Clinical rheumatology, 1994, 13, N° 4

559-563

Wrist Splints in Rheumatoid Arthritis A Question of Belief? A. S P O O R E N B E R G ,

M. B O E R S , S. VAN D E R L I N D E N

Summary

Wrist splints are often used in the treatment of rheumatoid arthritis (RA). We applied a questionnaire to RA patients and rheumatologists to assess wrist splint use and to assess the policy of prescription. We related the reported use to patient satisfaction, severity of disease and physician's advice. Of 44 RA patients admitted to our hospital in 1990, 32 received one or more splints. Most patients (23) had both a wrist immobilization splint and a wrist activity splint (Futuro R cockup splint). The response rate to the questionnaire sent to all ( n = 109) Dutch rheumatologists was 83%; 89 of 91 rheumatologists prescribed splints. Each rheumatologist prescribed yearly a mean of 30 immobilization splints (min-max: 2-120) and 51 activity splints (min-max: 4-170). Both types were mainly prescribed to relieve pain and reduce inflammation. From the patients' point of view, only the wrist activity splints were worth regular and continued use. Our findings suggest that if one prescribed splints, more attention should be paid to patient education and compliance.

Key words

Rheumatoid Arthritis, Splints, Compliance.

INTRODUCTION Splints are often used in the treatment of rheumatoid arthritis (RA); the rationale for prescribing and using them, however, is not very clear. TWOtypes of wrist splints are frequently prescribed. Splints used while the patient is resting are thought to reduce inflammation and prevent contractures (1), whereas splints used during activity support joints and in this way are thought to relieve pain and improve function. However, the efficacyof splinting has not been rigorously studied. Almost all studies about efficacy comprise small groups of patients followed for a short period; the hypotheses about the effect of splinting differ (1-4). In the absence of hard evidence on efficacy, compliance is probably strongly influenced by the belief of the prescribing rheumatologists and the patients. Reported compliance varies between 25 and 65% (5-7). Studies in small groups of patients indicate two factors to be related to splint use: family expectations (8) and the speed at which easing of stiffness occurs (9). Factors such as age, sex, treatment and severity of disease were not related to splint use (6). The studies are not easily comparable because different types

Department of Medicine,Divisionof Rheumatology,UniversityHospital Maastricht,The Netherlands.

of splints were used and definitions of compliance varied (5,9,10). To our knowledge, the rheumatologists' opinions on splint use have not yet been studied. We questioned our patients and all Dutch rheumatologists about wrist splint use and prescription. Our goal was to find out whether factors such as expectations and expressed aims influence reported behaviour. METHODS Patients

One of us (A.S.) applied a questionnaire to all RA patients (ACR-criteria 1987) (12) who had been admitted to the University Hospital of Maastricht for severe e~acerbation of arthritis in 1990. Where appropriate, splints are liberally applied in our Hospital. After informed consent, those patients who had splints prescribed or adapted during their hospital stay were contacted by telephone after discharge from the hospital. The study was limited to the most frequently prescribed splints: the wrist immobilization splint, which is used during rest, and the wrist activity splint, which is used as support during activity. The wrist immobilization splint is a rigid type of splint, most often made of orthoplast and sometimes of plaster of Paris. The splint maintains a functional posi-

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A. Spoorenberg, M. Boers, S. van der Linden

Table I: Characteristics of the 32 RA patients in the study*

Table II: Use of sp~n~ over past month, and satisfaction*

Sex (male/female) Age (years) Duration of disease (years) "IRGI2'-physicalfunction scale for: Mobility (min, max: 7 (worst), 28 (best)) Dependencyin ADL (8(best), 32) Pain (6(best), 25) Current NSAID use Current DMARD use

Hours/day

9/23 60 (29-72) 7 (1-13) 12 (8-21) 19 (10-27) 20 (14-24) 75% 100%

>3 2- 3 1- 2 0-1

Immobilization splint 1(1) 3(2) 8(6) 15(6)

Activity splint 9(9) 7(7) 4(3) 8(5)

*Numberof patients;betweenparentheses,numberof patients ("quite" or "completely")satisfiedwith splint. Rank correlationbetween satisfaction and immobilizationsplint use: 9=0.52, p < 0.01; between satisfaction and activitysplint use: 9 =0.33; p=0.08).

* Median, 80% range. IRGL: modifiedDutch AIMS;ADL: Activities of DailyLiving;NSAID:nonsteroidalantiinflammatorydrug;DMARD: disease modifyingantirheumaticdrug.

RESULTS

Patients tion of the hand while resting and is made individually for each patient. The activity wrist splint used almost exclusively is a ready-made fabric splint (Futuro R cock-up splint) with a palmar steel reinforcement that can be bent to the optimal resting position of 20-25 dorsiflexion of the wrist. The first part of the questionnaire contained questions about splint usage during the past month and perceived positive and negative aspects. The second part contained questions about the severity of disease assessed by the physical function scale of the 'IRGL'-questionnaire, comprising questions about pain and disability. This questionnaire is a newly validated Dutch modification of the Arthritis Impact Measurement Scales (AIMS) (13). Our patient questionnaire contained both open-ended and multiple choice questions. The latter included yes/no questions, questions on a four-point scale (never, sometimes, often, always) and questions on a five-point-scale (completely agree, agree, neutral, disagree, completely disagree).

Rheumatologists In 1991 all 109 members of the Dutch Society of Rheumatologists received a mailed questionnaire. This questionnaire contained questions about the policy and aims o-f'~rist splint prescription and about other therapists involved in splinting. The format of the questions was identical to that of the patients' questionnaire, except for one question on the degree to which the aims could be realized. This item had to be answered on a 10cm visual analog scale.

Statistical analysis Where appropriate, Spearman rank correlation and chi square statistics tested associations between variables at a 2-sided alpha level of 0.05.

Forty-four RA patients were admitted to the Division of Rheumatology of the Medical Department for exacerbation of arthritis in 1990. Of these, 9 patients did not receive wrist splints, 2 patients did not have a telephone and 1 only spoke Turkish. In all, 32 patients were available for the study. Of these, 23 had both types of Splints; 5 had only a wrist activity splint and 4 only a wrist immobilization splint. Most patients had severe RA (Table I).

The reported advice and use of splints Most (85%) of the 27 patients with a wrist immobilization splint reported that they were advised to wear the splint often while resting. Almost half of the patients (44%) were also advised to wear the splint during the night. Such prescriptions were in contrast with reported use: of 18 patients who rested more than 2 hours daily only 3 (17%)used their splint more than 2 hours daily. The splint was never worn at night. In contrast, the 28 patients with a wrist activity splint often wore their device. Most of these patients (75 %) reported that they were advised to wear the splint when physically active. Fifty-seven percent used their activity splint more than 2 hours daily (Table II). One fourth of these patients were advised to wear the splint at night also, again none complied.

Patients' perceptions of splints To gauge the patients' perceptions, we suggested some positive and negative aspects of wrist splints, supplemented with an open-ended question. On the positive side, 44% of the patients with a wrist immobilization splint agreed that the splint relieves pain, 22% agreed that it decreases swelling and 26% that it improves function (Table III). To the open-ended question 52% an-

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Wrist splints in rheumatoid arthritis: A question of belief?

Table V: Rheumatologists" check-up frequency of splints

Table III: Patientperception of wrist splints Immobilization splint

Activity splint

Relief of pain Decrease of swelling Improvement of function Satisfaction

44% 22% 26% 56%

75% 36% 75% 86%

Unwieldy Difficultto put on / take off Ugly Causing pain No positive aspect

78% 70% 78% 22% 44%

63% 36% 29% 25% 4%

Table IV: Characteristics of 91 Dutch rheumatologists

Check-up frequency

Immobilization

Activity splint

splint At every clinical visit

At regular frequencies Mean frequency/year(min-max) No check-up Not clear

28%

16%

56% 2.4 (0-12) 7% 9%

64% 2.5 (0-12) 1% 19%

ported splint use and satisfaction (for the immobilization splint rho =0.52, p < 0.01; for the activity splint rho = 0.33, p = 0.08; Table II). Frequency of splint use was not correlated to mobility, pain, A D L dependency, age or duration of disease.

Rheumatologists in practice:

solo 2 to 4 persons in a group > 4 persons in a group Work setting (%): Communityhospital Universityhospital* Years of work after registration (median, 80% range)

27% 51% 22% 67% 33% 7 (2-17)

* 7% also work in a community hospital.

sw~red that rest is an important positive aspect of the immobilization splint, while 41% could not make a positive suggestion. The remaining 7% made various suggestions. In all, 56% answered yes to the question: ' ~ r e you satisfied with the immobilization splint?" The wrist activity splint drew a more favourable response: 75% agreed that the splint relieves pain, 36% agreed that it decreases swelling and 75% agreed that it improves function (Table III). To the open-ended question 61% answered that physical support is an important positive aspect of the activity splint. Only 4% could not mention a positive aspect of the activity splint. In all, 86% stated they were satisfied with the activity splint. On the negative side, 78% of the patients with a wrist immobilization splint agreed that it is unwieldy, 70% agreed that it is difficult to put on or take off, 78% that it is ugly, 22% that it hurts and 4% that it does not fit. At the open-ended question, 9% complained of joint stiffness after splint use. Again the wrist activity splint drew a less negative response overall. Forty-three percent of the patier]ts with such a splint agreed that the splint is unwieldy, 36% that it is difficult to put on or to take off, 29% that it is ugly, 25% that it hurts, and 14% that it does not fit. To the open-ended question, 18% complained that the splint restricts movement and 14% that it is not waterproof. We found a positive correlation between re-

Rheumatologists In the Netherlands - a country with a population of 15 million - there are 109 rheumatologists. The questionnaire was returned by 91 rheumatologists, yielding a response rate of 83%. Most rheumatologists work in a community setting, usually in group practice (Table IV). In 1989 each saw a mean of 205 RA patients, of these 36 were newly diagnosed RA patients (data from: 'Standard Diagnosis Registration of Rheumatic Diseases (SDR) of the TNO Rheumatic Disease Research Committee'. Leiden, the Netherlands). Almost all (98%) prescribe wrist splints; 65% prescribe both types of splints, 10% prescribe only the immobilization splint and 23% only the activity splint. A mean of 30 immobilization splints (min-max: 2-120) and 51 activity splints (rainmax: 4-170) are prescribed yearly. Sixty-seven percent of the rheumatologists advised patients to use the immobilization splint often (i.e., more than 2 hours) or almost always (more than 3 hours) while resting and 55% advised them to wear the splint during the night. Regarding the activity splint, 93% advised using the splint often or almost always during activities and 11% advised wearing it during the night. The check-up of both types of splints is usually done by the rheumatologists and in 28% also by the occupational therapist (Table V). Finally, more than half of both types of splints are supplied by the occupational therapist and one third by the orthopaedic workshop. For both types of splints almost all rheumatologist think that pain relief is the most important aim, followed by decrease of inflammation (Table VI). Other important aims include prevention of deformities (immobilization splint) and increase of hand function (activity splint). For both splints, the rheumatologists' answer as to the degree to which such aims (e.g., relief of pain) could be realized in optimally compliant

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A. Spoorenberg, M. Boers, S. van der Linden

Table VI: Rheumatologists" intentions when prescribing wrist splints

Decrease pain Decrease inflammation Prevent deformities Prevent loss of function Increase function

Immobilization splint 96% 78% 50% 26% 16%

Activity splint 96% 63% 20% 23% 45%

patients was about the same. For the immobilization splint the median degree was 60% (i.e., 60% relief of pain due to splinting in an optimally compliant patient; 80% range: 49-83), and for the activity splint itwas 66% (80% range: 47-82). No other factors tested, such as years of work after registration as a rheumatologist, work setting, and the degree to which perceived aims could be realized, were significantly related to the number of wrist splints prescribed (data not shown). DISCUSSION Both questionnaires show that the wrist activity splint is more popular with patients and physicians, in contrast to the wrist immobilization splint, which is unpopular with patients. Feinberg (9) and Oakes (8) have reported compliance with the immobilization splint up to 65%; however, they considered patients as "compliant" if they reported wearing their splint at least 50% of the prescribed time. For the activity splint no compliance rates have been reported. In the current study only 17% of patients with immobilization splints most likely to be compliant - i.e., those who rested more than 2 hours daily - regularly used their splint; in contrast, 57% of patients with activity sptints regularly used their splint. The advice toward use during the night was universally ignored. In our study the rheumatologists' indications for splint prescription such as relief of pain and decrease of inflammation roughly match the effects of splint use found in other studies (1,2,3,11). In the case of the activity splint our patients also report pain relief and functional improvement. In contrast, Nicholas (5) reported that patients with a wrist activity splint did not use it for relief of pain but for support. In case of immobilization splints the perceptions of our patients do not match with their

own reported use, with the aims of the rheumatologists, nor with the effects of splint use found in previous studies (1,2,3,11). Less than half of our patients stated that the effects are relief of pain and improvement of function. From our RA patients' point of view, only the wrist activity splint is worth regular and continued use. Most rheumatologists also preferred this splint. This is notable because the rheumatologists' aims and the perceived efficacy was similar for both splint types. Such results indicate that our study, like previous studies, is unable to capture the full spectrum of aims and effects of splint prescription and splint use (1,2,3,11). For example, it may be that rheumatologists are aware of their patients' preferences or (non-)compliance. Maybe rheumatologists cannot always convince their patients of the positive effects they attach to splint use, possibly because they do not pay as much attention to patient education as needed. The rheumatologist questionnaire showed that a standardized protocol for splint use is seldom used. Some factors concerning splint use may not have been found due to the limited number of patients in this study. The patient survey reflects practice in a single hospital. Local physicians, however, were not found to differ from other rheumatologists concerning the number of splints prescribed and advice rendered at prescription. Moreover, splint use did not significantly correlate to physicians' advice. Therefore, reported patient satisfaction and use may well reflect a general sense among RA patients. It should be noted that parts of the questionnaires we used have not been validated in previous studies. The positive correlation between reported splint use and satisfaction renders some internal validation to the patient questionnaire. The efficacy of splinting needs to be tested more thoroughly in controlled trials. In any case rheumatologists and patients must agree on the objectives; the prescription of immobilization splints outside the hospital may need reconsideration. Standardized patient education and splint prescription will probably help to improve compliance (5,14). Efficacy cannot be demonstrated for splints that are not used. A c k n o w l e d g e m e n t s : We thank Dr. E. Terpstra for thoughtful comments, and the patients and rheumatologists for their participation.

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Wrist splints in rheumatoid arthritis: A question of belief?

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11. Meritt, J.k. Advances in orthotics for the patient with rheumatoid arthritis. J Rheumatol 1987, 14, 62-67. 12. Arnett, EC., Edworthy, S.M., Bloch, D.A. The American Rheumatism Association 1987 revised criteria for the classification of rheumatoid arthritis. Arthritis Rheum 1988, 31,315-324. 13. Huiskens, C.J., Kraaimaat, F.W., Bijlsma, J.W. Invloed van reuma op gezondheid en leefwijze: een zelfbeoordelingslijst voor het meten van de invloed van reuma op gezondheid en leefwijze ('The influence of rheumatoid arthritis on health and lifestyle: a self-assessment questionnaire'). Lisse, Swets en Zeitlinger, 1990. 14. Feinberg, J. Effect of the arthritis health professional on compliance with the use of resting hand splints by patients with rheumatoid arthritis. Arthritis Care Res 1992, 5, 17-23.

Received: 6 October 1993 Revision-accepted: 14 March 1994 Correspondence to: Dr. M. BOERS, University Hospital Maastricht, Department of Medicine, Division of Rheumatology, EO. Box 5800, 6202 A Z Maastricht, The Netherlands.