This Article Abstract Full Text (PDF) CME: Take the course for this article: Stroke: January 2007, Volume 38, Number 1 All Versions of this Article: 38/1/111    most recent 01.STR.0000251722.77088.12v1 Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Request Permissions Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Lannin, N. A. Articles by Herbert, R. D. Search for Related Content PubMed PubMed Citation Articles by Lannin, N. A. Articles by Herbert, R. D. Related Collections Exercise/exercise testing/rehabilitation

(Stroke. 2007;38:111.)
© 2007 American Heart Association, Inc.

Original Contributions

Effects of Splinting on Wrist Contracture After Stroke

A Randomized Controlled Trial

Natasha A. Lannin, PhD; Anne Cusick, PhD; Annie McCluskey, PhD Robert D. Herbert, PhD

From the Rehabilitation Studies Unit, University of Sydney (N.A.L.); the School of Biomedical and Health Sciences, University of Western Sydney (A.C., A.M.); and the School of Physiotherapy, University of Sydney (R.D.H.), Sydney, Australia.

Correspondence to Natasha A. Lannin, Rehabilitation Studies Unit, Northern Clinical School, Faculty of Medicine, Royal Rehabilitation Centre, PO Box 6 Ryde, Sydney, NSW 2112 Australia. E-mail nlannin{at}mail.usyd.edu.au

	Abstract

Top Abstract Introduction Subjects and Methods Results Discussion References

 
Background and Purpose— Splints are commonly applied to the wrist and hand to prevent and treat contracture after stroke. However, there have been few randomized trials of this intervention. We sought to determine whether wearing a hand splint, which positions the wrist in either a neutral or an extended position, reduces wrist contracture in adults with hemiplegia after stroke.

Methods— Sixty-three adults who had experienced a stroke within the preceding 8 weeks participated. They were randomized to either a control group (routine therapy) or 1 of 2 intervention groups (routine therapy plus splint in either a neutral or an extended wrist position). Splints were worn overnight for, on average, between 9 and 12 hours, for 4 weeks. The primary outcome, measured by a blinded assessor, was extensibility of the wrist and long finger flexor muscles (angle of wrist extension at a standardized torque).

Results— Neither splint appreciably increased extensibility of the wrist and long finger flexor muscles. After 4 weeks, the effect of neutral wrist splinting was to increase wrist extensibility by a mean of 1.4° (95% CI, –5.4° to 8.2°), and splinting the wrist in extension reduced wrist extensibility by a mean of 1.3° (95% CI, –4.9° to 2.4°) compared with the control condition.

Conclusions— Splinting the wrist in either the neutral or extended wrist position for 4 weeks did not reduce wrist contracture after stroke. These findings suggest that the practice of routine wrist splinting soon after stroke should be discontinued.

Key Words: function • pain • occupational therapy • upper limb disability • spasticity

	Introduction

Top Abstract Introduction Subjects and Methods Results Discussion References

 
Hemiplegia is often associated with contracture.¹ The joints most prone to contracture are the wrist and ankle.² Contractures of the arm are more prevalent than those of the leg.³ Wrist flexion contractures develop rapidly after stroke in people who have no early movement recovery.¹

To prevent contractures, people who have had a stroke are often prescribed wrist splints to wear at night.^4–6 Wrist splints are thought to prevent or reduce contracture, and the belief is that this will contribute to hand function, should motor recovery occur. Because the aim of splinting is to influence muscle extensibility, the degree of stretch provided by the splint is important. Some therapists believe that positioning a muscle close to its end of range will provide a greater effect on contracture.^6,7

The efficacy of hand splinting after stroke has been examined in several reviews.^8–10 Each review has concluded that there is insufficient evidence to either support or refute the effectiveness of hand splinting. Published trials either did not include a no-stretch control group^11–13 or suffered from methodological limitations such as short follow-up,¹³ lack of blinded assessment of outcomes,^11,13,14 or low statistical power.^11,13,14 We have previously published a trial of hand splinting with the wrist in neutral, which found no difference in outcomes between groups who received splinting plus hand stretching versus stretching alone.¹² Although adequately powered with blinded assessment of outcomes, the study did not compare the effect of splinting with a no-splint control group.

The aim of the current study was to determine the effect of 4 weeks of night splinting on contracture in the wrist and long finger flexor muscles in adults after stroke. Because there is uncertainty about whether the degree of stretch applied to splinted muscles is important, we also sought to determine whether splinting the wrist in an extended position was more effective than splinting the wrist in a neutral position.

	Subjects and Methods

Top Abstract Introduction Subjects and Methods Results Discussion References

 
The study was an assessor-blind, randomized, controlled, multicenter trial. The trial was undertaken from October 2002 through to September 2004 in 9 inpatient rehabilitation and stroke units in Sydney, Australia.

Participants
Sixty-three inpatients were recruited. To be included in the trial, participants had to have had a stroke within the previous 8 weeks; have been aged 18 years or older; have had no active wrist extension; have had sufficient cognitive and hearing function to be able to provide informed consent and fully participate in the trial; and to have resided in the greater Sydney metropolitan area. The sample size of 63 participants was sufficient to provide a 95% probability of detecting a 5° change in wrist extension, assuming a within-group standard deviation of 4.1°,¹² an of 0.05, and a loss to follow-up of 20%.

Participants were randomly assigned to 1 of 3 equally sized groups after baseline assessments were made: a neutral splint group, an extension splint group, or a control group. The allocation schedule was computer generated and concealed in opaque, consecutively numbered envelopes by a person not otherwise involved in the study.

Informed consent was obtained from each participant or, where appropriate, his or her legal guardian. The respective institutional review boards approved the study protocol at each institution.

Intervention
Participants in both splint groups wore custom-made, static, palmar mitt splints¹⁵ for up to 12 hours overnight for the 4-week intervention period. Participants in the neutral splint group wore a hand splint, which positioned the wrist in 0° to 10° extension^16,17 (Figure 1). Participants in the extension splint group wore a hand splint, which positioned the wrist in a comfortable end-of-range position (>45° wrist extension; Figure 2) with the metacarpophalangeal and interphalangeal joints extended.

View larger version (17K): [in this window] [in a new window]   Figure 1. Neutral wrist splint.

View larger version (32K): [in this window] [in a new window]   Figure 2. Extended wrist splint.

Control group participants did not wear a hand splint for the study period. Participants in all 3 groups received usual rehabilitation, except that stretches of the wrist or long finger flexor muscle were not performed during the 6-week study period. A maximum of 10 minutes of isolated wrist and finger extension practice was permitted per day in line with usual rehabilitation practices at the participating centers.

Outcomes
Measures were assessed at baseline (before randomization), after 4 weeks of intervention (12 to 24 hours after removal of the splint), and 6 weeks after randomization by an independent assessor who was unaware of which treatment the patient had received.

The primary outcome was extensibility of the wrist and finger flexor muscles. Muscle extensibility was determined by measuring wrist extension range with the metacarpophalangeal and interphalangeal joints in the extended position. A standardized torque was applied by using a device specifically designed for the purpose and previously tested for test-retest reliability (intraclass correlation coefficient=0.85).¹⁸ The method has been described in detail elsewhere.^12,18 In this study, the angle of wrist extension was measured from lateral photographs. Three consecutive measurements were taken on each occasion, and the mean of the 3 recordings was used for subsequent analysis.

Secondary measures included upper limb function, spasticity, and self-reported disability and symptoms. Upper limb function was assessed by summing scores of the 3 upper limb items of the Motor Assessment Scale (upper arm function, hand movements, advanced hand activities items),¹⁹ yielding a score of 0 to 18. The reliability and validity of this assessment scale have been established.^19–21 Spasticity was measured with the Tardieu scale.^22,23 The Tardieu scale yields both a spasticity rating and a spasticity angle. The spasticity rating quantifies muscle tone by measuring the intensity of the muscle reaction at specified velocities and is a score between 0 (no resistance) and 4 (unfatigable clonus at a precise angle). The difference between the angle of arrest of the joint at slow speed and the angle of catch at fast speed is called the spasticity angle. The spasticity angle provides an estimation of the relative contribution of neural mechanisms (spasticity) and the mechanical restraint of the soft tissues (the larger the spasticity angle, the greater the contribution of spasticity). The Tardieu scale is a valid clinical measure of spasticity after stroke.²⁴ Disability was assessed with the Disabilities of the Arm, Shoulder, and Hand Outcome Measure (DASH).²⁵ The DASH consists of a 30-item disability/symptom scale that is transformed to a percentage score ranging from 0 (no disability) to 100 (most severe disability). Pain scores were obtained from the DASH pain severity item (recorded as a percentage, with higher scores indicating greater perceived severity of pain at rest). Research has demonstrated the validity, reliability, and responsiveness of the DASH for clinical and research purposes.^26–28

Data Reduction and Analysis
Data were analyzed on an intention-to-treat basis.²⁹ Thus, outcome measures were obtained for all participants recruited to the trial, irrespective of compliance, and participants’ data were analyzed in the group to which they had been allocated. To determine the effects of splinting, we conducted an ANCOVA with the baseline extensibility score as a covariate to increase the precision of the estimate. Statistical significance was set at P<0.05.

	Results

Top Abstract Introduction Subjects and Methods Results Discussion References

 
Of 95 people screened, 82 were identified as eligible, and 63 agreed to participate and were randomized to the 3 groups (Figure 3). The groups were similar at baseline (Table 1).

View larger version (33K): [in this window] [in a new window]   Figure 3. Flow of participants through the trial. *One participant was randomized to the neutral splinting program but not included in the primary analysis after revision of the initial diagnosis of stroke by an independent physician blinded to treatment and outcome. One participant from each group refused to complete the primary outcome measure at follow-up; all secondary measurements were completed.

View this table: [in this window] [in a new window]   TABLE 1. Baseline Characteristics of the Study Groups

No participant withdrew from the study. One participant in each group refused the primary outcome measure at 6 weeks only (4.8% of sample). One participant in the neutral splint group had his diagnosis of stroke revised by a physician who was not involved in the study and who was blinded to treatment allocation. Data were therefore excluded from analyses, in line with recommendations on acceptable postrandomization exclusions in the application of intention-to-treat analysis.³⁰

The trial protocol dictated that participants receive 28 nights of splinting to the hemiplegic wrist of up to 12 hours per night: a total maximum time of 336 hours of splinting. Overall, there was high compliance with the splinting regimen. Participants wore their splints for a mean of 10 hours, 11 minutes per night (SD, 2.0 hours). There was higher compliance with the neutral splint (mean, 11.0 hours; SD, 1.1 hours) than with the extension splint (mean, 9.4 hours; SD, 2.3 hours; difference, 1.7 hours; 95% CI, 0.5 to 2.8 hours). Outcomes of all participants were assessed within 2 days of the final night of splinting.

Primary Outcome
On average, participants experienced a moderate loss of range of motion (mean, 16.7°; SD, 15.1°) during the 6-week study period. Splinting had little or no effect on the loss of range of motion (Figure 4). The mean effect in the neutral splint group was 1.4° (95% CI, –5.4° to 8.2°) at 4 weeks and 4.2° (95% CI, –3.2° to 11.7°) at follow-up compared with the control group. The mean treatment effect in the extension splint group was –1.3° (95% CI, –4.9° to 2.4°) at 4 weeks and 1.8° (95% CI, –3.4° to 5.1°) at follow-up compared with the control group.

View larger version (14K): [in this window] [in a new window]   Figure 4. Mean (SD) of wrist extension of all groups at commencement of the study (baseline), then after 4 weeks of splint intervention (end of treatment), and then 2 weeks after removal of the splint (follow-up).

Secondary Outcomes
The effects of splinting on secondary outcomes (upper limb function, spasticity, and self-reported disability and symptoms) were clinically unimportant and statistically nonsignificant (Table 2).

View this table: [in this window] [in a new window]   TABLE 2. Outcome Scores and Estimates of Effects of All Outcome Measures for the Control Group (n=21), Neutral Splint Group (n=20), and Extended Splint Group (n=21)

	Discussion

Top Abstract Introduction Subjects and Methods Results Discussion References

 
The primary finding of this study is that an intensive 4-week splinting program did not increase the extensibility of the wrist and long finger flexor muscles in adults after stroke.

On average, participants in the trial lost 17° of wrist range of motion by the end of the 6-week study. This finding of progressive loss of muscle extensibility in the hemiplegic upper limb after stroke is not new. Turton and Britton,³¹ in their trial evaluating stretch positioning in the upper limb, reported a loss of 13° of wrist extension range and 15° of shoulder external rotation range at 8 weeks, regardless of whether or not participants received prolonged stretching. Ada and colleagues⁷ also reported a progressive loss of shoulder range of motion in their trial. Participants who were receiving shoulder stretches to prevent loss of external rotation for 30 minutes, 5 days a week, lost an average of 6° of range over 4 weeks; those receiving shoulder flexion stretches lost nearly 12° of range on average.⁷

Splinting the wrist in extension for an average of 9 hours overnight did not result in an increase in range of movement. Current thinking, based on animal studies, is that muscle length adapts to stretch.^32–34 It has been hypothesized that longitudinal muscle growth occurs in response to the average position in which a muscle is held.³⁵ However, results from the current trial are contrary to findings predicted by this model. The results are consistent with a number of high-quality, randomized, controlled trials on neurological populations, all of which have shown that stretching programs do not produce clinically important effects on joint range of motion or muscle extensibility.^{12,31,36–38} After an earlier trial of hand splinting for stroke patients, which found that splinting was ineffective,¹² we speculated that hand splints that administered greater stretch at the wrist might be beneficial. In the current study, extension splints were monitored on a weekly basis and remolded to maintain stretch and maximize torque. Despite this, we have shown that splinting the wrist in either a neutral or an extended position did not produce clinically useful effects in adults after stroke.

The effects of splinting on spasticity were not statistically significant or clinically important. The common belief that hand splinting reduces spasticity^6,16,39 was therefore not supported by this study.

The strengths of this study are that it used a concealed, random allocation to intervention and control groups, blinded assessment of outcomes, used valid outcome measures, had complete follow-up, specified primary outcomes a priori, and analyzed data by intention to treat. Also, the patients were representative of those for whom splints might be considered, and the intervention (at least of neutral splinting) resembled that commonly used in clinical practice. Therefore, the results should be generalizable to the stroke population undergoing acute rehabilitation. One limitation was that participants were not blinded. This would have been difficult or impossible. Nonblinding of participants raises the possibility of bias attributable to placebo effects and differential misreporting of subjective outcomes. Differential misreporting of outcomes could not have substantially biased the findings because the majority of outcomes were objective measures (not self-reported) obtained by blinded assessors.⁴⁰

This trial involved splinting participants for 4 weeks. Longer-term effects of splinting were not examined. Nonetheless, we believe that the intervention was applied for a long enough period to observe an effect of intervention, if such an effect exists, because we observed moderate losses of wrist range of motion during the same time period.

Summary
The results of this study demonstrate that 4 weeks of overnight splinting in either a neutral or an extended wrist position does not prevent loss of range of motion at the wrist and that the use of a splint is no better than not splinting. These findings suggest that the routine practice of hand splinting to prevent muscle contracture during acute rehabilitation after stroke should be discontinued.

	Acknowledgments

 
The authors acknowledge the assistance of Belinda Armstrong, Annemieke Clark, Nadia Downey, Merilyn Ferris, Glade Vyslysel, Michelle Turnbull, Valerie Webster, Melani Boyce, Joanne Glinsky, Jan Hancock, Jenni Johnson, Alison Pearce, Natalie Fairbairn, Lauren Wade, and Rachael McQueen in completing this study. We also thank Darren Thomas, who built the measuring device.

Sources of Funding

Financial support for the study was provided through a University of Western Sydney Postgraduate Research Award. The study was undertaken at Bankstown Hospital, Blacktown Hospital, Mount Wilga Private Hospital, Prince Henry Hospital, Prince of Wales Hospital, Sacred Heart Rehabilitation Hospice, St. Joseph’s Hospital, War Memorial Hospital, and Westmead Hospital.

Disclosures

None.

	Footnotes

 
Continuing medical education (CME) credit is available for this article. Go to http://cme.ahajournals.org to take the CME quiz.

Received June 6, 2006; revision received July 21, 2006; accepted August 14, 2006.

	References

Top Abstract Introduction Subjects and Methods Results Discussion References

 

1. Pandyan AD, Cameron M, Powell J, Stott DJ, Granat MH. Contractures in the post-stroke wrist: a pilot study of its time course of development and its association with upper limb recovery. Clin Rehabil. 2003; 17: 88–95.[Abstract/Free Full Text]
2. Twitchell TE. The restoration of motor function following hemiplegia in man. Brain. 1951; 74: 443–480.[Free Full Text]
3. Yip B, Stewart DA, Roberts MA. The prevalence of joint contractures in residents in NHS continuing care. Health Bull. 1996; 54: 338–343.
4. Duncan RM. Basic principles of splinting the hand. Phys Ther. 1989; 69: 1104–1116.[Medline] [Order article via Infotrieve]
5. Lowe CT. Construction of hand splints. In: Trombly CA, ed. Occupational Therapy for Physical Dysfunction. 4th ed. Baltimore, Md: Williams & Wilkins; 1995: 583–597.
6. Milazzo S, Gillen G. Splinting applications. In: Gillen G, Burkhardt A, eds. Stroke Rehabilitation: A Function-Based Approach. St Louis: Mosby; 1998: 161–184.
7. Ada L, Goddard E, McCully J, Stavrinos T, Bampton J. Thirty minutes of positioning reduces the development of shoulder external rotation contracture after stroke: a randomized controlled trial. Arch Phys Med Rehabil. 2005; 86: 230–234.[CrossRef][Medline] [Order article via Infotrieve]
8. Dobkin BH. Rehabilitation after stroke. N Engl J Med. 2005; 352: 1677–1684.[Free Full Text]
9. Lannin NA, Herbert RD. Is hand splinting effective for adults following stroke? a systematic review and methodologic critique of published research. Clin Rehabil. 2003; 17: 807–816.[Abstract/Free Full Text]
10. Steultjens EMJ, Dekker J, Bouter LM, van de Nes JCM, Cup EHC, van den Ende CHM. Occupational therapy for stroke patients: a systematic review. Stroke. 2003; 34: 676–687.[Abstract/Free Full Text]
11. Langlois S, Pederson L, Mackinnon JR. The effects of splinting on the spastic hemiplegic hand: report of a feasibility study. Can J Occup Ther. 1991; 58: 17–25.[Medline] [Order article via Infotrieve]
12. Lannin NA, Horsley SA, Herbert R, McCluskey A, Cusick A. Splinting the hand in the functional position after brain impairment: a randomized, controlled trial. Arch Phys Med Rehabil. 2003; 84: 297–302.[CrossRef][Medline] [Order article via Infotrieve]
13. Rose V, Shah S. A comparative study on the immediate effects of hand orthoses on reduction of hypertonus. Aust Occup Ther J. 1987; 34: 59–64.
14. McPherson JJ, Kreimeyer D, Aalderks M, Gallagher T. A comparison of dorsal and volar resting hand splints in the reduction of hypertonus. Am J Occup Ther. 1982; 36: 664–670.[Medline] [Order article via Infotrieve]
15. Copley J, Kuipers K. Management of Upper Limb Hypertonicity. San Antonio, Tex: Therapy Skill Builders; 1999.
16. Wilton JC. Splinting and casting in the presence of neurological dysfunction. In: Wilton JC, ed. Hand Splinting: Principles of Design and Fabrication. London, UK: WB Saunders; 1997: 168–197.
17. Gillen G, Burkhardt A. In: Stroke Rehabilitation: A Function-Based Approach. St. Louis, MO: Mosby; 1998.
18. Harvey L, King M, Herbert R. Test-retest reliability of a procedure for measuring extensibility of the extrinsic finger flexor muscles. J Hand Ther. 1994; 7: 251–254.[Medline] [Order article via Infotrieve]
19. Carr JH, Shepherd RB, Nordholm L, Lynne D. Investigation of a new motor assessment scale for stroke patients. Phys Ther. 1985; 55: 175–180.
20. Poole J, Whitney S. Motor assessment scale for stroke patients: concurrent validity and interrater reliability. Arch Phys Med Rehabil. 1988; 69: 195–197.[Medline] [Order article via Infotrieve]
21. Lannin N. Reliability, validity and factor structure of the upper limb subscale of the Motor Assessment Scale (UL-MAS) in adults following stroke. Disabil Rehabil. 2004; 26: 109–116.[CrossRef][Medline] [Order article via Infotrieve]
22. Tardieu G, Shentoub S, Delarue R. A la recherché d’une technique de mesure de la spasticite. Rev Neurol. 1954; 91: 143–144.[Medline] [Order article via Infotrieve]
23. Gracies JM, Marosszeky JE, Renton R, Sandanam J, Gandevia SC, Burke D. Short-term effects of dynamic Lycra splints on upper limb in hemiplegic patients. Arch Phys Med Rehabil. 2000; 81: 1547–1555.[CrossRef][Medline] [Order article via Infotrieve]
24. Patrick E, Ada L. The Tardieu Scale differentiates contracture from spasticity whereas the Ashworth Scale is confounded by it. Clin Rehabil. 2006; 20: 173–182.[Abstract/Free Full Text]
25. McConnell S, Beaton DE, Bombardier C. The DASH Outcome Measure: a User’s Manual. Toronto: Institute for Work and Health; 1999.
26. Beaton DE, Katz JN, Fossel AH, Wright JG, Tarasuk V, Bombardier C. Measuring the whole or the parts? validity, reliability and responsiveness of the disabilities of the arm, shoulder, and hand outcome measure in different regions of the upper extremity. J Hand Ther. 2001; 14: 128–146.[Medline] [Order article via Infotrieve]
27. MacDermid JC, Tottenham V. Responsiveness of the disability of the arm, shoulder, and hand (DASH) and patient-rated wrist/hand evaluation (PRWHE) in evaluating change after hand therapy. J Hand Ther. 2004; 17: 18–23.[Medline] [Order article via Infotrieve]
28. SooHoo NF, McDonald AP, Seiler JG, McGillivrary GR. Evaluation of construct validity of the DASH questionnaire by correlation to the SF-36. J Hand Surg. 2002; 27: 537–541.[CrossRef][Medline] [Order article via Infotrieve]
29. Lachin JM. Statistical considerations in the intent-to-treat principle. Control Clin Trials. 2000; 21: 167–189.[CrossRef][Medline] [Order article via Infotrieve]
30. Fergusson D, Aaron SD, Guyatt G, Hébert P. Post-randomisation exclusions: the intention to treat principle and excluding patients from analysis. BMJ. 2002; 325: 652–654.[Free Full Text]
31. Turton AJ, Britton E. A pilot randomized controlled trial of a daily muscle stretch regime to prevent contractures in the arm after stroke. Clin Rehabil. 2005; 19: 600–612(erratum in Clin Rehabil. 2006;20:91).[Abstract/Free Full Text]
32. Herbert RD. How muscles respond to stretch. In: Refshauge KR, Ada LM, Ellis EE, eds. Science-Based Rehabilitation: Theories Into Practice. Oxford: Elsevier; 2004: 107–130.
33. Herbert R. The passive and mechanical properties of muscle and their adaptations to altered patterns of use. Aust J Physiother. 1988; 34: 141–149.
34. Williams PE. Effect of intermittent stretch on immobilised muscle. Ann Rheum Dis. 1988; 47: 1014–1016.[Abstract/Free Full Text]
35. Wren TA. A computational model for the adaptation of muscle and tendon length to average muscle length and minimum tendon strain. J Biomech. 2003; 36: 1117–1124.[CrossRef][Medline] [Order article via Infotrieve]
36. Ben M, Harvey L, Denis S, Glinsky J, Goehl G, Chee S, Herbert R. Does 12 weeks of regular standing prevent loss of ankle mobility and bone mineral density in people with recent spinal cord injuries? a randomized controlled trial. Aust J Physiother. 2005; 51: 251–256.[Medline] [Order article via Infotrieve]
37. Harvey LA, Batty J, Crosbie J, Poulter S, Herbert RD. A randomized trial assessing the effects of 4 weeks of daily stretching on ankle mobility in patients with spinal cord injuries. Arch Phys Med Rehabil. 2000; 81: 1340–1347.[CrossRef][Medline] [Order article via Infotrieve]
38. Harvey LA, Byak AJ, Ostrovskaya M, Glinsky J, Katte L, Herbert RD. Randomised trial of the effects of four weeks of daily stretch on extensibility of hamstring muscles in people with spinal cord injuries. Aust J Physiother. 2003; 49: 176–181.[Medline] [Order article via Infotrieve]
39. Kogler GF. Orthotic management. In: Gelber DA, Jeffery DR, eds. Clinical Evaluation and Management of Spasticity. Totowa, NJ: Humana; 2002: 67–91.
40. Schulz KF, Chalmers I, Altman DG. The landscape and lexicon of blinding in randomized trials. Ann Intern Med. 2002; 136: 254–259.[Free Full Text]

This article has been cited by other articles:

				J. E. Marossezky, J. A. Gurka, and I. J. Baguley Splinting Poststroke: the Jury Is Still Out Stroke, February 1, 2008; 39(2): e46 - e46. [Full Text] [PDF]

				N. Lannin, A. McCluskey, R. Herbert, and A. Cusick Response to Letter by Marossezky et al Stroke, February 1, 2008; 39(2): e47 - e47. [Full Text] [PDF]

				C. Manigandan and J. Charles Effect of Hand Splinting: Isn't Temporality Crucial? Stroke, November 1, 2007; 38(11): e146 - e146. [Full Text] [PDF]

				R. Herbert, N. Lannin, A. Cusick, and A. McCluskey Response to Letter by Manigandan and Charles Stroke, November 1, 2007; 38(11): e147 - e147. [Full Text] [PDF]

				S. Shah Wrist Splint for Upper Motor Neuron Paralysis Stroke, August 1, 2007; 38(8): e74 - e74. [Full Text] [PDF]

				R. D. Herbert, N. A. Lannin, A. McCluskey, and A. Cusick Response to Letter by Shah Stroke, August 1, 2007; 38(8): e75 - e75. [Full Text] [PDF]

				C. Seneviratne Overnight splinting of the wrist in a neutral or extended position did not prevent contracture after stroke Evid. Based Nurs., July 1, 2007; 10(3): 86 - 86. [Full Text] [PDF]

This Article Abstract Full Text (PDF) CME: Take the course for this article: Stroke: January 2007, Volume 38, Number 1 All Versions of this Article: 38/1/111    most recent 01.STR.0000251722.77088.12v1 Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Request Permissions Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Lannin, N. A. Articles by Herbert, R. D. Search for Related Content PubMed PubMed Citation Articles by Lannin, N. A. Articles by Herbert, R. D. Related Collections Exercise/exercise testing/rehabilitation