North-West Rheumatology Occupational Therapy Research Group Recommendations for Resting Splint provision

Developed by: The North-West Rheumatology OT Research Group Recommendation developers: Charlie Laver* (Pennine Musculoskeletal Partnership, Oldham) Alison Hammond*, Jo Mellson,* Yeliz Greenhill (University of Salford), Lynette Bowler, Jan Colclough, Nicky Walker (Mid Cheshire Hospitals NHS Foundation Trust) Karen Crosby (Central Manchester University Hospitals NHS Foundation Trust) Mary Dooley (Southport & Ormskirk Hospital NHS Trust) Sandra Hargreaves (East Cheshire NHS Trust), Yvonne Hough (Five Boroughs Partnership NHS Foundation Trust), Angela Jacklin (Stockport NHS Foundation Trust), Helen Rogerson (Salford Royal NHS Foundation Trust) Annette Sands (Wrightington, Wigan and Leigh NHS Foundation Trust) Sarah Whitford (Countess of Chester Hospital NHS Foundation Trust

* Resting splint survey and recommendations co-ordinators and focus group leads.

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These recommendations are intended to help standardise practice, particularly for those less experienced in splint provision. These consensus recommendations were developed based on review of the evidence, results of a resting splint practice survey amongst North-West Rheumatology Occupational Therapists and expert clinical opinion.

1.

The purpose of resting splints should be explained prior to obtaining informed consent for splint provision. This explanation should include:

a. the aims of OT b. explanation of the clients condition: facts and effects of the disease on the hands. Commonly, the condition will be rheumatoid arthritis (RA) or inflammatory arthritis (IA) c. Identifying and explaining the symptoms experienced by the person with arthritis. Linking the persons symptoms to the clinical rationale for resting splint provision (eg to reduce hand pain and swelling). The decision to provide the splint is then client-led, ie if a clinical need has been determined following assessment, it is the persons choice whether to be provided with the splint. Verbal consent should be obtained and recorded in the persons OT record.

2.

Assessment for resting splints should include (in priority order):

a. Hand pain (night and day) using Visual Analogue Scales and discussion about the nature and location* of hand pain b. Joint swelling/synovitis observation (and palpation if necessary) recording the degree of swelling on a hand chart c. Hand position on waking discussion d. Sleep disturbance discussion e. Joint changes/ deformities/ contractures observation and recording on hand chart f. Range of Movement either visual estimation or goniometry g. Other hand conditions (eg carpal tunnel syndrome, osteoarthritis) client report and assessment as appropriate h. Optionally: digital photography using standardised positions: bilateral dorsal and volar views, with wrists in neutral and fingers in extension. Other views (medial, lateral and/or full finger flexion) as required. * Note: if the patient has wrist pain only, consider providing a wrist splint for rest rather than a resting splint.

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3.

Why resting splints should not be provided in IA, early or established RA:

a. Limited psychological acceptance of the condition by the person b. c. d. e. f. g. Poor skin condition Poor sight affecting ability to don and doff correctly (unless a carer is available to assist) Severe fixed flexion contractures preventing splint fitting (even for serial splinting) Poor cognitive function affecting ability to understand correct wear Person states s/he will not wear the resting splint Inability to don/doff independently during the night (eg if regular toileting or childcare needs, unless a carer is available to assist). A review appointment may be appropriate later to determine if the situation has changed.

4.

Resting splint design:

a. Splint patterni. usually the patterns thumb support section is drawn downwards from the palmar section. This ensures thumb opposition can be achieved. ii. If greater CMC support is required and/or the person is unable to tolerate full thumb opposition then a mitten pattern may be used. See Appendix 1 for patterns. b. Position i. Wrist 10-20 extension: if the person has carpal tunnel syndrome, the wrist should be in neutral. ii. MCPs 25-40 flexion iii. PIPs 15-20 flexion iv. DIPS 5-10 flexion v. Thumb opposition to index finger maintaining an open C position with IPJ in slight flexion vi. Forearm: usually pronation but can be midline particularly if the patient has shoulder problems or finds this more comfortable vii. All hand arches should be maintained. These are optimum positions but can be modified according to the patients range of movement and for comfort. See Appendix 2 for examples of resting splint positioning. c. Splint length: three-quarters of the forearm; the minimum is half length

d. Strap placement straps should not be placed over a joint if the joint is very swollen or the person is unable to tolerate this. These are located at: a. The proximal end of the splint b. at the wrist: consider using a diagonal strap if the ulnar styloid is painful c. distal to the MCPJs. d. Optionally over the thumb (clients choice). A cushioned strap (of any make) is preferable to Velcro.

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e. Material choice: consider the following properties when selecting splint material: i. Conformability ii. Durability iii. The degree of rigidity (ie the degree required by the client) iv. Lighter weight v. Allowing for minor adjustments vi. Ease of use vii. The length of working time (ie sufficient for correct moulding/ positioning and therapists skill level) viii. Cosmetically acceptable ix. Ease of cleaning x. Cost A range of materials is needed to meet clients needs and choices. Provide stockinette or Tubifast for additional comfort to be worn under the splint, if necessary.

5.

Resting splint instruction sheets.

An instruction sheet must be provided to supplement verbal instructions. These must adhere to Trust policy (ie standard content and standard of any Trust information such as contact details, review date; reading age) and approved by the Trust, if required. The following should be included: a. Why the resting splint is provided: i. to reduce pain; ii. to rest and support joints; iii. and to maintain and improve function. iv. The sheet should not state it will prevent deformity*. *Silva et al (2008), NAROT (2003): there is no evidence that resting splints help to prevent deformity.

b. When and how to wear the resting splint: i. include tick boxes for the therapist to specify if the splint is for day and/or night wear. ii. Include a box in which additional information can be written to individualise the splint instruction (eg wear for up to 2 hours during the day; wear at night etc, as required to meet the clients needs) During the first few days or week only: gradually increase duration of splint wear during the day (for up to 2 hours) before wearing all night, in order to i) check for any changes in hand appearance or discomfort and ii) to get used to wearing the splint. Once used to wearing the splint, wear it during the night and/ or day, as recommended by the therapist. Wear during a flare and for up to 6 weeks following a flare When no longer experiencing hand symptoms, discontinue wearing. Retain the splint for future use if necessary. Hand range of movement exercises should be performed daily on removal of the splint.

iii.

iv. v. vi.

vii.

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c.

Precautions: Check for changes in: i. ii. iii. appearance of the hand (eg marking, redness, rash) sensation of the hand (pins and needles or numbness) If there are any changes in hand appearance, sensation, symptoms or discomfort caused by the resting splint, it should be removed. Contact the OT department as soon as possible to have the splint reviewed.

d. Splint care i. Cleaning: wash in cool, soapy water and rinse in cold water; use wet wipes; or a cool damp cloth. ii. Keep away from heat do not place on a radiator or in direct sunlight iii. Do not alter the splint contact the OT department if any changes are required.

6.

Resting splints should be used in conjunction with a hand exercise programme

a. The therapist should teach a range of movement hand exercise programme. . b. Hand exercises should be performed daily on splint removal c. A hand exercise instruction sheet should be provided.

7.

Follow-up evaluation.

a. Short-term review is essential: preferably completed face-to-face. This should include as a minimum: i. Confirming that the person is wearing the splint as advised; ii. if the person reports, or therapist identifies, any problems eg redness, skin marking, sensation changes; iii. whether the person reports obtaining pain relief. This should be measured using a pain VAS (related to pain experienced during the day and/or night as applicable to the recommended splint wearing regimen; iv. and the persons views about the splints effects. v. All clients should then be informed to contact OT in future if: they encounter any problems with the resting splint; any splint modifications are required; or their hands change and the splint no longer fits.

b. Long term review may be conducted at annual reviews or if/when the person attends for future appointments to check the splint is still fitting and of benefit.

8. Discharge a. The person is discharged after the first review appointment if no problems are identified. b. Discharge letters should follow Trust policy Resting splint provision On average, 25% (inter-quartile range: 10-35%) of clients with RA, who are referred to Rheumatology OTs in the North-West region, are provided with resting splints.

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Appendix 1: Resting Splint Patterns There are two patterns commonly used. Pattern 1 ensures the thumb is splinted in opposition. Pattern 2 may be used if the client finds a mid-abduction/opposition position is more comfortable. Pattern 1: Thumb opposition

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Pattern instructions (both designs) Both patterns: Draw around the hand, making sure the fingers are positioned comfortably (not too ad-or abducted). Use a thin pen, holding it at 90 degrees to the paper, to ensure the pattern is as accurate as possible. Mark on the MCPJs, thumb IPJ, wrist and first web space Draw a border around the hand shape of approximately cm. Optionally, an additional border extension can be drawn on the medial (5th finger) side (see Pattern 2: mitten pattern). Flare the outline from the wrist level downwards: Measure two/thirds the length of the forearm, and draw the pattern so that the forearm section will be this long. The pattern/ splint should be half the circumference of the forearm (to provide strength to the splint and distribute pressure evenly). Pattern 1: Thumb down: Distances a and b help in drawing the thumb section On the pattern, the thumb section starts from the first web space. The width a, ie from the first web space to the thumb IPJ, will be the width of the thumb section. . The length b, ie from the end of the thumb to the mid-point of first webspace to thumb IPJ, will be the length of the thumb section. When drawing the pattern, curve around the thenar eminence Both patterns: Try the pattern on the patient noting any alterations required

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Pattern 2: Mitten pattern

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Appendix 2: Examples of Resting Splint designs and strap positioning a) Forearm in pronation; straight wrist strap; thumb opposition (Pattern1: thumb opposition)

b) Forearm in pronation; diagonal wrist strap; thumb in position of comfort (Pattern 2: mitten pattern).

c) Forearm in midline; straight wrist strap; thumb in opposition (Pattern 1; pull the forearm/wrist section round to the ulnar border of the forearm when moulding)

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References: Mellson J, Laver C, Hammond A (2011). Resting splint provision: a survey of practice within the NW COTSS Rheumatology group. Journal of Rheumatology Occupational Therapy 26(2):3-8 National Association of Rheumatology Occupational Therapists (NAROT: 2003) Occupational Therapy Clinical Guidelines for Rheumatology. College of Occupational Therapists: London. Silva AC, Jones A, Silva PG, Natour J (2008) Effectiveness of a night-time hand positioning splint in rheumatoid arthritis: a randomised controlled trial. Journal of Rehabilitation Medicine 40:749-754.

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