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].

Table 6-1

Clinical Reasoning Approaches

Examples are inclusive, not exclusive.

Clinical Reasoning Throughout the Treatment Process

The following information assists with pragmatic and procedural reasoning.

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 6-3 Examples of Factors That May Influence Compliance with Splint Wear

Organizational/Clinic Environment

Time involved with splint wear

Interference with life tasks

Inconsistent therapists

Transportation issues

Long wait time for treatment

Inconvenient clinic location

Noisy clinic with little privacy

Client

Belief in the efficacy of wearing a splint

Belief in one’s ability to follow through with the splint-wearing schedule

Poor social support

Treatment

Splint is uncomfortable

Splint is cumbersome

Splint is poorly made

Therapeutic Relationship and Communication

Inconsistent communication between therapists and physicians concerning the splint

Poor understanding, difficulty reading, or being forgetful about instructions on splint wear and care

Adapted from Kirwan T, Tooth L, Harkin C (2002). Compliance with hand therapy programs: Therapists’ and patients’ perceptions. Journal of Hand Therapy 15(1):31–40.

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.

• Have you been wearing your splint according to the schedule I gave you? If no, why aren’t you wearing your splint?

• Have you noticed any reddened or painful areas after removing your splint? If so, where?

• Is the splint easy to put on and take off?

• Are there any tasks you want to do but cannot do when wearing your splint?

• Do you have any concerns about your splint-wearing schedule or care?

• Are there any broken or faulty components on your splint?

• Do you have any questions for me?

• Do you know how to reach me?

• Have you noticed any increased swelling or pain since you’ve been wearing the splint?

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

• Will you tell me about a typical day and when you put your splint on and take it off?

• What concerns, if any, might you have about your splint-wear and care schedule?

• What precautions have you been taking in regard to monitoring your splint wear?

• How is the splint affecting your activities at home and at work?

• Are there any areas to improve with our clinic management, which would help with your follow-through with splint wear?

• Can you tell me how you would contact me if you need to do so?

• Do you have any questions for me?

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 in Table 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.

Diagnosis

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.)

Therapist’s Judgment

The therapist can also determine the splint design and type on the basis of knowledge and experience. For example, when dealing with elective carpal tunnel release the therapist can place a wrist immobilization splint dorsally or volarly directly over the surgical site. As an advocate of early scar management, the therapist chooses a palmar splint and adds silicone elastomer or Otoform to the splint.

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.

Table 6-2

Common Positioning Choices in Splint Design