Occupation-Based Splinting and Contexts

According to the OTPF, occupational therapy is an approach that facilitates the individual’s ability to engage in meaningful activities within specific performance areas of occupation and varied contexts of living [AOTA 2002]. The performance areas of occupation define the domain of occupational therapy and include activities of daily living (ADLs), instrumental activities of daily living (IADLs), leisure, play, work, education, and social participation [AOTA 2002]. Context is a strong component of occupational engagement that permeates all levels of treatment planning, intervention, and outcomes.

An often overlooked issue surrounding splinting is attention to the client’s cultural needs. Unfortunately, to ignore culture is to potentially limit the involvement of clients in their splint programs. For example, there are cultures whereby the need to rely on a splint is viewed as an admission of vulnerability or as a weakness in character. Such feelings can exist due to large group beliefs or within smaller family dynamic units. Splinting within this context must involve a great deal of client education and possibly education of family members. Issuing small, unobtrusive splints that allow as much function as possible may diminish embarrassment and a sense of personal weakness [Salimbene 2000].

A knowledge of physical environments may contribute to an understanding of the need for splint provision. Physical environments may also hamper consistent use if clients are unable to engage in required or desired activities. For example, if a client needs to drive to work and is unable to drive while wearing a splint he might remove it despite the potential for reinjury.Figure 2-1A depicts a young woman wearing a splint because she sustained a flexor digitorum profundus injury. She found that typing at her workplace while wearing the splint was creating shoulder discomfort. She asked the therapist if she could remove her splint for work, and with physician approval the therapist created a modified protective splint (Figure 2-1B). The newly modified splint allowed improved function and protected the healing tendon.

Social contexts pertain to the ability of clients to meet the demands of their specific group or family. Social contexts are taken into consideration with splint provision. For example, a new mother is recently diagnosed with de Quervain’s tenosynovitis and is issued a thumb splint. The mother feels inadequate as a mother when she cannot cuddle and feed the infant without contacting the infant with a rigid splint. In such a case, a softer prefabricated splint or alternative wearing schedule is suggested to maximize compliance with the splint program (Figure 2-2).

Personal context involves attention to such issues as age, gender, and educational and socioeconomic status. When clinicians who employ occupation-based splinting fabricate splints for older adults or children, they consider specific guidelines (see Chapters 15 and 16). The choices in material selection and color may be different based on age and gender. For example, a child may prefer a bright-colored splint whereas an adult executive may prefer a neutral-colored splint. Concerns may arise about the role educational level plays in splint design and provision. For clients who have difficulty understanding new and unfamiliar concepts, it is important to have a splint that is simple in design and can be donned and doffed easily. Precautions and instructions should be given in a clear manner.

Although it is typically considered a cognitive function, expression of spirituality can be potentially affected by changes to the physical body. For example, some clients are not able to pray or to attend religious services because parts of their bodies are restricted by splints. All clients should be asked if their splints are in any way inhibiting their ability to engage in any life experience. Almost all splints affect a person’s ability to perform activities. The impact is a matter of degree, and consideration needs to be given to the tradeoff between how it enables clients (if only in the future) and how it disables them. Therapists must be aware of the balance between enablement and disablement and do their best to appropriately modify the splint or the wearing schedule or to provide an adaptation to facilitate clients’ occupational engagement.

Temporal concerns are addressed through attention to issues such as comfort of the splint during hot summer months or the use of devices during holidays or special events such as proms or weddings. An example is the case of a bride-to-be who was two weeks postoperative for a flexor tendon repair of the index finger. The young woman asked repeatedly if she could take off her splint for one hour during her wedding. A compromise reached between the therapist and the client ensured that her hand would be safe during the ceremony. A shiny new splint was made specifically for her wedding day to immobilize the injured finger and wrist (modified Duran protocol). The therapist discarded the rubber-band/finger-hook component (modified Kleinert protocol). This change made the splint smaller and less obvious. The client was a happy bride and her finger was well protected.

Virtual context addresses the ability to access and use electronic devices. The ability to access devices (e.g., computers, radios, PDAs, MP3 players, cell phones) plays an important role in many people’s lives. Fine motor control is paramount when using these devices and should be preserved as much as possible to maximize electronic contact with the outside world. Attention to splint size and immobilizing only those joints required can facilitate the ability of clients to manipulate small buttons and dials required to use such devices. “While use of a keyboard tends to be a bilateral activity, many devices (such as radios, PDAs, and cell phones) do not require bilateral fine motor skill. As technology improves with cordless and voice-activated systems, the needs for fine motor skill in operation of some electronic devices may decrease. A therapist is the ideal person to introduce this technology to the client” [personal communication, K. Schultz-Johnson, October 5, 2005].

For a splint to be accepted as a legitimate holistic device, it must work for the client within the context(s). Splints might perpetuate dysfunction and may prolong the return to meaningful life engagement without attention to the specifics of how and where clients live their lives. To ignore the interconnection of function to where and how function plays out is to practice a reductionist form of treatment that emphasizes isolated skills and body structures, without regard to clients’ engagement in selected activities.

Occupation-Based Splinting and Intervention Levels

Pedretti and Early [2001] described four intervention levels: adjunctive, enabling, purposeful activities, and occupations. Adjunctive methods prepare clients for purposeful activity and they do not imply activity or occupation. Examples include exercise, inhibition or facilitation techniques, and positioning devices. Enabling activities precede and simulate purposeful activity. For example, simulated activities (e.g., driving simulators) begin to prepare the client for participation in actually driving a vehicle. Purposeful activities are goal directed and have meaning and purpose to the client. In the case of driving, when a client actually gets into a vehicle and drives, the intervention level is considered purposeful activity. Occupation is the highest level of intervention. Clients participate in occupations in their natural context. The ability to drive to one’s employment site is considered an occupation.

At first blush, splinting could appear to be less than occupation oriented because it is initiated prior to occupational engagement and discontinued when hand function resumes. From an occupation-based perspective, splinting is not a technique used only in preparation for occupation. For appropriate clients, splints are an integral part of ongoing intervention to support occupational engagement at all levels of intervention: adjunctive, enabling, purposeful activity, and occupation. For example, some clients may receive a splint to decrease pain while simultaneously being allowed engagement in work and leisure pursuits.

Splinting as a Therapeutic Approach

The OTPF intervention approaches are defined as “specific strategies selected to direct the process of intervention that are based on the client’s desired outcome, evaluation data and evidence” [AOTA 2002, p. 632]. These treatment approaches include processes to (1) create or promote health, (2) establish or restore health, (3) maintain health, (4) modify through compensation and adaptation, and (5) prevent disability [AOTA 2002].

From an occupation-based perspective, when splints enable occupation it seems to elevate splint status to that of an integral approach to treatment versus an adjunctive technique. Custom fitted splints within the context of clients’ occupational experience can promote health, remediate dysfunction, substitute for lost function, and prevent disability. When teamed with a full occupational analysis and knowledge of the appropriate use of splints for specific pathologies (supported by evidence of effectiveness), splinting options are selected to produce the outcomes that reach the goals collaboratively set by the client and the practitioner.

Splinting as a Facilitator of Therapeutic Outcomes

Within the context of occupation-based practice, splinting is a therapeutic approach interwoven through all levels of intervention. Splinting is a facilitator of purposeful and occupation-based activity. The OTPF describes specific therapeutic outcomes expected of intervention. Outcomes are occupational performance, client satisfaction, role competence, adaptation, health and wellness, prevention, and quality of life [AOTA 2002]. Positive outcomes in occupational performance are the effect of successful intervention. Such outcomes are demonstrated either by improved performance within the presence of continued deficits resulting from injury or disease or the enhancement of function when disease is not currently present.

Splinting addresses both types of occupational performance outcomes (improvement and enhancement). Splints that improve function in a person with pathology result in an “increased independence and function in an activity of daily living, instrumental activity of daily living, education, work, play, leisure, or social participation” [AOTA 2002, p. 628]. For example, a wrist immobilization splint is prescribed for a person who has carpal tunnel syndrome. The splint positions the wrist to rest the inflamed anatomical structures, thus decreasing pain and work performance improves. Splints that enhance function without specific pathology result in improved occupational performance from one’s current status or prevention of potential problems. For example, some splints position the hands to prevent overuse syndromes resulting from hand-intensive repetitive or resistive tasks.

Satisfaction of the entire therapeutic process is increased when the client’s needs are met. When clients are included as an integral part of the splinting process, they are more likely to comply and to use the splint. Inclusion of clients in treatment planning is important to creating splints that minimally inhibit function and take the client’s lifestyle into consideration.

Role competence is the ability to satisfactorily complete desired roles (e.g., worker, parent, spouse, friend, and team member). Roles are maintained through splinting by minimizing the effects of pathology and facilitating upper extremity performance for role-specific activities. For example, a mother who wears a splint for carpal tunnel syndrome should be able to hold her child’s hand without extreme pain. Holding the child’s hand makes her feel like she is fulfilling her role as a mother.

Splints created to enhance adaptation to overcome occupational dysfunction address the dynamics of the challenges and the client’s expected ability to overcome it. An example of splinting to improve adaptation might involve a client who experiences carpal ligament sprain but must continue working or risk losing employment. In this case, a wrist immobilization splint that allows for digital movements may enable continued hand functions while resting the involved ligament.

Health and wellness are collectively described as the absence of infirmity and a “state of physical, mental, and social well-being” [AOTA 2002, p. 628]. Splinting promotes health and wellness of clients by minimizing the effects of physical disruption through protection and substitution. Enabling a healthy lifestyle that allows clients to experience a sense of wellness facilitates motivation and engagement in all desired occupations [Christiansen 2000].

Prevention in the context of the OTPF involves the promotion of a healthy lifestyle at a policy creation, organizational, societal, or individual level [AOTA 2002]. When an external circumstance (e.g., environment, job requirement, and so on) exists with the potential for interference in occupational engagement, a splinting program may be a solution to prevent the ill effects of the situation. If it is not feasible to modify the job demands, clients may benefit from the use of splints in a preventative role. For example, a wrist immobilization splint and an elbow strap are fitted to prevent lateral epicondylitis of the elbow for a client who works in a job that involves repetitive and resistive lifting of the wrist with a clenched fist. In addition, the worker is educated on modifying motions and posture that contribute to the condition.

Of great concern is the concept of quality of life [Sabonis-Chafee and Hussey 1998]. Although listed as a separate therapeutic outcome within the OTPF, quality of life is a subjective state of being experienced by clients. Quality of life entails one’s appraisal of abilities to engage in specific tasks that beneficially affect life and allow self-expressions that are socially valued [Christiansen 2000]. One’s state of being is determined by the ability of the client to be satisfied, engage in occupations, adapt to novel situations, and maintain health and wellness. Ultimately, splinting focused on therapeutic outcomes will improve the quality of life through facilitating engagement in meaningful life occupations.