As understood from a biomechanical hand therapy perspective, splints protect, preserve and mobilize tissues for the eventual physical recovery-and ultimate functional recovery-of the client. But splints also have the capacity to actually enable function when it is not otherwise possible because of an acute or chronic orthopedic problem. From this perspective, splinting becomes occupation-based.
Occupation-based splinting ensures the ability of the individual with hand dysfunction to engage in desired life tasks and occupations. Occupation-based splinting can be defined as attention to the occupational desires and needs of the individual, paired with the knowledge of the effects (or potential effects) of pathological conditions of the hand, and managed through client-centered splint design and provision.
As with general occupation-based practice, the first step to occupation-based splinting is to complete an assessment that evaluates the client, using a top down (abilities first, pathology second) approach. The most important information for the occupational therapist to determine is: What are the client's areas of dysfunction and what are his personal goals and desired occupations? Enabling the goals and occupations that are identified as significantly important to the client should become priority, particularly if a pathology that can be overcome through splinting is the cause of dysfunction.
Historical to occupational therapy is our concern for the entire life experience of the client. We understand that behind a healing limb is a person who has been removed from his normal experience of living. When splinting from an occupation based perspective, a therapist may actually encourage splint use to enhance function that was originally not suggested to aide in body healing.
An example is the case of a young mother who sustained a radial head fracture. To preserve movement, the physician instructed the woman to discontinue sling use after one week and to then begin gentle movement with absolutely no resistance to the arm; no splint was issued. Every OT/hand therapist who has worked with a stiff elbow understands the importance of movement in preventing contractures; this physician might be applauded for choosing movement over immobilization.
However, this particular woman was now unable to care for her 6-month old child. She was concerned that dressing, bathing, lifting and playing with her child might challenge her to use her fractured dominant arm. Without a supportive device, she thought it wise to send the child to live with relatives until her elbow was completely healed. Needless to say, this relatively simple fracture was now instrumental in creating a very sad and concerned parent who was having many functional difficulties due to fear of use.
The therapist recommended a thermoplastic splint holding the elbow in 60 degrees of flexion. When cleared by the physician, the client wore the splint whenever she wished to engage in an activity that had potential force. She was provided with specific guidelines for splint use and splint removal. The young women felt confident again in caring for her child; a splint enabled occupation.
When splinting from an occupation-based perspective, therapists should enable function while protecting and preserving healing or damaged structures. For example, in the case of DeQuervains' tenosynovitis or CMC arthritis, a therapist may be inclined to fabricate a standard forearm based thumb spica splint that immobilizes the wrist and thumb (to the IP joint) completely. Such a splint can cause awkward use of the hand, creating difficulty with tasks such as writing, cooking and dressing. In contrast, providing a minimally sized radial gutter thumb splint that extends only 3 inches past the wrist can provide adequate immobilization for the pathology but ensure mobility of the ulnar hand and wrist; allowing increased ease of function.
Splints designed as components of post-op protocols have not been created with the preservation of immediate occupational needs in mind. The hand therapist who understands the physical need that the splint must fill and the occupational needs of the client can often modify the splint to ensure that all needs are being met. With prior physician approval, a volar forearm-based resting pan type splint that holds the wrist and digits in flexion could be created in place of a dorsal blocking splint for a 5th digit flexor tendon repair client. This modification may be an option for a client who must continue to work on a computer key board post repair. The client may have attempted compensations, but developed secondary shoulder pain as a result of the excessive shoulder elevation and internal rotation required to enable the index finger to type within a dorsal splint. This new splint is not intended to be a substitute for the dorsal blocking splint, but to simply be used intermittently at work to enable function. The client is able to resume standard protocol exercise between as appropriate.
Open and ongoing communication within the client-physician- therapist triad can ensure that all goals are addressed quickly and thoroughly through the technique of occupation-based splinting.
Deborah Amini, MEd, OTR/L, CHT, is director of the occupational therapy assistant program at Cape Fear Community College in Wilmington, NC. A 1983 graduate of Quinnipiac University, Hamden, CT, she has been a clinical hand therapist for 17 years. Readers may reach her at 910-362-7096 or by e-mail at firstname.lastname@example.org. or through ADVANCE at email@example.com.