Static splinting after stroke: evidence and practice

Danny Minkow, studying for an MSc in Occupational Therapy, invites other students and therapists to consider the problem of continuing use of therapies which lack evidence to support them or have been shown to be ineffective, and explores this in relation to splinting and stretching as stroke rehabilitation interventions. Sarah Chapman from Cochrane UK has revised and republished the blog with recent evidence and guidance.

 Page originally published 4 April 2014; revised and republished 29 December 2022.

Take-home points

Take-home points: Writing in 2014, occupational therapist Danny Minkow reflected on the use of static splints for people after stroke as an example of a treatment in use but not supported by evidence The most recent (living) guideline, from the Stroke Foundation in Australia, which includes Cochrane evidence, says the use of splints or muscle stretch for stroke survivors at risk of developing contractures is not recommended. Updated guidance on stroke rehabilitation is in development from NICE and from SIGN The Royal College of Occupational Therapists and James Lind Alliance Priority Setting Partnerships identified the Top 10 Priorities for occupational therapy research in the UK in 2021, setting the research agenda to address the the unanswered questions that matter most to people accessing and delivering occupational therapy services

Occupational therapy as a field is striving to be known for being “science driven and evidence based”. I’m currently in my 3rd semester pursuing a Master of Science in Occupational Therapy at Brenau University and I feel proud to be in an OT program that answers this call. During my first semester, I took a course called Evidence Based Practice. Thanks to my exceptional instructors, I felt this was one of the most important courses I’ve ever taken in school…ever! Now that I’ve started my field work and I’m learning more about different interventions, I’ve made a habit of ‘asking for the evidence’. However, I’ve discovered that many common interventions have little or poor evidence to justify their widespread use. So I’d like to take this opportunity to reach out to other students and therapists, and to explore an example about arm and hand splinting and stretching for stroke rehabilitation. These interventions are still in use to prevent or treat contractures after stroke, but is there good evidence to support this practice?

Does splinting help with contractures?

Danny Minkow writes, in 2014:

While there’s anecdotal evidence and a few older non-randomized studies that suggest stretching from static splinting is effective for preventing and treating contractures, when subjected to more rigorous testing, positive results simply have not materialized. For example, Effects of splinting on wrist contracture after stroke: a randomized controlled trial, involving 63 post-stroke patients studied the effects of either neutral static splint or extended static splint worn overnight for 4 weeks, as compared to a control group wearing no splint. The study found that splinting the wrist in either the neutral or extended wrist position for 4 weeks did not reduce wrist contracture after stroke. Citing this, the Scottish Intercollegiate Guidelines Network (SIGN) guideline on stroke management and rehabilitation (2010) says that splinting is not recommended for improving upper limb function or for reducing spasticity in the wrist and finger flexors following stroke.

A few years later, the same study was included in the Cochrane systematic review ‘Stretch for the treatment and prevention of contractures’ (September 2010) along with 34 other studies, with 1,391 participants. This review went even further and investigated if stretching, whether it was administered from splints, manual stretching, or even positioning programs, help prevent or treated contractures caused by several neurological conditions (stroke, traumatic brain injury, spinal cord injury, and cerebral palsy) as well as non-neurological conditions.

The authors concluded that there is moderate to high quality evidence to show that there is little or no effect of stretching/splinting on joint mobility, if this treatment is used for up to seven months (no study explored the use of stretch for longer periods). The effects of stretch on quality of life and activity limitation haven’t been well investigated, but in the few studies where this was evaluated there was no benefit from stretching. Stretch did not decrease pain or spasticity and was found to cause an immediate increase in pain in people with neurological conditions.

Update by Sarah Chapman, December 2022:

The most recent (living) guideline, from the Stroke Foundation in Australia, says the use of splints or muscle stretch for stroke survivors at risk of developing contractures is not recommended. This guideline (and five others) includes the Cochrane Review Stretch for the treatment and prevention of contractures, which was updated in January 2017. The review authors concluded that:

  • There was high‐quality evidence that stretch did not have clinically important effects on joint mobility in people with or without neurological conditions if performed for less than seven months. The effects of stretch performed for periods longer than seven months have not been investigated
  • The effect of stretch is consistent in people with different types of neurological or non‐neurological conditions
  • There was moderate‐ and high‐quality evidence that stretch did not have clinically important short‐term effects on quality of life or pain in people with non‐neurological conditions, respectively
  • The short‐term effects of stretch on quality of life and pain in people with neurological conditions, and the short‐term effects of stretch on activity limitations and participation restrictions for people with and without neurological conditions are uncertain

The SIGN guideline has been archived and a replacement guideline is in development, with publication expected in the Winter of 2023. This will cover the complete clinical pathway for stroke (from management of transient ischaemic attack to community reintegration).

An updated version of the NICE guideline on stroke rehabilitation in adults is also in development, following a surveillance report of new evidence (2019) likely to impact existing recommendations, with an expected publication date of October 2023.

Evidence-based practice?

Danny, 2014:

Well, despite the evidence, static hand splints are still used by occupational therapists (OTs) to treat patients post-stroke. In 2011, a fascinating cross-sectional survey of hand-splinting practice among inpatient OTs in Ireland examined the perceived hand splinting efficacy and splint prescription pattern after stroke (Adrienne, 2011). The study found almost two-thirds of the respondents, 38 (61.3%) out of 62 OTs surveyed, believe splinting to be effective or very effective for rehabilitation after a stroke. Now granted, that’s a relatively small study, but it seems that OTs perceive hand splints to be effective and continue to prescribe splints regularly to their clients, despite inadequate evidence to support their continued use. All this comes at a time when healthcare systems are trying to reduce their costs while improving patient care. Reducing the use of less efficient interventions would help lower costs and improve outcomes.

So what does this mean for therapists?

I may have oversimplified the full picture of stretching and splinting for spasticity and contractures after stroke, as splints can be used for many reasons. It just seems that static splinting to prevent or treat contractures shouldn’t be one of these reasons.

The most important message here is that a treatment is in use which can be painful for patients and offer them no benefit in the short term, while the long-term effects are unknown. Similar examples can be found in other areas of healthcare too. It’s a reminder that we therapists must frequently review the best available evidence to see if it supports our interventions. Perhaps we are all at risk of falling into patterns of treatment that could even develop into a discipline’s “tradition” of practice. Sure, we could blame outdated medical guidelines based on much weaker evidence, but we shouldn’t be afraid to challenge health science’s guidelines or status quo with the best available evidence.

What do you think? Do you know of other widely used interventions that are not as effective as people believe? What can we do to encourage better use of available evidence?

Update by Sarah, December 2022:

The Royal College of Occupational Therapists’ research and development strategy 2019-2024 is “intended to inform, guide and direct the development of research capability and capacity in the occupational therapy profession in the UK and the quality and impact of the associated research outputs”. The Royal College of Occupational Therapists and James Lind Alliance Priority Setting Partnerships together identified the Top 10 Priorities for occupational therapy research in the UK. This sets the research agenda to address the unanswered questions that matter most to people accessing and delivering occupational therapy services.

References (pdf)

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Static splinting after stroke: evidence and practice by Danny Minkow

is licensed under a Creative Commons Attribution-NoDerivatives 4.0 International

21 Comments on this post

  1. This is very interesting. I am nearly 4 years post stroke and I find the splint helps me so much. Sometimes I can’t open my right hand and as other have explained my fingernails dig into my palm. I feel so good when I keep it on all day. I feel the stretching just provides comfort. I wish I could find something for my elbow. I understand professionals saying the splints don’t work long term but the benefits daily are much better for quality on life and some relief. I have had to spend so much money on finding this myself but the hand splint I have now is perfect. I just have to find one for my elbow and right knee.

    Nouha Tavita / Reply
    • Hello Nouha, Thank you for your comment. It’s so good to hear that you have found something that helps!
      Best wishes,
      Sarah Chapman [Editor]

      Sarah Chapman / (in reply to Nouha Tavita) Reply
  2. Thank you for this article which I found helpful. I think there is not enough distinction made between spasticity and contracture. My partner has right hemiplegia with moderate arm spasticity. This has stabilised after 3 years. I found the Saebo splint cumbersome. I can stretch his finger joints to full extension and his hand is in good condition. A new OT told us off the other day for not splinting every night and I found this upsetting so was relieved to see your review. I understand that hand care and comfort needs care and devices that provide this care (sheepskin etc) but I think that simply splinting spastic limbs is not really part of preventing contractures. Nobody suggests splinting the elbow in full extension as it would be an obstacle to mobility.

    roseanna pollen / Reply
    • Thank you for your comment. I’m sorry you had an upsetting experience with the OT and I’m glad you found the information in this blog helpful. It can be hard to navigate what can feel like a power imbalance between patients and their family members and health professionals can’t it? If you want to have a discussion about this aspect of your partner’s care, perhaps sharing the information in the blog might help.
      With best wishes,
      Sarah Chapman [Editor and blogger]

      Sarah Chapman / (in reply to roseanna pollen) Reply
  3. I think it’s about time we talked about the evidence for STATIC CONTRACTURE splints vs. FUNCTIONAL and COMPENSATORY splints. A static contraction splint is all this article discusses. A splint that temporarily supports a joint in a position to allows the body to relieve discomfort due to disability, pain, ect… and a splint that allows a person to functionally complete a valued occupation are both very different things. I made a splint for a client with a radial nerve palsy that allowed them to hold their favorite coffee cup, that’s all it was made for, but man…that thing was valued.

    Steven Cherry / Reply
  4. I have been working in the field of OT hand therapy for the past 6 years and have had many clients with varying degrees of disability post-CVA. I have questioned the same over and over again regarding whether the traditional treatment method of splint and stretch has been beneficial to my clients. My two cents: no two cases are the same. It is incorrect to make a blanket statement that “splinting does not work” or “stretching has no positive effect”, when in reality, it depends on what results you are trying to obtain. For example: Client A may have issues with hygiene due to clenched fingers from hypertonicity which may cause discomfort due to their nails breaking skin or excessive palm moisture from the clenching. It would be unrealistic to expect for splinting to regain Client A’s range of motion, however, they may have increased comfort and quality of life due to not having to deal with the clinched fist issue as long as they are compliant with the anti-spasticity splint. A proper focus on proper positioning of the upper limb via education to the client and caregiver would be my main goal vs expecting to regain partial ROM. A more functional Client B may not need splinting but may benefit from AAROM stretching and proximal strengthening. In all, blanket statements never do our profession any good as it causes an “Us vs Them” school of thought and can really deprive our clients from appropriate treatment techniques in cases that it can be necessary and appropriate. And never forget that evidence is always changing and long-term research has not even touched the surface of this subject, so take what you read with wisdom and cautious skepticism.

    Alex Pinon / Reply
  5. Thank you so much for your article. I’m a Portuguese Physical Therapist working with neurologic patients since 1994, I have an MSc in Neurological Rehabilitation and a Post-graduation in Neuroscience.
    Hand splinting does NOT work, and I’m so glad research is pointing in that direction. The first thing I do to my patients is getting rid of hand splints, and not one single one got worse because of that.
    Congratulations for your work.

    Cristina Soares / Reply
  6. I want to add that I have a newer splint than the one they gave me in the hospital. The new one is padded and soft, so comfortable to wear. It’s easy to put on and lightweight. I love it. It really helps me. Luckily, I had an OT in stroke rehab who taught me how to put one on by myself with one hand. She also taught me how to brush my teeth, put on my clothes, and how to put deodorant on with one hand. All those essential skills that are not, I’m sure, in those research articles you’re glued to.

    Dodie Price / Reply
  7. This is a horrible article. I am almost six years post stroke, and splinting is almost the ONLY thing that helps me. I am a member of several stroke groups, some of them have over a hundred thousand members, and I hear the same thing from others all the time. I think the problem is this: You are INEXPERIENCED. You’re just now working on your Masters (yes, I have one, too) and you haven’t been in practice to see what PATIENTS have to say. Patients, not research, is what matters when it comes to effective techniques. Find someone who has a lot of experience in Occupational Therapy and spend a few weeks shadowing them and learning.

    Dodie Price / Reply
  8. I am a 9.5 year post-stroke patient and I disagree with this article. I have always worn a splint at night only and my husband does stretches for me about 4 times a week. While I have never regained movement, my hand has gone from a fist so tight that my nails dug into my palm and it could only be opened with a great deal of work to a hand that rests either in a very loose fist to mostly opened and relaxed. This has helped improve my actual quality of life because; 1, it is so much more comfortable and 2, since I can close it but not open it, being looser allows me to do things like get it around smaller jars to hold them so I can open or hold them. So, even though it is mostly paralyzed, I can still make use of it to a useful degree…it also allows me to have it do things such as hold a handle on a bowl while using a hand mixer with my other hand and folding clothes. In being able to use it for these things has allowed me to regain some strength in it as well. I will never give up my nighttime splinting because I know first hand how much it helps. It may not seem like much to an OT but as a patient, I know I would not be nearly as productive. That being said, there is a big difference in hand splints…most do not work at all because the spasticity pulls the hand right out of the straps. I think every patient is different and what works for one may not work for the other because the level of spasticity varies so much. The other options they gave me were botox and muscle relaxers. I won’t ever try botox(poison) and for a while tried muscle relaxers which worked great for the first month and then they kept increasing the dose to the point of addiction(which they never told me that it was addictive) and it never worked well after that first month anyway. A study this short proves absolutely nothing.

    deb / Reply
  9. I am a post-stroke patient. I no longer use the hand-wrist splint provided by the rehab hospital over 2 years ago. It is difficult to put on with one hand. It holds my thumb in an unnatural position and the metal edge irritates the side of my palm. HOWEVER, I am looking at devices to wear while sleeping to hold my fingers in a comfortable position, ease contracture, and especially prevent fingernails from digging into my palm. This seems to be an intermittent problem, but a little comfort would be nice.

    Teri Davis / Reply
  10. Some colleagues of mine and I were having a discussions similar to this topic just other day.
    We have a pt who one OT wrote a contracture prevention goal with the use of splints, however the pt remains flaccid, limited interaction and participation who we are able to position well without splinting, I feel at this time there is no need to add a device to both the pt’s daily routine or the nursing staff who would have to manage the splint.
    For contractures I do use some splinting to help optimize positioning for joint protection and especially in hands where the finger nails are digging into the palm to help prevent additional issues because of the contracture. Like any good treatment should be it depends on all the factors for the individual so sometimes I like the use of splints, sometimes I don’t. experience in the population you are working with definitely helps you look at evidence differently than just reading it from the journal. Research and efficacy are extremely important to help the pt with to best treatments but they need to be the best intervention for that person at that time also.

    Sara Jo / Reply
    • I also usually try to engage pt, in other ROM programs or functional activities to promote improved muscle function to restore what functional use I can prior to utilizing any splinting in the long term. I do like to use some UE splints as tools to help the pt progress, much like using reachers and sock aids and walkers as opposed to just placing a splint and that be the only thing addressing an issue

      Sara Jo / (in reply to Sara Jo) Reply
  11. I have always use static splints post stroke, my aim is to for positioning, to prevent muscle, tendon and soft tissue shortening which may arise from prolong flexed wrist and digital joints as a result of stroke. From the evidence sampled in my practice it really helps, I also know that splinting will not help improve function, reduce spasticity but it can help reduce pain, maintain range of motion, comforts
    and positiom

    Alfred / Reply
  12. I am a physiotherapist with 15 years experience in treating stroke patients. Splinting is used by physiotherapists. I have found it not to be helpful and infact bad. Patients are happy to wear it because it can support positioning without spending much effort. It also reduces the workload for the therapist. Sadly, despite repeatedly proving that it is not beneficial, after so many years of existence of the profession haven’t we found better means to improve contracture than using splints and rest their hand and fingers in peace? Everywhere we see this. This shows how poorly we are trained in understanding biological system and/or we close our eyes and believe it is so. Over and above this those of us who claim it is beneficial cannot perform an RCT but tell ‘am seeing benefit’ so it is good and just write 4 lines claiming ineffective treatments to be so beneficial, art, tradition etc. We are happy in changing all aspects of our life as modern, but when it comes to patient care follow age old tradition, additionally creating wrong beliefs among patients that resting in peace will help in not worsening.
    Whole world is suffering because of lifestyle disorders and human body improves by being active. muscle length increases by being active.

    Vasanthan / Reply
    • So what do you prescribe for post stroke patients in a nursing home with limited resources

      COTA / (in reply to Vasanthan) Reply
      • The reason for looking at evidence is NOT to move with individual prescription. So, if some treatment starts to work, evidence will surface. Its important to keep looking for it. ‘it’ means the effect sizes with beneficial mcid from high quality RCT.

        Vasanthan / (in reply to COTA) Reply
  13. Thanks for sharing. It is always nice to share recommendations you think may be helpful when putting down the established therapy. Thanks!

    Katie / Reply
  14. Forty two years ago we focused on evidence in M.O.T. school and also in my high school and college biology classes. While it is very important to keep up with studies and evidence, ours is equally a field of art – the art of evaluating evidence as well as individuals. Also, I am concerned that many today see lack of evidence as proof it doesn’t work rather than need for more studies. I do not think today’s focus on the latest study, especially since most are so short and the average post stroke patient has many years of hygiene and function to deal with; so as in most good, double blind studies, this topic also sparks the need for longer term studies, comparison of different types of splints and wearing periods, level of severity, secondary effects such as protection, and predicting which clients will use it for longer . I agree with you that if the client is only to use if for a few months,, there is little benefit. Keep up your admirable concern for using the best procedures to give our clients their lives back.

    Sandra Otto / Reply
  15. Hey Danny, thanks for your work. We can definitely all strive for more evidenced based daily interventions. We have seen some research in the past few years in the effectiveness of dynamic splinting post stroke, including much done with the saebo brand splints. Resting hand splints are often used post stroke for a flaccid extremity to try to prevent damage to the hand and give a chance for tone to recover. Having the splint may not improve function in that case but is preventing unintentional injury when used with positioning recommendations. Additionally, while active stretching can be painful, a splint should not be painful to wear. If it is, it shouldn’t be worn. Again, thanks for your research, it’s a part of good clinical reasoning!

    Cheryl / Reply
  16. It is always nice and healthy to think aboutour daily practice. Although many reviews do not show evidence based results regarding splinting , some studies shows improvement or maintenance of range of motion, normalization of muscular activity, comfort and better positioning during daily activities or sleep,according to the goals, design and wear regimens of the splint and how the clientes understand it’s value and meaning. Is ouro work to develop more high quality studies to show and validate this practice that has been used for so many therapists and a long ago.

    denise / Reply

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