Upper Limb Orthoses

(Royal College of Occupational Therapists, 2019, p2-3)

“Occupational therapists believe that the ability to engage in meaningful occupation is fundamental to the facilitation and maintenance of health and wellbeing. By engaging with occupations (activities we have to, need to, or want to do) we gain a sense our own being. It is not enough, however, to just ‘do and be’, we also need to engage in meaningful occupations in order to become something in the future.”

Upper Limb Function

• Upper limb function allows for complex task accomplishment in reaching, prehension, and manipulation.

• The upper limb can be examined as a linkage system.

• The main effector of the upper limb is the hand; the wrist, elbow, and shoulder act to place the hand in space.

• The description and analysis of function can be assisted by studies using biomechanical principles. Application of this information is especially relevant for orthotic design and prescription.

Upper Limb Orthoses in Arthritis

Hand involvement is almost ubiquitous in rheumatoid arthritis and even with changing medical management, orthoses are still a core intervention for people with arthritis, to reduce hand symptoms and improve hand function, alongside hand exercises and joint protection.

The use of orthotics for people with arthritis has been identified as the following (Deshais 2018):

• To reduce inflammation
• To decrease pain
• To support unstable joints
• To properly position joints
• To limit undesired motion
• To increase range of movement

Royal College of Occupational Therapists

The RCOT Specialist Section - Trauma and Musculoskeletal Health developed a series of clinical guidelines to include hand and wrist orthoses for Adults with rheumatological conditions based on the latest evidence-based practice (2nd Ed 2020).

Functional Wrist Orthoses

Ramsey et al 2014; Thiele et al 2009

It is recommended that a functional wrist orthosis should be prescribed for people experiencing wrist pain as a result of rheumatoid arthritis.

Resting/Night Orthoses

Adams et al 2008; Silva et al 2008

It is suggested that where a night or resting orthosis is being considered as potentially beneficial to reduce symptoms for a person with rheumatoid arthritis, both subjective and objective measures are used for the monitoring and review of effectiveness.

Orthoses for Swan Neck Deformity

Giesen et al 2010; Giesen et al 2009; Spicka et al 2009

It is suggested, when considering an orthosis for swan neck deformity, that a potential positive effect on dexterity should be balanced by possible adverse effects such as pressure and paraesthesia.

Orthoses to Reduce Pain and/ or Improve Function

Cantero-Tellez et al 2018; Vegt et al 2017; Bani et al 2014

It is recommended that an orthosis should be prescribed for people experiencing pain and/or functional difficulties with activities of daily living as a result of thumb base osteoarthritis.

Orthoses to Improve Grip and Pinch Strength

Bani et al 2014; Hermann et al 2014; Maddali-Bongi et al 2014

It is suggested that an orthosis can improve the grip/ pinch strength for some people with thumb base osteoarthritis.

Outcome Measurement

Duong et al 2018; Healey et al 2018; Aebischer et al 2016; Hammond et al 2016

It is recommended that validated, standardised assessment and outcome measures are used pre- and post- provision of an orthosis to monitor progress, evaluate effectiveness, assess functional outcomes and understand individual satisfaction.

Performance and Choice

Cantero-Tellez et al 2018; Almeida et al 2017; Bertozzi et al 2015

It is suggested that, given the inconsistent evidence of superior orthosis fabrication/ design or wearing regimen, the orthoses selected should maximise occupational performance and individual choice.

Tailored Approach

Tada et al 2018; Almeida et al 2017; Vegt et al 2017

It is recommended that, to optimise adherence to wearing a prescribed orthosis, the occupational therapist should discuss with the person the potential benefits and limitations; practicalities of use and comfort; provide the opportunity to try on orthoses prior to issue; and routinely arrange follow-up review of the intervention.

Things to Consider

• Patient-centred practice
• Clinical reasoning
• Shared decision-making
• Aesthetics
• Wearability
• Skin integrity
• Adherence
• Patient education
• Clear wearing instructions
• Do not immobilise joints that it does not need to be!

• Aebischer B, Elsig S, Taeymans J (2016) Effectiveness of physical and occupational therapy on pain, function and quality of life in patients with trapeziometacarpal osteoarthritis a systematic review and meta-analysis. Hand Therapy, 21(1), 5-15.

• Adams J, Burridge J, Mullee M, Hammond A, Cooper C (2008) The clinical effectiveness of static resting splints in early rheumatoid arthritis: a randomized controlled trial. Rheumatology, 47(10), 1548 1553.

• Almeida, P de, Henrique T, MacDermid J, Pontes TB, Dos Snatos-Couto-Paz CC, Matheus JPC (2017) Differences in orthotic design for thumb osteoarthritis and its impact on functional outcomes: a scoping review. Prosthetics and orthotics international, 41(4), 323-335.

• Bani MA, Arazpour M, Hutchins SW, Layeghi F, Bahramizadeh M, Mardani MA (2014) A custom-made neoprene thumb carpometacarpal orthosis with thermoplastic stabilization: an orthosis that promotes function and improvement in patients with the first carpometacarpal joint osteoarthritis. Prosthetics and Orthotics International, 38(1), 79 82.

• Bertozzi L, Valdes K, Vanti C, Negrini S, Pillastrini P, Villafañe JH (2015) Investigation of the effect of conservative interventions in thumb carpometacarpal osteoarthritis: systematic review and meta-analysis. Disability and Rehabilitation, 37(22), 2025-2043.

• Cantero-Téllez R, Valdes K, Schwartz D, Medina-Porqueres I, Arias JC, Villafañe JH (2018) Necessity of immobilizing the metacarpophalangeal joint in carpometacarpal osteoarthritis: short term effect. Hand, 13(4), 412-417.

• Duong V, Bennell K, Deveza L, Eyles J, Hodges P, Holden M, Hunter D, Jongs R, Knapp D, Mei Y, Vicenzino B, Wajon A, Robbins S (2018) Attitudes, beliefs and common practices of hand therapists for base of thumb osteoarthritis in Australia (The ABC Thumb Study). Hand Therapy, 23(1), 19-27.

• Giesen FJ van der, Nelissen RGHH, Lankveld WJ van, Kremers-Selten C, Peeters AJ, Stern EB. . Vliet Vlieland TPM (2010) Swan neck deformities in rheumatoid arthritis: a qualitative study on the patie splints. Musculoskeletal Care, 8(4), 179 188.

• Giesen FJ van der, Lankveld WJ van, Kremers-Selten C, Peeters AJ, Stern EB, Le Cessie S… Vliet Vlieland TPM (2009) Effectiveness of two finger splints for swan neck deformity in patients with rheumatoid arthritis: a randomized crossover trial. Arthritis Care & Research, 61(8), 1025 1031.

• Hammond A, Jones V, Prior Y (2016) The effects of compression gloves on hand symptoms and hand function in rheumatoid arthritis and hand osteoarthritis: a systematic review. Clinical Rehabilitation, 30(3), 213-224.

• Healy A, Farmer S, Pandyan A, Chockalingam N (2018) A systematic review of randomised controlled trials assessing effectiveness of prosthetic and orthotic interventions. Plos One, 13(3), e0192094. Available at: https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0192094

• Hermann M, Nilsen T, Eriksen CS, Slatkowsky-Christensen B, Haugen IK, Kjeken I (2014) Effects of a soft prefabricated thumb orthosis in carpometacarpal osteoarthritis. Scandinavian Journal of Occupational Therapy, 21(1), 31 39.

• Maddali-Bongi S, Del Rosso A, Galluccio F, Sigismondi F, Matucci-Cerinic M (2014) Is an intervention with a custom-made splint and an educational program useful on pain in patients with trapeziometacarpal joint osteoarthritis in a daily clinical setting? International Journal of Rheumatic Diseases, Mar 6. [Epub ahead of print].

• Ramsey L, Winder RJ, McVeigh JG (2014) The effectiveness of working wrist splints in adults with rheumatoid arthritis: a mixed methods systematic review. Journal of Rehabilitative Medicine, 46(6), 481 492.

• Silva AC, Jones A, Silva PG, Natour J (2008) Effectiveness of a night-time hand positioning splint in rheumatoid arthritis: a randomized controlled trial. Journal of Rehabilitation Medicine, 40(9), 749 754.

• Spicka C, Macleod C, Adams J, Metcalf C (2009) Effect of silver ring splints on hand dexterity and grip strength in patients with rheumatoid arthritis: an observational pilot study. Hand Therapy, 14(2), 53 57.

• Tada K, Toribatake Y, Yamamoto D, Nakajima T, Nakada M, Matsuta M, Tsuchiya H (2018) Tin ring splint treatment for osteoarthritis of the distal interphalangeal joints. Hand, February. [epub ahead of print].

• Vegt AE van der, Grond R, Grüschke JS, Boomsma MF, Emmelot CH, Dijkstra PU; Sluis CK van der (2017) The effect of two different orthoses on pain, hand function, patient satisfaction and preference in patients with thumb carpometacarpal osteoarthritis: a multicenter, crossover, randomised controlled trial. The Bone and Joint Journal, 99B(2), 237-244.