SOMAYA MALKAWI, PhD Chapter 6 Clinical Reasoning for Splint Fabrication

SPLINT DESIGN AND WEARING SCHEDULE VARY BECAUSE EACH INJURY IS UNIQUE TEACHERS ONLY GIVE ONE WAY TO DO SOMETHING WHEN IN REALITY  MANY WAYS TO ACHIEVE A GOAL THERAPISTS USE CLINICAL REASONING WHEN SPLINTING 2 Clinical Reasoning Models in Splinting

Clinical Reasoning Models / Table Interactive Reasoning: Narrative reasoning Pragmatic reasoning Conditional reasoning Procedural reasoning

Interactive Reasoning Getting to know the person through understanding the impact the hand condition has had on the person’s life Focus is person’s perspective Splint color for a person who is sensitive about appearance

Narrative reasoning The person’s occupational story (life history) Activities, habits, roles, routines Dorsal based wrist immobilization splint for a secretary with CTS

Pragmatic reasoning Practical factors such as reimbursement, documentation, equipment availability, expected discharge environment, therapist’s values, knowledge, and skills Therapist with no experience might review the literature about one splint. Or refer the client with more experience

Person’s whole condition, taking into consideration the person’s life before condition happened, current status, and possible suture status Meaning of having a condition Cooperation of the person Conditional reasoning

Procedural reasoning Problem solving the best splinting approach taking into consideration the person’s diagnostically related performance areas, components, and contexts Fabricate the splint based on the condition itself and nothing else

REFERRAL THERAPIST/PHYSICIAN COMMUNICATION SPLINT PROVISION 9 CLINICAL REASONING THROUGHOUT TREATMENT

Referral 10 No time for preparation Quick clinical decisions Take demographics: Diagnosis, date of onset Management, purpose and type of splint Precautions and instructions Wearing schedule

Therapist/physician communication 11 Prepare “specific” questions What splint? For how long If inappropriate, therapist apply clinical reasoning See examples (Box 6-1) and (6-2)

Splint provision 12 Categories: Splints for chronic conditions (hemiplegia)  prevent skin maceration and contractures Splints for traumatic or acute (surgical or non surgical)  tendinitis KNOW PROTOCOLS and precautions for splinting Functional splint for CTS?!!!

AGE OCCUPATION EXPECTED ENVIRONMENT ADL RESPONSIBILITIES MOTIVATION AND COMPLIANCE COGNITIVE STATUS 13 Factors Influencing Splint Approach

PHYSICIAN ORDERS: YOU DON’T LIKE IT; CALL HIM DIAGNOSIS: TAKING CARE OF THE REPAIRED TISSUE! THERAPIST’S JUDGMENT: YOU THINK, THEN, IT IS YOUR CALL! PERSON’S FUNCTION: WRIST SPLINT FOR A CONSTRUCTION WORKER! TEACHER, LITTLE KID! Check table 6-2 (common positioning choices in splint design based on person’s occupation/function) 14 Splinting Approach and Design Consideration

INFECTION CONTROL PROCEDURES TIME REQUIRED TO FABRICATE SPLINT 15 Splinting Approach and Design Consideration

16 Post fabrication monitoring

Monitoring 17 Pressure. Skin maceration. Edema. Physical and functional status.

18 Evaluation and adjustment of splints

adjustments 19 Accomplished the purpose? Good biomechanics? Best materials? Fluctuating edema? Does it look nice!!!!!!!!!!!!!!!!!!!!!!!???? Pressure-free? Client’s occupation? Client’s function? If I have the chance to re do it, what would I change?

PART 3 20 Splint-wearing Schedule factors

Wearing schedule 21 No magic numbers or formulas! Only general guidelines available Joint limitation! Improving ROM  decrease wearing time functional. Lost function, splint is compensating! Discontinuation of a splint: physician or therapist No benefit, achieved purpose, compliance DOCUMENTATION