Splints for the upper limb: patients perceptions of their use in rheumatology treatment

There are over 400,000 people with rheumatoid arthritis (RA) in the UK[2]. RA is a systemic inflammatory condition characterised by the proliferation of the synovial tissues resulting in pain, reduced muscle function and destruction of the articular surfaces and soft tissue structures responsible for joint stability. The wrist and hand are commonly affected in the early stages of RA, with most hand deformities occurring during the first year of the disease[3]. 85% of patients are affected in the later stages of the disease[4]. Optimal hand function is dependent on normal skeletal integrity, joint alignment and muscle function, all of which may be affected by RA. Synovitis results in pain and altered biomechanics of the hand which in turn will also compromise wrist and hand function. The common presentation of the RA wrist is one of flexion and radial deviation with ulnar deviation of the fingers. This wrist position compromises the efficiency of the flexor muscles which impacts on hand function during activities of daily living (ADL). The stability and position of the wrist are fundamental in facilitating hand function so it is often appropriate to prescribe a wrist hand orthosis (WHO) when patients present with dysfunction of the hand. An orthosis is defined as 'an externally applied device used to modify the structural and functional characteristics of the neuromuscular and skeletal systems'[5]. Functional wrist hand orthoses (splints) or activity orthoses as they are sometimes referred to are commonly prescribed in the comprehensive management of RA. It is thought that use of an orthosis which positions the wrist in an improved position of extension and which prevents radial deviation of the wrist thereby influencing the ulnar drift of the fingers reduces synovitis and increases the mechanical advantage of the flexor muscles thus improving hand function. Typically the orthosis only provides control of the wrist enabling free motion of the fingers and thumb to facilitate function. A wrist hand splint user questionnaire was developed to seek and evaluate the opinions of WHO users with RA who had been prescribed a commercially available prefabricated WHO. Quantitative and qualitative analysis of the data in conjunction with a systematic literature review provides a synthesis of the potential benefits of orthosis use, and highlights the negative aspects and factors affecting compliance. There is a clear need for further research into the use of 'functional' WHOs particularly over the longer term and to develop enhanced designs of WHO to achieve optimal improvements to functional deficit and to address users' concerns