Clinical Reasoning for Splint Fabrication


Clinical Reasoning for Splint Fabrication

Note: This chapter includes content from previous contributions from Sally E. Poole, MA, OTR, CHT and Joan L. Sullivan, MA, OTR, CHT.

In clinical practice there is no simple design or type of splint that applies to all diagnoses. Splint design and wearing protocols vary because each injury is unique. Clinical reasoning regarding which splint to fabricate involves considering the physician’s referral, the physician’s surgical and rehabilitation protocol, the therapist’s conceptual model, the therapist’s assessment of the person’s needs based on objective and subjective data gathered during the evaluation process, and knowledge about the reimbursement source.

Instructors sometimes teach students only one way to do something when in reality there may be multiple ways to achieve a goal. For example, this book emphasizes the typical methods that generalist clinicians use to fabricate common splints. Learning a foundation for splint fabrication is important. In clinical practice, however, the therapist should use a problem-solving approach and apply clinical reasoning to address each person who needs a splint. Clinical reasoning may include integration of knowledge of biomechanics, anatomy, kinesiology, psychology, conceptual models, pathology, splinting protocols and techniques, clinical experience, and awareness of the person’s motivation, compliance, and lifestyle (occupational) needs.

This chapter first overviews clinical reasoning models and then addresses approaches to clinical reasoning from the moment the therapist obtains a splint referral until the person’s discharge. This chapter also presents prime questions to facilitate the clinical reasoning process the therapist undertakes during treatment planning throughout the person’s course of therapy.

Clinical Reasoning Models

Clinical reasoning helps therapists deal with the complexities of clinical practice. It involves professional thinking during evaluation and treatment interventions [Neistadt 1998]. Professional thinking is the ability to distinctly and critically analyze the reasons for whatever actions therapists make and to reflect on the decisions afterward [Parham 1987]. Skilled therapists reflect throughout the entire splinting process (reflection in action), not solely after the splint is completed (reflection on action) [Schon 1987]. Clinical reasoning also entails understanding the meaning a disability, such as a hand injury, has for each person from the person’s perspective [Mattingly 1991]. Various approaches to clinical reasoning have been depicted in the literature, including interactive, narrative, pragmatic, conditional, and procedural reasoning. Although each of these approaches is distinctive, experienced therapists often shift from one type of thinking to another to critically analyze complex clinical problems [Fleming 1991] such as splinting.

Interactive reasoning involves getting to know the person as a human being so as to understand the impact the hand condition has had on the person’s life [Fleming 1991]. Understanding this can help identify the proper splint to fabricate. For example, for a person who is very sensitive about his or her appearance after a hand injury the therapist may select a skin-tone splinting material that blends with the skin and attracts less attention than a white splinting material.

With narrative reasoning, the therapist reflects on the person’s occupational story (or life history), taking into consideration activities, habits, and roles [Neistadt 1998]. For assessment and treatment, the therapist first takes a top-down approach [Trombly 1993] by considering the roles the person had prior to the hand condition and the meaning of occupations in the person’s life. The therapist also considers the person’s future and the impact the therapist and the person can have on it [Fleming 1991]. For example, through discussion or a formal assessment interview a therapist learns that continuation of work activities is important to a person with carpal tunnel syndrome. Therefore, the therapist fabricates a wrist immobilization splint positioned in neutral and has the person practice typing while wearing the splint.

With pragmatic reasoning, the therapist considers practical factors such as reimbursement, public policy regulations, documentation, availability of equipment, and the expected discharge environment. This type of reasoning includes the pragmatic considerations of the therapist’s values, knowledge, and skills [Schell and Cervero 1993, Neistadt 1998]. For example, a therapist may need to review the literature and research evidence if he or she does not know about a particular diagnosis that requires a splint. If a therapist does not have the expertise to splint a client with a complicated injury, he or she might consider referring the person to a therapist who does have the expertise.

In addition, a therapist may need to make an ethical decision such as whether to fabricate a splint for a terminally ill 98-year-old person. This ethical decision would involve the therapist’s values about age and terminal conditions. In today’s ever-changing health care environment, there is a trend toward cost containment. Budgetary shortages may require therapists to ration their clinical services. Prospective payment systems for reimbursing the costs of rehabilitation, such as in skilled nursing facilities (SNFs), are a reality. Therapists fabricate splints quickly and efficiently to save costs. The information provided throughout this book may assist with pragmatic reasoning.

With conditional reasoning, the therapist reflects on the person’s “whole condition” by considering the person’s life before the injury, the disease or trauma, current status, and possible future life status [Mattingly and Fleming 1994]. Reflection is multidimensional and includes the condition that requires splinting, the meaning of having the condition or dysfunction, and the social and physical environments in which the person lives [Fleming 1994]. The therapist then envisions how the person’s condition might change as a result of splint provision and therapy. Finally, the therapist realizes that success or failure of the treatment will ultimately depend on the person’s cooperation [Fleming 1991, Neistadt 1998]. Evaluation and treatment with this clinical reasoning model begin with a top-down approach, considering the meaning of having an injury in the context of a person’s life.

Procedural reasoning involves finding the best splinting approach to improve functional performance, taking into consideration the person’s diagnostically related performance areas, components, and contexts [Fleming 1991, 1994; Neistadt 1998]. Much of the material in this chapter, which summarizes the treatment process from referral to discontinuation of a splint, can be used with procedural reasoning. To demonstrate clinical reasoning,Table 6-1 summarizes each approach and includes questions for the therapist to either ask the person or reflect on during splint provision and fabrication. As stated at the beginning of this discussion, each approach is explained separately. However, experienced therapists combine these approaches, moving easily from one to another [Mattingly and Fleming 1994].

Clinical Reasoning Throughout the Treatment Process

The following information assists with pragmatic and procedural reasoning.

Essentials of Splint Referral

The first step in the problem-solving process is consideration of the splint referral. The ideal situation is to receive the splint referral from the physician’s office early to allow ample time for preparation. In reality, however, the first time the therapist sees the referral is often when the person arrives for the appointment. In these situations the therapist makes quick clinical decisions. Aside from client demographics, Fess et al. [2005] suggest that therapists also need or should determine the following information.

Therapist/Physician Communication About Splint Referral

A problem that many therapists encounter is an incomplete splint referral that lacks a clear diagnosis. Even an experienced therapist becomes frustrated upon receiving a referral that states “Splint.” Splint what? For what purpose? For how long? An open line of communication between the physician and the therapist is essential for good splint selection and fabrication. Most physicians welcome calls from the treating therapist when those calls are specific. If the physician’s splint referral does not contain the pertinent information, the therapist is responsible for requesting this information. The therapist prepares a list of questions before calling, and if the physician is not available the therapist conveys the list to the physician’s secretary or nurse and agrees on a specific time to call again. Sometimes the secretary or nurse can read the chart notes or fax an operative report to the therapist. The therapist must never rely solely on the client’s perception of the diagnosis and splint requirements.

In some cases, the physician expects the therapist to have the clinical reasoning skills to select the appropriate splint for the specific clinical diagnosis. Sometimes a therapist receives a physician’s order for an inappropriate splint, a nontherapeutic wearing schedule, or a less than optimal material. It is the therapist’s responsibility to always scrutinize each physician referral. If the referral is inappropriate, the therapist should apply clinical reasoning skills to determine the appropriate splinting approach. The therapist makes successful independent decisions with a knowledge base about the fundamentals of splinting and with the ability to locate additional information. Then the therapist calls the physician’s office and diplomatically explains the problem with the referral and suggests a better splinting approach and rationale. See Boxes 6-1 and 6-2 for examples of complete and incomplete splinting referrals. Reflect on what you would do if you received the incomplete splint referral.

Diagnostic Implications for Splint Provision

The therapist identifies the person’s diagnosis after reviewing the splint order. Often, the therapist can begin the clinical reasoning process by using a categorical splinting approach according to the diagnosis. The first category involves chronic conditions, such as hemiplegia. In such a situation, a splint may prevent skin maceration or contracture. The second category involves a traumatic or acute condition that may encompass surgical or nonsurgical intervention. For example, the person may have tendinitis and require a nonsurgical splint intervention for the affected extremity.

Regardless of whether the condition is acute or chronic, it is very important that the therapist have an adequate knowledge of diagnostic protocols. By knowing protocols, therapists are aware of any precautions for splinting. For example, for a person with carpal tunnel syndrome the therapist knows to splint the wrist in a neutral position. If the therapist splinted the wrist in a functional position of 30 degrees of extension it could actually harm the person by putting too much pressure on the median nerve. Therapists should keep abreast of current treatment trends through literature, continuing education, and communication with physicians. In all cases, the splint provision approach is individually tailored to each client, beginning with categorization by diagnosis and then adapting the approach according to the client’s performance, cognition, and physical environment.

Factors Influencing the Splint Approach

The sections that follow offer specific hints that elaborate on areas of the splinting evaluation the therapist can use with clinical reasoning. (See Chapter 5 for essential components to include in a thorough hand evaluation.)


From the interview with the person, family, and caregiver (and from the medical record review), the therapist obtains information about the impact a splint may have on occupational function, economic status, and social well-being. The therapist should carefully consider the meaning the condition has for the person, how the person has dealt with medical conditions in the past, how the person’s condition may change as a result of the splint provision, and the person’s social environment. Thus, when choosing the splint design and material the therapist considers the person’s lifestyle needs. The following are some specific questions to reflect on when determining lifestyle needs.

If a physician refers a person for a wrist immobilization splint because of wrist strain, the therapist might contemplate the following question: Is the person a construction worker who does heavy manual work or a computer operator who does light, repetitious work? A construction worker may require a splint of stronger material with extremely secure strapping. The computer operator may benefit from lighter, thinner splint material with wide soft straps. In some situations the person may best benefit from a prefabricated splint.

The therapist determines the person’s activity status, including when the person is wearing a splint that does not allow for function or movement (such as a positioning splint). If the person must return to work immediately, albeit in a limited capacity, the splint must always be secure. Proper instructions regarding appropriate care of the limb and the splint are necessary. This care may involve elevation of the affected extremity, wound management, and periodic range-of-motion exercises while the person is working.

When the person plans to continue in a sports program (professional, school, or community based), the therapist checks the rules and regulations governing that particular sport. Rules and regulations usually prevent athletes from wearing hard splint material during participation in the sport, unless the splint design includes exterior and interior padding. Therapists need to communicate with the coach or referee to determine appropriateness of a splint [Wright and Rettig 2005].

Person Motivation and Compliance

There has been a limited amount of research investigating compliance issues with splint provision. Only recently have experts considered compliance as it relates to persons with hand injuries [Groth and Wilder 1994, Kirwan et al. 2002]. Many considerations affect compliance with a treatment regimen, including such external factors as socioeconomic status and family support (and such internal factors as the person’s perception of the severity of the condition). Knowledge, beliefs, and attitudes about the condition also influence compliance [Bower 1985, Groth and Wulf 1995].

Another factor addressed in research is the psychosocial construct of locus of control, which proposes a relationship between a person’s perception of control over treatment outcomes and the likelihood the person will comply with treatment. This perception of control can be internally or externally based [Bower 1985]. For example, an internally motivated person would follow a splint schedule on his or her own motivation. An externally motivated person may need encouragement from the therapist or caregiver to follow a splint-wearing schedule. Often not discussed with compliance are organizational variables and clinic environment issues such as transportation problems, interference with daily schedule, wait time, differing therapists, and clinic location [Kirwan et al. 2002].

The therapist can positively influence the person’s compliance and motivation to wear a splint. Establishing goals together may help invest the person in the treatment. Perhaps doing an occupation-focused assessment such as the Canadian Occupational Performance Measure (COPM) can help invest the client in wearing the splint [Law et al. 1998]. If the goals determined by the COPM are improvement of hand function, the therapist discusses how the splint will meet this goal. Furthermore, it is important for the therapist to examine her own treatment goals in relation to the client’s goals because there might be disparity between them [Kirwan et al. 2002]. Sometimes the client will have input about the splint design, which should be considered seriously by the therapist. Therapists should convey to clients that success with rehabilitation and splints involves shared responsibility. To attain the splint goal, the therapist must always clarify the person’s responsibilities in the treatment plans.

In addition, the therapist should perceive the person as a whole individual with a lifestyle beyond the clinic, not just as a person with an injury. Paramount to compliance is education about the medical necessity of wearing splints, in which the therapist should consider the person’s perspectives on the ways the splints would affect his or her lifestyle. Education should be repetitive throughout the time the person wears the splint [Southam and Dunbar 1987, Groth and Wulf 1995]. When the therapist and the physician communicate clearly about the type of splint necessary, the person receives consistent information regarding the rationale for wearing the splint. Showing the way the splint works and explaining the goal of the splint enhance client compliance.

Rather than labeling the person as noncompliant or uncooperative, trained personnel must make a serious attempt to help the person better cope with the injury. The therapist should be an empathetic listener as the person learns to adjust to the diagnosis and to the splint. Compliance also involves both therapist and client [Kirwan et al. 2002].Box 6-3 presents some of the many factors that may influence compliance with splint wear.Box 6-4 provides some suggested questions that may assist the therapist in eliciting pertinent information from clients about splint compliance, fit, and follow-up.

Box 6-4   Questions for Follow-up Telephone Calls or E-mail Communication Regarding Clients with Splints

The following open- and closed-ended questions may assist you in eliciting pertinent information from clients about splint compliance, fit, and follow-up. Closed-ended questions usually elicit a brief response, often a yes or no.

Open-ended questions elicit a qualitative response that may give the therapist more information.

Others can also have an impact on client compliance. Sometimes a peer wearing a splint can be a role model to help a person who is noncompliant. A supportive spouse or caregiver encourages compliance, and physician support influences compliance. Sometimes a person may need more structured psychosocial support from mental health personnel.

Selection of an appropriate design may alleviate a person’s difficulty in adjusting to an injury and wearing a splint. Therapists should ask themselves many questions as they consider the best design. (See the questions listed in the section on procedural reasoning inTable 6-1.)

In addition to splint design, material selection (e.g., soft instead of hard) may influence satisfaction with a splint [Callinan and Mathiowetz 1996]. People with rheumatoid arthritis who wear a soft prefabricated splint consider comfort and ease of use when involved in activities important factors for splint satisfaction [Stern et al. 1997]. (See the discussion of advantages and disadvantages of prefabricated soft splints in Chapter 5.)

Making the splint aesthetically pleasing helps with a person’s compliance. A person is less likely to wear a splint that is messy or sloppy. This is especially true of children and adolescents, for whom personal appearance is often an important issue.

Splint and strapping materials are now available in a variety of colors. Persons, both children and adults, who are coping successfully with the injury may want to have fun with the splint and select one or more colors. However, a person who is having a difficult time adjusting to the injury may not want to wear a splint in public at all, let alone a splint with a color that draws more attention.

Finally, fabrication of a correct-fitting splint on the first attempt eases a person’s anxiety. The therapist is responsible for listening to the person’s complaints and adjusting the splint. A therapist’s attitude about splint adjustments makes a difference. If the therapist seems relaxed, the person may consider adjustment time a normal part of the splintmaking process. Encouraging effective communication with the person facilitates understanding and satisfaction about splint provision.

Cognitive Status

When a person is unable to attend the therapy program and follow the splinting regimen because of his or her cognitive status, the therapist must educate the family, caregiver, or staff members. Education includes medical reasons for the splint provision, wearing schedule, home program, splint precautions, and splint cleaning. This leads to better cooperation. Sometimes the therapist chooses designs and techniques to maximize the person’s independence. For example, instructions are written directly on the splint. Such symbols as suns and moons to represent the time of day can be used in written instructions [personal communication, K. Schultz-Johnson, March 1999]. Simple communication strategies such as showing the client a sheet with a smiley face, neutral face, or frowning face can be used to determine how the client feels about splint comfort.

Splinting Approach and Design Considerations

The five approaches to splint design are dorsal, palmar, radial, ulnar, and circumferential. The therapist must determine the type of splint to fabricate, such as a mobilization splint or immobilization splint. Understanding the purpose of the splint clarifies these decisions. For example, when working with a person who has a radial nerve injury the therapist may choose to fabricate a dorsal torque transmission splint (wrist flexion: index-small finger MP extension/index-small finger MP flexion, wrist extension torque transmission splint, ASHT, 1992) to substitute for the loss of motor function in the wrist and MCP extensors. On the basis of clinical reasoning, the therapist may choose in addition to fabricate a palmar-based wrist extension immobilization splint once the person regains function of the MCP extensors. The wrist splint allows the person to engage in functional activities.

In addition to the information the therapist obtains from a thorough evaluation, other factors dictate splint choice. To determine the most efficient and effective splint choice, the therapist must consider the physician’s orders, the diagnosis, the therapist’s judgment, the reimbursement source, and the person’s function.

Physician’s Orders

Physicians often predetermine the splint-application approach on the basis of their training, surgical technique, and restriction/torque transmission splint with the ring and little fingers in the anticlaw position of MCP flexion (ring-small finger MP extension restriction/ring-small finger IP extension torque transmission splint, ASHT, 1992). However, a spring wire splint to hold the MCPs in flexion may be ordered if that is the physician’s preference. Sometimes the therapist may apply clinical reasoning to determine a different splint design or material than what was ordered. In that case, the therapist calls the physician.


Frequently, the diagnosis mandates the approach to splint design. The diagnosis determines the number of joints the therapist must splint. The least number of joints possible should be restricted while allowing the splint to accomplish its purpose. Diagnosis also determines positioning and whether the splint should be of the mobilization or immobilization type. For example, using an early mobilization protocol for a flexor tendon repair, the therapist places the base of the splint on the dorsum of the forearm and hand to protect the tendon and to allow for rubber band traction. The wrist and MCPs should be in a flexed position (alternatively, some physicians now prefer a neutral position to block extension). These splints protect the repair and allow early tendon glide. In this example, the repaired structures and the need to begin tendon gliding guide the approach. (See Chapter 11 for more information on mobilization splint fabrication with tendon repairs.)

Person’s Function

The person’s primary task responsibilities may influence splint choice. A construction worker’s wrist has different demands placed on it than the wrist of a computer operator with the same diagnosis. Not only does the therapist choose different materials for each client but the design approach may be different. A thumb-hole volar wrist immobilization splint decreases the risk of the splint migrating up the arm during the construction worker’s activities, as it tightly conforms to the hand. The computer operator may prefer a dorsal wrist immobilization splint to allow adequate sensory feedback and unimpeded flexibility of the digits during keyboard use. (See Chapter 7 for patterns of wrist splints.)

Table 6-2 outlines a variety of positioning choices for splint design. However, therapists should not view these suggestions as strict rules. For example, a skin condition may necessitate that a mobilization extension splint be volarly based rather than dorsally based.

Mar 13, 2017 | Posted by in PHYSICAL MEDICINE & REHABILITATION | Comments Off on Clinical Reasoning for Splint Fabrication

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