BAOT/COT Specialist Section Rhuematology Conference 2010

1. 1c J Mellson,A Hammond, C Laver 2010
Resting Splint Survey:
NW COTSS-Rheumatology
Group
Jo Mellson1, Alison Hammond1 Charlie Laver2
Centre for Health, Sport & Rehabilitation
Research, University of Salford1
ICATS, Pennine MSK Partnership2

2. 2
Background
Agenda item at NW COTSS (April 2009)
to discuss: Midline or pronation? Benefits
of pressure gloves?
Survey questions submitted by members
to include in survey
Decision by the group to investigate current
practice due to unclear evidence base

3. 3c J Mellson,A Hammond, C Laver 2010
Aim of the study
Investigate current practice amongst COT-SS
Rheumatology OT members related to provision of NRS
in RA:
rationale for splint provision in early and established RA;
differing splint designs used and rationale for these;
wearing regimens recommended ;
patient instructions regarding splint wear and care;
methods used by OTs to assess for splint provision and
evaluate effectiveness;
and rationale for use of compression gloves as an
alternative to RS.

4. 4c J Mellson,A Hammond, C Laver 2010
Method
Potential content generated at COTSS-R meeting;
additional items submitted; literature.review
Draft questionnaire v 1 developed
Reviewed at COTSS-R meeting;
additional items recommended
Draft questionnaire v 2
Reviewed by COTSS-R members; revisions recommended
Final version
University ethics approval
E-mailed/ mailed to 35 NW Rheumatology OTs

5. 5c J Mellson,A Hammond, C Laver 2010
Analysis
Quantitative:
– descriptive medians and inter-quartile ranges
Qualitative:
– content analysis (Burnard 1991)
– Thematic analysis or
– Frequency counts (as applicable).

6. 6c J Mellson,A Hammond, C Laver 2010
Questionnaire: six sections
1. Resting splint provision
2. Resting splint design
3. Wearing regimens and splint instructions
4. Splint evaluation
5. Compression gloves
6. Final comments

7. 7c J Mellson,A Hammond, C Laver 2010
Response Rate
24/ 35 OTs replied (69%)
79% of respondents made splints
Respondents (n=19)
Majority of sample Band 7 OT’s
Years splinting experience: 14.95 (SD
8.09)
Years experience in Rheumatology: 14.00
(SD 8.42)

8. 8c J Mellson,A Hammond, C Laver 2010
Resting Splint (RS)
service provision
Early RA:
13/19 when stable on DMARDs
On average 25% of patients receive RS (IQR
10-35%)
On average 3 splints provided per month (IQR
1-5)
Established RA
On average 22.5% of patients receive RS (IQR
13.75-32.50%)
On average 3 splints provided per month (IQR
2-5.25)

9. 9c J Mellson,A Hammond, C Laver 2010
Importance of RS aims in early and established
rheumatoid arthritis (median: IQR) (n=19).
1=low; 5 = high importance Early RA
(< 2 years)
Established
RA(> 2 years)
Decrease pain at night 5 (5-5) 5 (5-5)
Rest/ immobilise weakened joint structures
to decrease local inflammation
5 (4-5) 5 (4-5)
Correctly position joints in which
deformities have already begun to develop
4 (2-5) 4 (3-5)
Minimise joint contractures 3 (2-4) 4 (3-4)
Minimise risk of deformity development (eg
MCPJ subluxation)
3 (2-4) 3 (2-4)
Decrease pain during the day 3 (2-4) 3 (1-3)
Increase joint stability 2 (1-4) 2 (1-4)
Improve hand function during the day 2 (1-3) 2 (1-3)

10. 10c J Mellson,A Hammond, C Laver 2010
Symptoms/issues influencing decision to provide NRS in early
and established rheumatoid arthritis (n=19).
1=low; 5 = high importance Early RA
(< 2 years)
Established
RA(> 2 years)
High levels of night pain 5 (5-5) 5 (5-5)
“Clawing” or strong finger flexion at night 5 (5-5) 5 (5-5)
Maintaining a comfortable hand position at
night/ at rest
5 (4-5) 5 (4-5)
Joint swelling 4 (3-5) 4 (3-5)
Joint changes (eg early deformity
development)
4 (3-5) 4 (3-4)
At patient request as had splint previously 3 (3-5) 4 (3-5)
High levels of day pain 3 (2-4) 3 (2-4)
Presence of pins and needles 3 (2-3) 3 (2-3)
Early morning stiffness in the hands 2 (1-4) 3 (1-4)
Limited range of movement 2 (1-3) 2 (1-3)

11. 11c J Mellson,A Hammond, C Laver 2010
Symptoms/ problems assessed
Free text responses: Total
assessing (n)
Standardised
method eg (n)
Pain 12 10 (VAS)
Range of movement 11 4 (goniometer )
Joint swelling 9 4 (ring sizer, tape
measure)
Impact of hand problems (on ADL, work or
leisure)
8 4
Sensation 8 0
Hand function 7 5 (DASH)
Grip/pinch strength 7 5 (Jamar, bulb
dynamometer)
Deformities 6 0
Patient’s attitudes to splints 4 0
Skin colour/ changes 3 0
Hand chart/assessment sheet 4
Stiffness; hand dominance; sleep disturbance 2

12. 12c J Mellson,A Hammond, C Laver 2010
Reasons for non-prescription of RS
1. Psychological: (15/19)
2. Physical
3. Practical
4. Cognitive impairment
5. Recent medication changes/
steroid injections

13. 13

14. 14
Splint patterns: 2. thumbs up 8/13
6/13 used both designs (1 & 2)

15. 15

16. 16
Example pattern 1 splints:
pronation

17. 17c J Mellson,A Hammond, C Laver 2010
Resting splint positioning
7 splinted in one position only; 12 used a 2nd
position at times:
Wrist position (n):
Pronation
Midline
Between pro /mid
8
10
1
Wrist extension ° (median (IQR) 20 (15-25)
MCPJ flexion (median (IQR) 40 (30 – 46.25)
PIPJ flexion (median (IQR) 20 (11.5 – 30)
DIPJ flexion (median (IQR) 5 (0 – 11.25)
Thumb position:
Palmar abduction (n)
Extension/radial abduction (n)
Between abduction/ extension (n)
10
4
5

18. 18c J Mellson,A Hammond, C Laver 2010
Rationale for positioning
“Functional / Resting position”
Comfortable mid-range
Not pulling more on extensors or flexors
Well-tolerated
Promotes sleep in fatigued patients
Minimises stress on joints and structures
Protects structures and minimises
deformity.

19. 19
Splint material

20. 20
Splint Straps

21. 21c J Mellson,A Hammond, C Laver 2010
Short-term splint evaluation
No. Time
(weeks)
Duration
(minutes)
Face to face 14 2
(IQR 2– 3.25)
20
(IQR 13.5– 27.5)
Telephone 6 2
(IQR 2-3)
5
(IQR 5-12.5)
None 2

22. 22c J Mellson,A Hammond, C Laver 2010
Long-term splint evaluation
10 = long-term review at some stage when
saw patients
Only 4 did regular review (eg annual
review)
9 conducted no long-term review
All 19 asked patients to contact them if
any problems with splint

23. 23c J Mellson,A Hammond, C Laver 2010
Time and cost of RS
On average it takes 45 minutes (SD 17.32) to:
assess for, make, fit and give instructions in correct
resting splint wear and precautions, excluding teaching
hand exercises.
Cost of OT time average Band 7@£32/hr (PSSRU
figures 2009): £24
Cost per patient of 1 splint + exercise + short-term
review = 75 minutes = £40
Splint costs: average cost £29 per splint
Total cost of providing splint + exercises = £69