1991). Functional ranges of motion of the wrist joint. Journal of Hand Surgery, 16A, Schultz-Johnson, K. (1992). Splinting: A problem-solving approach. In B. G. Stanley & S. M. Tribuzi, (Eds.), Concepts in hand rehabilitation (pp ). Philadelphia: F. A. Davis. SPSS, Inc. (1999). SPSS for Windows [Computer software]. Chicago: Author. Stern, E. B. (1991). Wrist extensor orthoses: Dexterity and grip strength across four styles. American Journal of Occupational Therapy, 45, Stern, E. B. (1996). Grip strength and finger dexterity across five styles of commercial wrist orthoses. American Journal of Occupational Therapy, 50, Stern, E. B., Sines, B., & Teague, T. R. (1994). Commercial wrist extensor orthoses: Hand function, comfort, and interference across five styles. Journal of Hand Therapy, 7, Stern, E. B., Ytterberg, S. R., Krug, H. E., & Mahowald, M. L. (1996). Finger dexterity and hand function: Effect of three commercial wrist extensor orthoses on patients with rheumatoid arthritis. Arthritis Care and Research, 9, Stern, E. B., Ytterberg, S. R., Krug, H. E., Mullin, G. T., & Mahowald, M. L. (1996). Immediate and short-term effects of three commercial wrist extensor orthoses on grip strength and function in patients with rheumatoid arthritis. Arthritis Care and Research, 9, Wilton, J. C. (1997). Splinting to address the wrist and hand. In J. C. Wilton (Ed.), Hand splinting: Principles of design and fabrication (pp ). London: Saunders. 184 March/April 2002, Volume 56, Number 2