Determinants of the use of wrist working splints in rheumatoid arthritis

Authors


Abstract

Objective

To gain insight into the determinants of the use of wrist working splints among patients with rheumatoid arthritis (RA).

Methods

A qualitative descriptive study was performed among 18 patients with RA who recently received a fabric wrist working splint because of pain due to arthritis of the wrist. Patients were interviewed at home using semistructured in-depth interviews. Interviews were audiotaped and transcribed verbatim and analyzed using the framework approach.

Results

The majority of patients indicated that their splint use was dependent on the seriousness of the symptoms (pain, swelling, or tingling feelings) they perceived. Important reasons to wear the splint were reduction of symptoms, wrist support, and immobilization of the wrist. Important reasons to stop wearing the splint were reduced functional abilities using the splint and the performance of dirty or wet activities.

Conclusion

The reasons for patients to wear and not wear wrist working splints are related to intentional decisions of the patients, which are primarily based on perceived benefits and barriers of splint wearing. The results of this study have been used to develop educational and behavioral strategies to increase adherence to wearing wrist working splints.

INTRODUCTION

Wrist working splints are frequently prescribed to patients with rheumatoid arthritis (RA) and wrist arthritis (1). Their purpose is to reduce pain and inflammation and decrease the effort required to perform hand-related activities by providing rest, support, and stabilization of the wrist (1, 2). These splints permit movement of the metacarpophalangeal and finger joints, enabling the performance of activities. Studies on the efficacy of wrist working splints are scarce and are difficult to conduct. A serious methodologic issue concerns patients' adherence to the advice on wearing these splints. Adherence rates with splints are relatively low (1, 3). Nonadherence will affect the effect of splint treatment.

Knowledge of the determinants of adherence is necessary to improve adherence. Several theories explain health-related behavior and (non)adherence in particular, including the social cognitive theory and the theory of planned behavior. These theories treat adherence as intentional decisions of the patient to comply with health-related advice. These decisions are based on beliefs that adherent behavior will lead to certain positively or negatively valued outcomes (outcome expectations), and that an individual has the skills and abilities to perform the behavior under a variety of circumstances (self-efficacy). Furthermore, perceived benefits and barriers and social influences may exert influence on the motivation of the patient to adhere to health-related advice (4).

Many studies have provided evidence for the applicability of the above-mentioned theories on (non)adherence to treatment regimens in general (4–6). Studies on the determinants of adherence associated with the use of wrist working splints are scarce. Agnew and Maas performed a quantitative study on adherence among patients with RA who were fitted with a custom-made elastic wrist working splint (7). They concluded that the perceived benefit of splint wearing is the most important determinant of splint use, followed by the expectations of the doctor and family and ease of attaching the splint by means of loops. Moreover, patients tended to use their splints more with activities that place greater demands on the wrists and hands. Discomfort and appearance of the splint contributed little to adherence. It is questionable whether and to what extent these results can be generalized to Dutch patients and fabric (not custom-made) wrist working splints. Other studies have focused on perceived positive and negative aspects of several types of fabric splints, without relating this to (non)adherence (1, 8, 9). Another study investigated the conditions under which patients were most likely to wear a wrist working splint (type unknown), without focusing on the conditions under which patients were not likely to wear a splint (10). The results of these studies imply the following possible determinants of (non)adherence to splint wearing: relief of symptoms (pain, swelling), wrist support, increased hand strength, splint fitting and comfort, problems with attaching and removing the splint, limited freedom of movement, type of activity, and sex. Conflicting results were reported with regard to functional ability, which might be deteriorated or improved by splint wearing. A search of the literature on hand resting splints revealed some additional possible determinants of adherence to splint wearing, namely, seriousness of symptoms, patients' personality (extraversion) and demographic characteristics (age, education), disease duration, and therapist–client interaction (11–14).

The primary goal of the present study was to evaluate patients' motivations for and perceived barriers to using their wrist working splint. Once the determinants of splint use are known, measures can be taken to increase adherence and to study the efficacy of wrist working splints.

PATIENTS AND METHODS

Patients and study design.

Participants in this study were adult patients with RA who had recently (between 1 and 12 months earlier) received a fabric (commercially available) wrist working splint from their attending rheumatologist because of pain due to arthritis of the wrist. Eligible patients were identified from the hospital files and asked by mail by their rheumatologist to participate.

A qualitative descriptive approach, using in-depth interviews, was chosen to describe the experiences, knowledge, and opinions of patients with regard to the use of their splints (15). Patients who gave informed consent were visited and interviewed by an independent researcher (MJW). The interviews were semistructured to ensure that all relevant aspects were addressed. The main topics of the interviews, which were developed after studying the literature on determinants of adherence in general and determinants of adherence to splint wearing, are shown in Table 1. The interview format was pretested in 2 pilot interviews, which were excluded from further analysis. All interviews were audiotaped and transcribed verbatim (MJW).

Table 1. Main topics of the interviews with examples of questions
Prescription and knowledge
 Wearing advice
 Purpose of the splint and reason for prescription
 Other information given
 Satisfaction
 Example: What did the rheumatologist tell you about when you should wear the splint?
Splint use
 Activities during which the splint is (not) worn
 Example: Can you tell me during what activities you wear the splint?
Advantages and disadvantages of splint wearing
 Reasons to wear and not wear the splint
 Perceived and expected advantages and disadvantages
 Example: Why do you wear the splint during these activities?
Appearance, comfort, and fit of the splint
 Example: Does the appearance of the splint influence your splint wearing?
Social environment
 Verbal/nonverbal reactions
 Example: How did your family and acquaintances react when you started to wear a splint?

Analysis.

The interview transcripts were analyzed using the framework approach (16, 17). This approach consists of 5 stages. The first stage involved familiarization with the data by reading the transcripts and identifying major responses/statements (MMV). The second stage involved the development of a thematic framework. Five transcripts were discussed in detail with another researcher (ET) to identify all themes and subthemes by which the data can be examined. The thematic framework was guided by the main topics used in the interviews and by emerging issues from the familiarization stage. All themes and subthemes were given unique codes. In the third stage, called indexing, MMV and ET independently applied this thematic framework to the remaining 13 transcripts and coded all statements made by the patients. Interrater agreement on the codes was assessed by calculating kappa statistics. All statements to which initially different codes were ascribed were discussed by MMV and ET to fully reach consensus. Subsequently, the first 5 transcripts were coded using the thematic framework (MMV). In the fourth stage, all statements were grouped using the themes and subthemes from the thematic framework. The final stage consisted of interpretation of the results.

RESULTS

Fifty-seven patients were invited by mail to participate in this study. Of these, 20 gave informed consent and were interviewed, 9 indicated that they did not wish to participate, and the remaining 28 did not respond. Reasons for nonparticipation were not investigated. Two interviews were used as pilot interviews and were excluded from further analysis. The mean ± SD age of the patients was 56.3 ± 16.4 years. Most patients were female (78%) and married (72%). The mean ± SD time interval between splint prescription and interview was 6.0 ± 3.5 months. Almost all patients had received a splint for 1 hand (n = 17). One patient had received a splint for both hands. The interview results are presented in accordance with the main themes of the interviews. Kappa values for agreement between the codings of the 2 raters ranged from 0.47 to 1.00, indicating moderate to perfect agreement (18).

Prescription and knowledge.

Two types of splints were prescribed. Sixteen patients received a Rolyan D-ring (SproFit, Genk, Belgium) and 2 patients received a Futuro splint (BSN Medical, Almere, The Netherlands). Both types of splints had a removable volar metal stay. Only a few patients tried more than 1 type of splint. Some patients reported that they did not receive advice from their rheumatologist on wearing the splint. Others were advised to wear their splint when they had a painful wrist, by day and/or night, or when performing heavy activities.

Almost all patients were able to discuss the purpose of the splint and the reason for prescription. Mentioned purposes were pain reduction, rest, immobilization, support, protection, and reduction of tingling feelings. Reasons mentioned for prescription were pain, inflammation/swelling, and tingling feelings. A few patients were uncertain about this or had inaccurate knowledge. Regarding the function of the splint, one patient said: “The splint fits very tightly around my wrist. But, if this is the reason why I have less pins and needles in my fingers, I don't know.” Another patient stated: “If I had an inflammation in my wrist, I do not think that the splint would have influenced that.” Some patients were uncertain about the washing of the splint or the wearing schedule. Reported remarks were as follows: “Do the fasteners still work when they get wet?”; “Can the fasteners be cut shorter?”; “If you have a painful wrist, do you have to wear the splint then, or is it better to wait?”; “How could I best stop or diminish my splint use?” Other patients had inaccurate knowledge about this: “You cannot put the splint into the washing machine”; “The fasteners may not get wet, because then they will not work anymore.”

Few patients returned to the rheumatologist for control of their splint only. Most patients indicated not needing such a visit. Many patients stated that they already have to go to the hospital so many times that they call their rheumatologist when they have questions or experience problems. Finally, the majority of the patients stated being satisfied with the information they received during splint prescription. Only a few patients missed information on wearing advice, drying time after washing, and car driving.

Splint use.

Many patients indicated that splint use is dependent on the seriousness of the symptoms they perceive. Splints were only worn during periods of pain, swelling, or tingling feelings. One patient stated: “Only if my wrist really hurts do I want to wear the splint. I believe that it's better to go without the splint if you don't have too much pain.” Some patients used their splint on a daily basis and 1 patient indicated that she did not wear the splint. If patients used their splint, they used it during heavy activities or the whole day and/or night.

Many patients indicated that they did not wear their splint during wet or dirty activities (such as cleaning windows, mopping, and cooking), during personal care activities (such as bathing, dressing, and using the toilet), and at night. One patient said: “When I'm peeling potatoes I cannot wear the splint, because the splint will get dirty.” Another patient remarked: “I don't wear the splint when I'm dressing, even if I am experiencing pain. It is just very impractical, because the fasteners stick to my clothes.” Some patients indicated that they do not wear the splint at parties, when they are visiting people, or during meals.

Advantages.

Reduction of symptoms appeared to be a major reason to wear the splint, as this was reported by all patients. Symptoms that patients mentioned to be reduced by splint wearing were pain, tingling feelings, and swelling/inflammation. One patient noted: “The pain is really annoying. But if I wear the splint, it becomes lessened. The pain is not completely gone, but it just has become lessened.”

Many patients reported wrist support and rest/immobilization of the wrist as supplementary reasons to wear the splint. The latter, however, was simultaneously reported as a disadvantage of the splint by some of these patients. One patient remarked on the following as an advantage: “When I am driving in my car, I sometimes have to make a sudden movement with my wrist. This hurts a lot. When I am wearing my splint, this sudden movement is not possible because my wrist is fixed. So, I have less pain.” The same patient also remarked on the following as a disadvantage: “One reason to take off my splint is inconvenience. It is, for example, not possible to fasten my bra because of a lack of mobility of my wrist.”

Other mentioned advantages were improved functional abilities, prevention of overload of the wrist, increased strength, improved sleep, and less hard squeezing of other people's hands during hand shaking.

Disadvantages.

Although some patients indicated that their functional abilities improved by wearing the splint, the majority of patients also experienced decreased functional ability. Examples of activities that were more difficult to perform were dressing; going to the toilet; fine motor activities such as picking up tiny objects, fastening buttons, or turning a page; cycling and driving; holding and using cutlery; cooking; writing; and computer activities. Almost all patients took off their splint when they experienced reduced functional ability.

Two other major disadvantages and reasons to take off the splint were that the splint gets wet and dirty easily. One patient noted: “I always wear the sleeve of my sweater over my splint, so the splint does not get so dirty. If I do activities and the splint could get dirty, I always take off the splint.” Another patient said: “Of course, when I am in contact with water, like with bathing or doing the dishes, I do not wear the splint.”

Other reported disadvantages were long drying time, unpleasant physical contact with the splint because of the hard metal stay, sweating, wear and tear, difficulty wearing gloves and long-sleeved garments, inability to wear a watch, prohibited ability to drive a car, and inability to take off the splint independently. These disadvantages were (sometimes) reasons for patients not to wear the splint, except for wear and tear, difficulty wearing long-sleeved garments, and inability to wear a watch.

Expectations.

Most patients reported having positive expectations with regard to the effectiveness of the splint in advance. Some patients stated that they did not believe that a splint would relieve their symptoms. Some patients reported that they did not wear their splint the whole time because they did not want to become used to the splint and were afraid that their wrist would grow stiff or weak.

Appearance, comfort, and fit.

Most patients were neutral or negative on the appearance of their splint. Neutral patients judged the appearance of their splint as not important. Statements made by these patients were: “If you have pain, you gladly want to wear a splint, regardless of how it looks”; “The appearance of the splint does not interest me. If the splint is nice or not, the main point is that it is effective”; and “Even though the splint would be bluish purple with yellow dots, it does not interest me.” For some patients who were negative on the appearance of their splint, appearance was reason to take the splint off during special occasions such as going out, dining, or visiting people. A few patients were positive on their splint and 1 patient was positive on her right splint but negative on her left one, which was another type of splint.

Many patients were generally positive about the comfort and fit of the splint. Nevertheless, negative remarks on material, straps and metal stay, and/or side effects of the splint were made by almost all patients. These complaints are summarized in Table 2. For some patients, these complaints were reason enough to take off the splint.

Table 2. Negative comments made by the patients on comfort and fit of the splint
Material
 Not stain and waterproof
 Sweaty
Straps
 Stick to clothing
 Difficult to release
 Difficult to adjust equally
 Too long
Metal stay
 Feels hard, contact with splint not pleasant
 Slips out of splint proximally
 Decreases sense in palm of the hand
 Makes splint slippery
 Reduces grip
Side effects
 Unpleasant feelings (e.g., tingling) and/or pressure points due to tight fit

Social environment.

Almost all patients had heard responses from family members and acquaintances regarding their splint. Most reactions consisted of asking what is wrong with the wrist and why a splint is worn. Some people asked if they could help the patient and wanted to prevent the patient from overburdening his or her wrist. A minority of patients received attention from unknown people, such as staring or asking what is wrong. Many patients stated that the reactions of the social environment did not influence their splint use. One patient commented: “I do not care about the reactions of other people, the splint is for my own good.” Some patients were persuaded by their partners to wear or not wear the splint in certain situations.

DISCUSSION

This study demonstrates that splint use is dependent on the seriousness of the perceived symptoms. If patients experience wrist-related symptoms, they wear their splint primarily to reduce these symptoms. Other reasons are to support and/or immobilize the wrist. Reasons to take off or not wear the splint are related to perceived barriers of splint wearing. Important barriers are decreased functional abilities and dirty or wet activities. Other reasons to take off the splint are concerns with comfort and fit.

In the absence of a theoretical model on splint use, we used the social cognitive theory and the theory of planned behavior as frameworks to establish the determinants of splint use (4). The results of our study imply that splint use is related to patients' intentional decisions. This finding is fully in line with these theories. The social environment, another important determinant according to these theories, was not mentioned by our patients as a major influence on the decision to wear or not wear the splint. To assess the role of the social environment, we evaluated the influence of the reactions of people in the environment on splint use. Furthermore, we asked patients if they were encouraged or discouraged by people in their environment to use the splint and if they complied with this influence. We did not engage patients' perceptions on the value that these people place on splint use (subjective norms) or the outcome expectations of these people. Future studies might address the influence of these factors.

As an alternative to the general models for explaining splint use, we might have used more specific models of assistive technology (AT) outcomes (19–21). Many determinants of splint use that arose from our study are cited in these models. A specific model on the prediction of AT use has been introduced by Lenker and Paquet (20). According to this model, the intention to use AT is a function of perceived advantages in terms of effectiveness, efficiency, satisfaction, and subjective well-being, and might be modified by personal characteristics, task, AT intervention strength (including characteristics of the device and associated services), and environmental factors (20). An advantage of Lenker and Paquet's model over general models is that it provides a more detailed description of possible determinants of AT use. However, the model has not yet been validated. Validation and application of the model to splint use will require further attention in future studies.

The perceived advantages and disadvantages of splint wearing mentioned by our patients are largely in accordance with the results of previous studies on wrist working splints (1, 7–10). In this study, however, we also examined the relationship with splint use and nonuse. To the best of our knowledge, some perceived advantages, such as rest resulting from immobilization of the wrist and the experience of other people trying to prevent patients from overburdening their wrist (for example, by less hard squeezing during hand shaking or by opening a door), have never been mentioned before. The same is applied to some disadvantages patients perceived: unpleasant physical contact with the splint because of the hard metal stay, long drying time, and fear that the splint will weaken or stiffen the wrist. Feelings such as being less tense, reported by Nordenskiöld (8), were not mentioned by our patients. Furthermore, expectations of the doctor and family did not seem to be important determinants of splint use, in contrast to the findings of Agnew and Maas (7). These differences between our study and previous studies might be explained by differences in applied research methods (qualitative versus quantitative, interviews versus written questionnaires), type of questions (open-ended questions versus closed questions), type of wrist working splints, prescription process, and culture.

With regard to functional ability, both detrimental and beneficial effects were reported by the patients. Reasons to take off the splint during some activities were increased awkwardness and reduced wrist mobility, secure grip, and speed of performing activities. A reason to wear the splint was to enable the performance of some activities. Patients' perceptions concerning functional ability are largely in accordance with the results of clinical studies on the efficacy of wrist working splints. Detrimental effects were reported by Stern et al (22) and Pagnotta et al (23) with regard to time to accomplish daily activities. In contrast, Haskett et al (24) reported no harmful effect on time needed to accomplish daily tasks. Conflicting results with former studies might be attributed to differences in daily activities that have been carried out and the time between splint fitting and measurements (24). According to Haskett et al, it takes some time to become accustomed to the use of a splint (24). A small but positive effect of wrist splints was reported by Pagnotta et al (25) with regard to endurance and perceived task difficulty. The effect of splint wearing varied across the tasks, however. These studies demonstrate that perceived functional ability is likely to be task dependent. According to Pagnotta et al, splints are most detrimental for tasks that require a mobile wrist or a tight, secure grip of an object in the hand (23, 25). All in all, the results of these clinical studies emphasize the importance of informing the patients on the time needed to become accustomed to the use of a splint and the beneficial and detrimental effects of splints on functional ability to promote realistic expectations with regard to splint use and to increase adherence.

This study was performed among Dutch patients with RA with wrist pain due to wrist arthritis who were willing to participate in the study and who received a fabric wrist working splint at our rheumatology outpatient clinic. Splints were prescribed by the patients' attending rheumatologist, which is a usual practice in The Netherlands. Therefore, the results of this study should be generalized with caution to the entire population of patients with RA or all patients with an indication for a wrist working splint. However, barriers for splint use identified in this study (e.g., reduced functional ability, wet or dirty activities) are relevant for all patients who receive wrist working splints.

By knowing the determinants of splint use, measures can be taken to increase adherence. We focused on factors that could be changed, and developed educational and behavioral strategies to increase adherence (Table 3). Next to strategies derived from the results of our study and previous studies on wrist working splints, we included general adherence-enhancing measures, such as shared outcome expectations between the therapist and patient (13, 26), verbal and written instructions (5–7), monitoring adherent behavior (4–6, 27), and evaluation of the regimen (5, 6, 13). All of these adherence-enhancing measures will be used in a randomized controlled trial on the efficacy of wrist working splints.

Table 3. Educational and behavioral strategies to increase adherence to wrist working splint wearing
Splint prescription by an expert (occupational therapist) to optimize splint fitting and perceived comfort
Shared outcome expectations between occupational therapist and patient, and understanding of the regimen by the patient
 Outcome expectations of the patient concerning benefits and working of the splint are evaluated and discussed if necessary
 The daily activities of the patient are discussed and activities during which the splint will be worn are agreed upon
 Clear information is given on washing of the splint and the importance of adherence
 Understanding of the information is checked and the patient is given all opportunity to ask questions
Verbal and written instructions
Involvement of the patient in the selection of the splint
 The patient tries on several splints and chooses the most comfortable, aesthetic splint and/or the easiest to put on/remove
Discussing and removing barriers to wear the splint
 Patient's barriers for splint use are checked and removed if possible
 Information on possible barriers is given (e.g., performance of dirty or wet activities, possible impeding effect on some activities, possible side effects, long drying time, sticking of straps to clothing, etc.)
 As a solution for the performance of dirty and wet activities and a long drying time, the patient receives 2 identical splints
 To prevent the splint from getting wet and dirty during wet and dirty activities, the patient tries on several gloves and receives the best fitting
 To decrease the possibility that the straps will stick to clothing, and to make it easier to release the fasteners, the straps are cut at the correct size and folded and sewn up at the end
Patients keep a daily log of splint use to monitor and stimulate adherence
Evaluation of splint use after 1 week of prescription
 The patient is called by the occupational therapist to evaluate the perceived benefits and barriers of splint wearing, comfort and fit, and adherence; the occupational therapist takes measures/gives advice if necessary

AUTHOR CONTRIBUTIONS

Ms Veehof had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Study design. Veehof, Taal, Willems, van de Laar.

Acquisition of data. Veehof, Willems.

Analysis and interpretation of data. Veehof, Taal.

Manuscript preparation. Veehof, Taal, van de Laar.

Statistical analysis. Veehof, Taal.

Acknowledgements

The authors would like to thank the patients for their participation in this study.

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