Answers to Quizzes, Laboratory Exercises, and Case Studies
1. The therapist should seek to learn about the culture of the client, either through personal interview with the individual or family or through reading. If the client speaks a language that you do not speak, ensure that a translator is present so that information is accurately transmitted between you and the client. Different cultures may have views about illness and disability that are different from yours. They may also be of a different faith or have family obligations and responsibilities different from those you are accustomed to. Wearing a splint during certain ceremonies or religious events may not be acceptable to your client. Discuss the splint plan and appropriately explain the importance of compliance. If you learn that cultural difference may be a barrier to compliance, work with the client in an attempt to arrive at a workable solution.
2. The performance areas of play and education as well as developmentally appropriate activities of daily living (ADL) and instrumental activities of daily living (IADL) skills should be considered. Personal context factors such as age and gender will enter into color selection and the level of independence the child may have with splint donning/doffing and care. A younger child may need to have additional straps applied to prevent unwanted splint removal or shifting. An older child may be able to independently monitor a splinting schedule.
1. Henry’s wife, who is his primary caretaker, has accompanied him to the treatment sessions. As an important part of his social context, she is able to assist Henry with accurate completion of the intake interview. To ensure Henry’s role, including competence as the husband and head of household within this traditional family, the therapist should first address questions to Henry and verify responses with his wife only if needed.
2. Splint care sheet should be written in large bolded font. Instructions should be written in simple phrases and line drawings used as appropriate to illustrate splint and strap placement. Black-and-white or photocopied photos should be avoided because they may not provide high contrast. High-contrast color photos taken of the splint on Henry’s hand may assist with accurate placement. Splint care instructions must be reviewed with Henry and his wife using the splint care sheet prior to issuing the device. Henry should be asked to repeat instructions and precautions back to therapist with the assistance of his wife.
3. As with the splint care sheet, large font and line drawings can be used to assist with low vision. Instructions should be phrased simply and the order of the exercises should be clearly indicated. Line drawings can be effective, as can color photographs of Henry’s hand. Exercise instructions must be reviewed with Henry and his wife using the handout. Henry should be asked to demonstrate the exercises and verbalize repetitions and frequency with the assistance of his wife prior to leaving the clinic.
1. Malcolm indicated that he is not satisfied with his handwriting, typing, or meat cutting abilities. All of these areas scored poor in performance and satisfaction. Despite these issues being caused by limited hand function, they should be addressed during the first treatment sessions in order to enhance the quality of life for Malcolm. Although these functions should return eventually as hand function improves, waiting for eventual hand movement, strength, and coordination will create an unnecessary lack of ability to complete meaningful life tasks. Handwriting and meat cutting are reported to be the most difficult and least satisfactory areas for Malcolm.
2. A client-centered treatment model and a rehabilitative approach will expedite Malcolm’s return to function. The client-centered model focuses attention on his immediate concerns (handwriting, typing, meat cutting). The rehabilitative approach uses adaptations and modifications as treatment methods to enhance function.
3. The Canadian Occupational Performance Measure (COPM) was used to investigate the functional capabilities of the client within all areas of daily functioning. Issues were discovered within the patient’s social, personal, and virtual contexts.
1. Randy has a radial nerve injury, which he sustained from falling asleep with his arm positioned over the top of a chair.
2. Never hesitate to call the physician’s office. If the physician is not available, leave your question with the nurse.
3. The therapist should suggest a splint for radial nerve and research splints for that condition. He or she should review both textbooks and evidence-based practice articles, time permitting.
4. Randy should be educated about splint precautions, such as monitoring the splint for pressure sores, and about a splint-wearing schedule including removal for hygiene and exercise.
5. As discussed, compliance can be a tricky issue because so many factors need to be considered for why a person is noncompliant. Is Randy’s noncompliance related to a self-image problem with the splint or for some other reason that he has not stated? Refer to Box 6-3 for ideas of factors contributing to noncompliance. The therapist should provide open-ended questions to get Randy’s perception about his noncompliance and what it would take for him to become compliant with splint wear. More specific education, including sharing of research evidence about the importance of splint wear with a radial nerve injury for regaining function, would be helpful. This education would also help Randy understand the slow process of nerve regeneration. Due to Randy’s history of alcohol abuse leading to the development of the condition, he may need psychosocial support beyond the therapy clinic. Psychosocial support can be tactfully suggested by the therapist and Randy can request a referral from his primary physician for intervention.
1. Many areas were missing from the charting. Charting initially did not specify the extremity. It did not include client history of having de Quervain’s tenosynovitis, or prior level of function. It did not mention prior treatment of receiving a prefabricated splint and did not specify where the reddened area was on the thumb. It provided an opinionated comment about client compliance. It would have been better to have provided factual information, such as a direct quote from Marie. The inclusion of normal measurements for range-of-motion, grip, and pinch strengths would make it easier for the reader to have a better understanding of deficits. It did not address the impact of the condition on doing work and home occupations. It did not address Marie’s current level of pain. It should include the type of splint, position, and location. It should include a statement on fit, comfort, and function of the fabricated thumb immobilization splint. Goals are vague and not related to function. It would have been helpful to involve Marie with the goal setting, perhaps through administering the COPM.
2. In every situation, questions using the interactive clinical reasoning approach will be different. The following are a few of many suggested questions.
• What questions do you have about wearing this fabricated splint? (This question may open up discussion, considering that Marie did not continue to wear the prefabricated splint due to developing some chafing on the volar surface of the thumb IP joint.)
• How will you go about following a splint schedule based on the home and work demands in your life? (This question may be helpful, considering Marie’s history of noncompliance with the first splint.)
• What type of support do you need to help you with your splint and hand injury? (This question may help you better understand how Marie is coping with her condition.)
3. For this discussion, respect Marie’s confidentiality by moving to a private area if in a large therapy room. You might assume that one reason Marie was noncompliant with the prefabricated splint was because it caused a reddened area on the thumb IP joint due to fitting improperly. However, you should tactfully question Marie for her reasons for noncompliance, which might be different from your assumption. Refer to Box 6-3 for ideas of factors that contribute to noncompliance and to Box 6-4 for ideas for open-ended questions to ask Marie. In any case, you should fabricate a well-fitted comfortable splint and monitor the fit carefully for potential pressure sores. Clear education about the reason for splint wear along with any evidence from research may help Marie’s compliance. It will be important to check with Marie regularly about follow-through with the splint-wearing program. Consider making a phone call or e-mailing Marie to check on her level of compliance and to answer any questions.
1. MCP flexion is inhibited because the splint metacarpal bar is too high. The wrist appears to be radially deviated. The wrist strap is placed incorrectly.
2. Potential development of skin irritation or pressure areas exists with digital flexion, and the person does not have a full functional grasp.
1. (1) The prefabricated splint was not the best choice because it migrated up the forearm and did not fit properly, limiting finger and thumb motions. (2) The splint was in the incorrect position of 20 degrees wrist extension and had not been readjusted to the correct position of neutral.
2. Wrist positioned as close to neutral as possible.
3. There are a variety of options for a splint-wearing schedule, but based on one recent study (Walker et al. 2000) the person should wear the splint all the time with removal for exercise and hygiene.
4. The therapist should observe areas such as the ulnar styloid, the first web space, and the volar and dorsal aspects of the hand over the metacarpal bones for skin irritation. Mrs. B. should notify the therapist immediately if irritation occurs. In addition, Mrs. B. should be educated to not perform full finger flexion in the splint due to that motion causing increased pressure on the carpal tunnel.
5. In this case, trust was violated because Mrs. B. dutifully followed a wearing regimen for a splint that did not correctly fit and was exacerbating her condition. As McClure [2003] suggests, providing research evidence specific to her situation might help her better understand the rationale for a custom-fabricated splint in a neutral position. Conservative management with splinting may help because the condition was caught early [Gerritsen et al. 2003] and because after giving birth carpal tunnel syndrome (CTS) symptoms may dissipate due to less fluid retention in the body and the client regaining hormonal balance.
1. The therapist should splint Mrs. P’s wrist in neutral to provide a low-load stretch.
2. The therapist should continue to serially splint the wrist to get Mrs. P’s wrist into a functional wrist extension position.
3. This decision is made in collaboration with Mrs. P’s physician based on her progress. Discontinuation of splinting could occur when Mrs. P. obtains more functional wrist extension because wearing the splint too long will result in muscle weakness and/or joint stiffness. Once the splint is removed, the therapist will continue to work on obtaining increased active wrist extension and normal wrist motions for function.
1. The two problems are the following: (1) the metacarpal bar is too high to allow full finger MCP flexion and (2) the thumb IP joint flexion is limited because the material around the thumb extends too far distal.
2. An irritation might develop at the thumb IP joint (where the thumb opening is too high) and at the base of the index finger, where the metacarpal bar is too high. The splint limits full finger flexion.
1. The hand is splinted in a hand-based thumb immobilization splint (MP radial and ulnar deviation restriction splint) with the CMC joint in 40 degrees of palmar abduction and the MCP joint in neutral to slight flexion and ulnar deviation.
2. To provide rest and protection during healing.
3. The splint is worn continuously for 4 to 5 weeks, with removal for hygiene checks.
4. An option as suggested by Ford et al. [2004] is to fabricate a hybrid splint with a circumferential thermoplastic mold around the thumb covered by a neoprene wrap. This splint will provide stability to the MCP joint and allow for functional movements during skiing.
1. Based on SY’s symptoms, the therapists should fabricate a hand-based splint. Because only the CMC joint is involved, the splint designed by Colditz [2000]—which only immobilizes the CMC joint—would be appropriate.
2. To provide stability, and to control subluxation and pain.
3. Based on Colditz’s [2000] recommendations, SY should wear the splint continuously for 2 to 3 weeks (with removal for hygiene). After that time period, she should wear the splint during times when the thumb is irritated by activities.
4. Because of the wrist and thumb involvement, the therapist would consider fabricating a forearm-based thumb splint.
5. The therapist should position the thumb MCP joint in 30 degrees flexion and in palmar abduction as tolerated.
1. Diabetes mellitus is associated with Dupuytren’s disease.
2. Either a resting hand splint or a dorsal forearm-based static extension splint is appropriate to use after a Dupuytren’s contracture release.
3. The therapeutic position includes wrist in neutral or slight extension and metacarpophalangeals (MCP), proximal interphalangeals (PIP), and distal interphalangeals (DIP) in full extension. The thumb does not need to be included in the splint.
4. Shelly should wear her splint well after the wounds have completely healed. After healing, she should wear the splint several weeks or months thereafter during the nighttime to provide stress and tension to counteract the scar contraction. (She may discontinue her resting hand splint in favor of individual finger splints.) The splint can be removed for hygiene, exercise, and ADLs.
5. To accommodate for bandage thickness, the design of the splint should be wider. As bandage bulk is reduced, the splint should be modified to maintain as close to an ideal position as possible. Therefore, thermoplastic material that has memory will assist with the modification process. In addition, because this is a fairly long splint a material with rigidity is helpful to adequately support the weight of the forearm, wrist, and hand.
6. Assuming no major complications in Shelly’s rehabilitation, she may require outpatient therapy. At a minimum, Shelly should be seen for a home program and monitored until the wound heals. The therapy may entail a minimum of one visit per week.
7. Shelly may require assistance for any wound care and dressing changes initially. In addition, if she has difficulty with any one-handed techniques she may require some assistance with ADLs or instrumental ADLs (particularly writing). Temporary accommodations may be required at work or when driving if the automobile has a manual transmission.
1. Posterior elbow immobilization splint: elbow in 120 degrees of flexion, forearm in neutral, and wrist in 15 degrees of extension.
2. Supine on a plinth, with the shoulder in 90 degrees of forward flexion, elbow in 120 degrees of flexion, forearm in neutral rotation, and wrist in neutral extension of 15 degrees.
3. Protect the olecranon, medial and lateral epicondyles, radial and ulnar heads, by padding the bony prominences and molding the splint over the padding.
4. Splint is worn at all times, and removed for protected range-of-motion exercises only in a protected environment.
1. A commercial brace that can be blocked at 90 degrees of flexion and allow for active flexion from 90-degree position as tolerated.
2. To wear the brace at all times, and to perform the exercises within the brace. The brace will be adjusted in therapy every week to increase the flexion angle by 10 to 15 degrees.
1. Dorsal PIP splint because the injury involved the volar plate.
2. PIP joint in 20 to 30 degrees of flexion to protect the injured volar plate.
3. The index and long fingers should be buddy taped to support the injured long finger and maintain alignment. With injury to the radial collateral ligament, the middle phalanx would have a tendency to ulnarly deviate and the buddy strap helps correct this tendency.
4. Teach DS how to use self-adherent compressive wrap to treat the edema. Consider building up the girth of her tennis racquet handle to minimize stress on her injured joint.
1. Yes, to improve her active PIP flexion.
2. Fabricate trial thermoplastic splints for a few fingers and assess if they help.
3. Important client factors are AW’s job dealing with the public and what she finds to be most cosmetically appealing. Splints will be needed for multiple fingers and will be used long term, and thus streamlined fit and durability are desired qualities. Splint adjustability may also be beneficial because PIP size may fluctuate from swelling related to her arthritis.
4. During the daytime only because these are functional splints.
Laboratory Exercise 13-1 Answers
O: Pt. reports that pain has decreased with resisted pronation from a score of 5 out of 10 to 2 out of 10. Manual muscle testing for the the pronator quadratus, pronator teres, flexor carpi radialis, palmaris longus and flexor digitum superficialis, flexor pollicis longus, and flexor digitorium profundus to index and long fingers were all 4 (good). The long-arm splint was discontinued on (date) with physician order.
A: PT was receptive to continue doing ADL and home program. PT plans to modify work and home activities to decrease repetitive pronation and supination. PT has been instructed in a light strengthening program.
1. Activities that require grasp and pinch.
2. An elbow splint. Due to interosseous weakness, the hand should be monitored for a possible hand-based splint for ulnar nerve.
3. The elbow is flexed 30 to 45 degrees and the wrist is in neutral to 20 degrees of extension.
4. There are a couple of options the therapist may consider. The first option is lining the splint to make it more comfortable. Another option would be to consider the comfort benefits of a prefabricated elbow splint. Care must be taken, however, that the prefabricated splint correctly position his elbow in the appropriate amount of flexion.
5. Because symptoms are continuous, the therapist should suggest that Mark wear the splint all of the time.
6. Mark must become aware of activities that irritate his condition, such as positioning his arm on the window frame.
1. B. Because limited pain-free passive range of motion (PROM) is available at wrist and fingers, providing comfort offered by submaximum positioning and gentle stretch furnished by dynamic resistance is important. The hard-cone design allows orthotic management to begin even though the fingers are flexed. Because wrist and finger PROM are affected, orthotic design should span all affected joints.
2. Because the soft device has increased flexion tightness, the nursing staff should review the literature that addresses this dilemma. After discussion of other options, the staff members should be more open to attempt alternative splints.
3. E. Wrist and finger motions, though weak, are now adequate for light functional tasks. The present thumb web space tightness position remains the greatest threat to advanced prehension patterns.
4. With the thumb positioned in opposition, the client may be involved in some self-care activities such as grasping a napkin, assisting in combing hair, and arranging a bed sheet.
1. A material that has high drapability and moldability is not a good choice for antigravity splinting. A material that has resistance to drape and memory is suitable. A slightly tacky splinting material that lightly adheres to underlying stockinette may be helpful. Preshaping techniques assist in molding.
2. A positioning soft splint such as soft roll or palm protector places the involved joints in submaximum extension. This position permits adequate skin hygiene.
3. A splint should not limit the use of uninvolved joints. An arthritis mitt splint immobilizes only the affected joints and positions the thumb in a resting position. The client can still use the fingers for functional activities at night.
4. Pad the outside of the splint.
5. The straps should be soft, wide foam straps that are cut a little long to adjust for edema. The splint design should be made wide enough to accommodate the edema.
Laboratory Exercise 16-1 Answer
Two fabrication problems are present in this splint. First, the C bar does not fit into the web space of the thumb and provides inadequate positioning of the thumb between radial and palmar abduction. Second, the sides of the forearm trough are too high—resulting in bridging of the straps.
The straps are not keeping the wrist positioned in the splint. The distal forearm strap should be placed just proximal to the ulnar styloid, and a second strap should be added just distal to the ulnar styloid—preventing the flexor action of the wrist from lifting the wrist away from the splint’s surface. The splint does not fit snugly into the thumb web space.
The splint does not fit snugly into the web space. In addition, the thumb trough is slightly too long and does not allow tactile contact of the tip of the thumb with an object being grasped.
Option A would probably not be adequate to address concerns of losing range of motion of the wrist and fingers. Once range is lost, it can be difficult (if not impossible) to regain. Therefore prevention is paramount. Relying on passive range of motion may be disruptive to other activities and occupations during the day. The constant effects of moderately to severely increased tone will be difficult to overcome with activities alone. The thumb splints alone would not be adequate to address concerns with the wrist and finger flexors.
Option B would probably best meet Aaron’s needs at this time. Prolonged stretch to the wrist and finger flexors could occur at night. Active functional movement during play, self-care, communication, and school activities could be emphasized during his waking hours. Because the left upper extremity is tighter and less functional, it would also be prudent to wear the left resting splint on this hand periodically during the day. A thermoplastic thumb splint for the right hand would control some of the increased tone in the hand but leave the wrist and fingers free for active and functional movement. Range-of-motion measurements would be required to determine optimal wearing schedules.
You will contact Aaron’s parents to discuss your splinting recommendations and the purpose of the splints and to get their input. Assuming they are in agreement, you arrange a meeting with his parents prior to the splints’ going home. At this time, you will review the purpose of the splints, demonstrate how to apply the splints, and provide an opportunity for the parents to practice donning and doffing the splints. You will also give the parents written instructions, precautions, and your phone number. Photographs of the splints on Aaron’s hands will be included if needed.
Option C would be excessive use of resting hand splints at the present time. Aaron should continue to experience active movement and sensory feedback as much as possible during the day, especially with the right hand.
Option D would unnecessarily restrict active use of the hands during the day while leaving the wrist and finger flexors shortened during the night and on weekends. This family is involved in Aaron’s programming, and you will address the issue of correct application at home by meeting with the parents as described under option B. If you have questions regarding follow-through at home, you should obtain more information about the family’s strengths and limitations, the parent’s understanding of intervention, and family routines. You should then individualize your style of collaboration and provide instruction for that family.
Option A, resting hand splint, would not be appropriate because Maria has full passive range of motion in the left wrist and hand. Elongation of wrist and finger flexors is desirable but could be accomplished through weight-bearing activities.
Option B, a standard wrist cock-up (immobilization) splint, would not adequately address the problem of thumb adduction into the palm. It is likely that positioning the thumb in opposition will have an inhibitory effect on the wrist and hand. If the wrist flexion continues to be a problem after the thumb is addressed, other splinting or treatment options could be considered.
Option C, using a neoprene thumb splint as part of an overall intervention plan, is the correct answer. The thumb can serve as a key point of control for the hand, and once positioned may have an overall inhibitory affect. Tone is probably not severe enough to start with a thermoplastic thumb splint, but Maria might need additional assistance in the form of an added C bar attached to the neoprene thumb splint. If neoprene does not adequately limit thumb adduction, a thermoplastic thumb splint could be considered.
2. A.B.’s history of falls necessitates use of an orthosis. If strength and endurance improve, the device may be discontinued. Remind A.B. that falls result in fractured hips that often require placement in long-term care facilities.
5. Encourage A.B. to continue his walking program indoors at a local mall or health club. Inspect shoes to ensure that soles are not worn and that a non-skid surface is adequate for inclement conditions such as snow and ice.
1. Case A: M.H. may be attempting to wear the orthosis over pants because it is easier to don and doff the device in this manner. If the device was donned under the pants with ample leg room, the device would be undetectable to others.
2. Case B: A video of T.F. walking with an ankle-foot orthosis (AFO) and without an AFO might illustrate that the AFO provides a more “normal” gait pattern. It would also be appropriate to discuss the effects of overstretching soft structures.
3. Case C: D.F.’s condition necessitates gentle prolonged stretch of the plantar surface structures. She may benefit from wearing specialty AFOs at night to increase stretching time and reduce overall pain.
1. The guide to determining whether a situation involves ethics includes answering the following three questions: (1) Is there more than one morally plausible resolution?, (2) Is there no clearcut best resolution?, and (3) Is there direct reference to the welfare or dignity of others? In this case, because Collin is inexperienced one could expect that he would need supervision as he gains mastery over the techniques necessary to treat clients. Mercedes has already noted that Collin needs more supervision. Thus, the welfare of clients is affected. Mercedes realizes that the ideal solution would be for her to spend more time supervising Collin, but she does not believe this is possible because of her administrative duties. There is more than one morally plausible option in the case. Because the answer to two of the three criteria is “yes,” the case does involve an ethical issue.
2. Clearly, the ethical principles of nonmaleficence and beneficence are involved. Mercedes and Collin have an obligation to protect all clients from unnecessary harm and to do good for them within the constraints of available resources. There are not enough qualified staff members to supervise Collin. The lack of senior staff members could be considered a problem of justice. There is not enough of Mercedes to go around. She is not capable of completing all of the tasks assigned to her, and thus she must make decisions about what takes priority.
A fair and equitable work setting should have adequate personnel to do the job safely and effectively. The current shortage of staff could be due to chance (i.e., the unfortunate coincidence of a retirement and maternity leave). However, both of these events are predictable. Thus, as the manager Mercedes should have foreseen that there would be a problem and have made advance plans for it. If Mercedes is making a good-faith effort to recruit replacement staff, we would not hold her accountable for sustaining a work environment that is unsafe and short staffed. We could, however, hold her accountable for poor planning and the impact this has had on Collin’s orientation and client care.
According to care-based reasoning, Mercedes should consider what a caring work environment would look like for new employees and clients. It is true that novices do not become expert without experience, but how we provide experience makes a great deal of difference.
Finally, virtues that are required in this situation could include perseverance, compassion, courage, justice, and integrity. One of the alternatives available to Mercedes is to reassign her administrative and management responsibilities to someone else, in that there is no one else in her institution who is an occupational therapist and can supervise direct client care. It would take courage to delegate administrative authority, because it would require relinquishing power. However, if client care holds a central position in the values of the organization this is a plausible option.
3a. Mercedes could limit the type of clients Collin treats, selecting only those he can treat safely with minimal supervision. The principles that support this action are nonmaleficence and beneficence, in that clients would be protected. Collin would not receive the type of experience he would like, which might interfere with his autonomy but client welfare would not be in jeopardy.
3b. Mercedes could maintain the status quo and continue with things the way they are, with minimal supervision. The principles of nonmaleficence and beneficence are threatened. It is possible that Collin would not commit any serious mistakes, but because of his inexperience it is clear that clients would not be getting the quality of care they need or deserve.
3c. Mercedes could ask for release time from her administrative duties so that she could be free for direct client care. The principles of nonmaleficence, beneficence, and justice are supported by this action—in that client welfare is protected and Collin receives the type of supervision he should have to become a competent clinician.
3d. Hire on a temporary basis an occupational therapist for specific supervision of Collin and complex cases. This action may require greater expense, but it would allow Mercedes to continue with her administrative duties (if those duties contribute to the benefit of clients) and Collin would receive the supervision he needs. Clients would be protected from harm and would benefit from the expertise of an experienced therapist.
4. The principles in the Code of Ethics that are helpful in this case include principle 4, which demands the maintenance of high standards of competence. There is a clear responsibility for all occupational therapists to maintain their own level of competence and to monitor that of peers. Depending on the reason for incompetence, various methods can be taken to resolve the problem—such as further education, increased staffing, workshops, drug and alcohol treatment programs, and so on. In this case, Collin is incompetent because he is inexperienced and needs more supervision. This is a state that is temporary and could be resolved with adequate supervision. Second, principle 1C strictly enjoins protecting clients from harm. Mercedes should be guided by this principle above all others as she attempts to resolve the problem.