Splinting the rheumatoid wrist and hand: evidence for its effectiveness

Background: therapeutic aims of static splinting in rheumatoid arthritis (RA) include; supporting inflammed joints; decreasing localised pain and joint swelling; improving wrist stability; maintaining hand function and dexterity and preventing/correcting joint deformity. However, the theoretical biological basis for intermittent splinting is weak and evidence to support the effectiveness of conservative splinting in RA remains anecdotal (Akil and Amos1995, Scott et al 1998). Synovitis, capsular weakening and instability are the primary causes of rheumatoid hand deformity and dysfunction. Later biomechanical disruption of the wrist and hand can lead to structural deformity in up to 85% of individuals with RA. Structural impairment can effect functional upper limb and hand performance in the later stages of the disease. This paper discusses the effectiveness of different types of splints, commonly used in rheumatology practice, in preserving anatomical and functional ability.Methods: EMBASE, PUBMED, CINAHL and MEDLINE were used to search the splinting literature over the past 40 years. Evidence was sought for a variety of static splints meeting the stated therapeutic aims of splinting.Results: all studies reported hand functional ability in isolation without any reference to overall disease activity. A minority were conducted as unblinded RCTs, most were cross over or observational pre and post test designs. None had power calculations or estimated effect sizes included. Certain forms of static splinting, applied at varying stages of RA, have been demonstrated to:1. Provide localised pain relief2. Improve wrist stability when worn3. Increase functional dexterity and grip force when worn4. Re align deviated and lax joints when wornAs yet there is no robust evidence that static splinting will prevent or delay deformity from occurring or maintain hand function in the long term. Evidence is also lacking as to the possible detrimental effects that splints may have.Conclusions: static splints are designed to maintain structural and functional ability in the rheumatoid wrist and hand. In some patients these may work. Further well designed, well powered clinical effectiveness and efficacy trials are required to establish which splinting protocols work, for whom and why