Reports of primitive splints date back to ancient Egypt [Fess 2002]. Decades ago, blacksmiths and carpenters constructed the first splints. Materials used to make the splints were limited to cloth, wood, leather, and metal [War Department 1944]. Hand splinting became an important aspect of physical rehabilitation during World War II. Survival rates of injured troops dramatically increased because of medical, pharmacologic (e.g., the use of penicillin), and technological advances. During this period, occupational and physical therapists collaborated with orthotic technicians and physicians to provide splints to clients: “Sterling Bunnell, MD, was designated to organize and to oversee hand services at nine army hospitals in the United States” [Rossi 1987, p. 53]. In the mid 1940s, under the guidance of Dr. Bunnell many splints were made and sold commercially. During the 1950s, many children and adults needed splints to assist them in carrying out activities of daily living secondary to poliomyelitis [Rossi 1987]. During this time, orthotists made splints from high-temperature plastics. With the advent of low-temperature thermoplastics in the 1960s, hand splinting became a common practice in clinics.

Today, some therapists and clinics specialize in hand therapy. Hand therapy evolved from a group of therapists in the 1970s who were interested in researching and rehabilitating clients with hand injuries [Daus 1998]. In 1977, this group of therapy specialists established the American Society for Hand Therapy (ASHT). In 1991, the first certification examination in hand therapy was given. Those therapists who pass the certification examination are credentialed as certified hand therapists (CHTs).

Specialized organizations (e.g., American Society for Surgery of the Hand and ASHT) influence the practice, research, and education of upper extremity splinting [Fess et al. 2005]. For example, the ASHT Splint Classification System offered a uniform nomenclature in the area of splinting [Bailey et al. 1992].

Splintmakers

A variety of health care professionals design and fabricate splints. Occupational therapists (OTs) constitute a large population of health care providers whose services include splint design and fabrication. Certified occupational therapy assistants (COTAs) also provide splint services. Along with OTs and COTAs, physical therapists (PTs) specializing in hand rehabilitation often fabricate splints for their clients who have hand injuries. PTs are frequently involved in providing splints for the lower extremities. In addition, certified orthotists (COs) are trained and skilled in the design, construction, and fitting of braces and orthoses prescribed by physicians. Dentists frequently fabricate orthoses to address selective dental problems. Occasionally, nurses who have had special training fabricate splints.

Splint design must be based on scientific principles. A given diagnosis does not specify the splint the clinician will make. Splint fabrication often requires creative problem solving. Such factors as a client’s occupational needs and interests influence a splint design, even among clients who have common diagnoses. Health care professionals who make splints must allow themselves to be creative and take calculated risks. Splintmaking requires practice for the clinician to be at ease with the design and fabrication process. Students or therapists beginning to design and fabricate splints should be aware of personal expectations and realize that their skills will likely evolve with practice. Therapists with experience in splinting tend to be more efficient with time and materials than novice students and therapists.

Occupational Therapy Theories, Models, and Frame-of-Reference Approaches for Splinting

The OTPF outlines the occupational therapy process of evaluation and intervention and highlights the emphasis on the use of occupation [AOTA 2002]. Performance areas of occupation as specified in the framework include the following: activities of daily living (ADL), instrumental activities of daily living (IADL), education, work, play, leisure, and social participation. Performance areas of occupation place demands on a person’s performance skills (i.e., motor skills, process skills, and communication/interaction skills). Therapists must consider the influence of performance patterns on occupation. Such patterns include habits, routines, and roles. Contexts affect occupational participation. Contexts include cultural, physical, social, personal, spiritual, temporal, and virtual dimensions. The engagement in an occupation involves activity demands placed on the individual. Activity demands include objects used and their properties, space demands, social demands, sequencing and timing, and required actions, body functions, and body structures. Client factors relate to a person’s body functions and body structures.Table 1-1 provides examples of how the framework assists one in thinking about splint provision to a client.

Table 1-1

Examples ^* of the Occupational Therapy Practice Framework and Splint Provision

^*Examples are inclusive, not exclusive.

The practice of occupational therapy is guided by conceptual systems [Pedretti 1996]. One such conceptual system is the Occupational Performance Model, which consists of performance areas, components, and contexts. A therapist using the Occupational Performance Model may influence a client’s performance area or component while considering the context in which the person must operate. The therapist is guided by several treatment approaches in providing assessment and treatment. The therapist may use the biomechanical, sensorimotor, and rehabilitative approaches. The biomechanical approach uses biomechanical principles of kinetics and forces acting on the body. Sensorimotor approaches are used to inhibit or facilitate normal motor responses in persons whose central nervous systems have been damaged. The rehabilitation approach focuses on abilities rather than disabilities and facilitates returning persons to maximal function using their capabilities [Pedretti 1996]. (See Self-Quiz 1-1.)

SELF-QUIZ 1-1 ^*

Match the approach used in each of the following scenarios.

a. Biomechanical approach

b. Sensorimotor approach

c. Rehabilitation approach

1. _________ This approach was used on a child who has cerebral palsy. The goal of the splint was to decrease the amount of tone present.

2. _________ This approach allowed a person who had a stroke to grasp the walker by using splints that were adapted to assist with grasp.

3. _________ This approach helped a person who had a tendon repair that resulted in flexor contractures of the metacarpophalangeal (MCP) joint to regain full range of motion.

^*See Appendix A for the answer key.

Each approach can incorporate splinting as a treatment intervention, depending on the rationale for splint provision. For example, if a person wears a tenodesis splint to recreate grasp and release to maximize function in activities of daily living, the therapist is using the rehabilitation approach [Hill and Presperin 1986]. If the therapist is using the biomechanical approach, a dynamic (mobilization) hand splint may be chosen to apply kinetic forces to the person’s body. If the therapist chooses a sensorimotor approach, an antispasticity splint may be used to inhibit or reduce tone.

Pierce’s notions [Pierce 2003] of contextual and subjective dimensions of occupation are powerful concepts for therapists who appropriately incorporate splinting into a client’s care plan. Understanding how a splint affects a client’s occupational engagement and participation are salient in terms of meeting the client’s needs and goals, which may result in an increased probability of compliance. Contextual dimensions include spatial, temporal, and sociocultural contexts [Pierce 2003]. Subjective dimensions include restoration, pleasure, and productivity.Box 1-1 explicates both contextual and subjective dimensions of occupation. In Chapter 3, Pierce’s framework is used to structure questions for a client interview.

Box 1-1 Contextual and Subjective Dimensions of Occupation

Contextual Dimensions