Would a splint be contraindicated in this case?

November 17, 2008 at 8:09 pm 22 comments

We all know that one of the purposes of splinting by occupational therapists is for joint protection and to preserve function and range of motion.  I have blogged before about my experience with fabricating below knee amputation (BKA) splints, used to preserve knee extension for being able to fit orthoses at a later date.

Sometimes, however, I wonder if a patient really needs the splint.  For example, I once had a 85 year old patient who had severe Alzheimer’s dementia, was completely bedbound at a nursing home at baseline and had a BKA due to gangrene.  While normally I would make a splint, I wasn’t sure that it was indicated in this case.

First, the patient was bedbound at baseline, and therefore an unlikely canditate for a prosthetic.  Second, a patient is very likely to develop skin breakdown and sores from a splint if the splint schedule isn’t adhered to, or frequently monitored.  Third, splints aren’t generally the most comfortable things.

Providing a splint would not increase or improve quality of life, and so it would seem to me that a splint would not be indicated in this case for the reasons listed above.  What are your thoughts?

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Entry filed under: acute care, dementia, Ethics, hospital, occupational therapy, Open Questions, OT, phys dys, splint. Tags: , , , , , .

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22 Comments Add your own

  • 1. sarah  |  November 18, 2008 at 4:34 am

    Oh I’d say definitely contraindicated. In OT we are all about promoting function, and unless the cause of the amputation was the reason she had been bedbound, one would not be expecting that she would regain a higher level of mobility after the amputation. So, like you wrote, the risks are too high to warrant a splint that will not be promoting her function.

    Reply
  • 2. Daniel  |  November 25, 2008 at 2:24 am

    Hey, i had splints made for my hands when i was little, the material was like leather at first anmd they traced my hand outline onto it then cut it out, heated it up, wrapped it around my arm and when it cooled it was hard… i was just wondering if you know what it’s called?
    Oh and sorry this isnt like a real comment, so yeah, i’d say it’s contradictory =)
    Thanks
    -Dan

    Reply
  • 3. aishel  |  November 25, 2008 at 11:00 pm

    Hi Dan, thanks for your comment. I’m not sure specifically, but perhaps a finger pan splint?

    Reply
  • 4. Ciaran O'Hagan  |  January 10, 2009 at 5:25 pm

    I enjoyed reading your comments and as a 3rd Year OT student in the UK I really wonder if Splinting is truly OT – where is the occupation in splinting? Don’t OT’s use activity as their treatment medium and i can see no activity in splinting. I feel this is a job of the Physio. Althought splinting does have benefits, such as protection against contracture, alignment, I feel it is on a par with providing medication which acts to improve a persons health. What do you all feel about OT’s who splint?

    Reply
    • 5. Nadia  |  September 19, 2009 at 3:02 pm

      Hi there! May I know which university in UK are you currently in? Thanks.

      Reply
      • 6. Ciarán O'Hagan  |  September 20, 2009 at 4:52 am

        I’ve just left Bournemouth University – why did you ask? Just to make you aware that my above comments are my own thoughts and don’t necessarily represent the University’s stance on OTs and hand-splinting….

      • 7. Nadia  |  September 21, 2009 at 2:46 pm

        Oh nono, please dont get me wrong.. I have no issues with your comments above.. I’m actually an occupational therapy student in my country at a diploma level and I would have to go to either to UK or Australia for a year to obtain a degree hence I’m kinda doing a little research on Universities that offer occupational therapy as a course. yeah.

    • 8. Segornae  |  July 9, 2010 at 10:17 pm

      While I am a newer OT and a total splinting novice, I do think it is definitely a worthy OT intervention as it often allows a patient to participate in their meaningful activities. Additionally, here in the US, it sometimes seems that other professions are frequently treading on the OT ground, although not maliciously I would hope. Splinting, especially for those who are skilled at it, can provide a significant relief of discomfort and improve function. For example, a short opponens splint assists a quadrapalegic in attaining tenodesis grasp, which may allow them to complete self-feeding and grooming/hygiene–very worthwhile activities 😉

      Reply
      • 9. Gary Hess  |  July 3, 2011 at 7:20 pm

        As far as treading into and on to other therapy disipline grounds. It can be a concern but as long a therapist is competant in a certain area and has the best interest in mind for the pt, than I think it is justifable for the disiplines to overlap. Ultrasound and other modalities is another great example.

  • 10. James Bishop  |  January 14, 2009 at 8:57 am

    I think splinting for perfectally ok for OT’s to do. I think of splinting as a preporatory method, or something that can prepare a pt. for function. Splinting can also improve function, as in the case of a tenodesis splint for someone with wrist drop.

    Reply
  • 11. Ciaran O'Hagan  |  January 14, 2009 at 4:30 pm

    I see the point that you’re making but splinting doesnt have an activity as it’s treatment medium – giving medication to ease pain also has the same affect of improving function or prepares people to be more functionally in daily occupations e.g. washing and dressing – so should OT’s train to give out medication?
    OT philosophy is to use activity/occupation as our medium of treatment and i feel this differs us from other professions.

    Reply
  • 12. Shawn  |  February 22, 2009 at 10:19 pm

    I agree splinting is not necessarily OT treatment however I believe that the OT part of splinting comes from providing education or attempting to incorporate splint wear into daily routines.

    Reply
  • 13. robert  |  August 27, 2009 at 4:17 pm

    As for the amputee, consider this scenario (that I recently encountered): a very recent BKA nursing home resident whose knee is contracted at about 90 degrees. This resident is in bed half the day, and in her chair the rest of the time. While in bed, the patient lies supine, which means that the stump is resting directly on the bed. Would splinting be indicated in this case to help treat the contracture so that the terminal end of the leg wouldn’t have direct pressure on it?

    Reply
  • 14. aishel  |  August 27, 2009 at 5:30 pm

    Robert, in your case, I think I would adapt a heel elevator (aka waffle boot) to raise the stump off the bed.

    Reply
  • 15. dax  |  October 1, 2009 at 5:24 am

    1. you all know what splints are for.
    2. true, one of OT’s philosophies is to use activity/occupation to treat our pts.
    3. if im not mistaken, i believe that the OT definition from the 8th ed of spackman still applies, which states: OT is the art and science of DIRECTING man’s participation in selected task … however you want to re/direct it through our many approaches/FORS its up to you as long as that task is considered as purposeful to the pt.
    4. true, splinting is not an activity in itself but it is an adjustment (adaptation) of an activity that yields to a desired end result thus making it purposeful to the pt. only with a little change with the internal or external mechanism. but isnt PA the foundation where OT is built upon?
    5. with regards to the patient cited, i think the purpose for splinting is definitely not the quality of life of the pt but rather to facilitate the efficient delivery of care by the primary caregivers if ROM will be preserved. so long as the wearing schedule is strictly being observed, i think giving her a splint would still be a good decision.

    Reply
  • 16. Segornae  |  July 9, 2010 at 10:18 pm

    Hey! What a cool site! I work in acute care and would certainly not have splinted in that instance–first do no harm 😉

    Reply
  • 17. Frank  |  August 26, 2010 at 9:18 pm

    Splinting that knee may help prevent further contracture. So, even if the patient has dementia and is bed bound, it can be really helpful to keep their joints as mobile as possible. That daily task may no longer be the patient’s responsibility but It’s still part of their daily routine. Keeping the joints mobile can make dressing and bathing less difficult for the nursing assistant and as a result less painful for the patient. Plus, contracture and arthritis that goes along with it can be really painful. Your Alzheimer’s patient may not be able to communicate pain in the future.

    Reply
  • 18. Jodie  |  September 20, 2010 at 2:34 pm

    I feel as though splinting is definitely within the realm of Occupational Therapy, however in this instance, I would not recommend utilization of a splint. If the client is bedbound at baseline, what would splinting accomplish if it would not be utilized functionally? A splint is meant to be utilized to adapt and accomodate for a physical impairment in order to help reduce pain, improve functional mobility, improve joint posturing, etc. I do not believe that providing this client with a splint would be indicated as this would not be a client-centered, occupation-based treatment.

    Reply
  • 19. azalia  |  November 11, 2010 at 8:21 am

    I really love this blog.
    I’m an OT student from Malaysia.
    Thx for sharing the info.

    Reply
  • 20. Ally Wong  |  December 9, 2010 at 9:00 am

    hey, since there’s a gathering of OTs on this site, can i ask a question?

    i’m a ex-college student on the verge of choosing OT as a career (in Australia) but I haven’t really conversed with international OTs and of course the practice may differ between countries…why did you guys make OT your career choice? what’s so great about it?

    Thanks

    Reply
  • 21. robert  |  January 9, 2011 at 1:40 am

    scenario 1: u believed that u are supposed to do no harm hence u decided not to give this patient a splint. usual cases in the snf setting, wait for a good 6 months, even if u have an RNA order for either AAROM or PROM, patient will develop tightening and ultimately ending up in contracture. positioning pt up in reclining w/c will be more difficult. provision of nursing care would be more painful.
    what do u think u just did to the pt. u just caused harm to the poor pt. DHS will be after your butt and headache starts disabling u and your practice.

    scenario 2: order orthotic fitting and training for this patient. develop a good wearing schedule. do the necessary training for proper carry over of splinting upon pt discharge. pt happy, caregivers happy, you happy, DHS happy. Everybody happy =)

    just a thought. but then i could be wrong so u can stick with just leave the stump alone. let us know

    Reply
  • 22. hannah  |  January 22, 2011 at 5:27 pm

    heya, im a first year OT student so i cant claim to have any level of expertise but iv found this blog really interesting, specifically the debate over whether OT’s should splint as i am currently wearing splints provided to me by an OT! As iv said i dont have much OT knowledge but in what I have covered we have looked at how an OT should consider 3 areas: the person, the occupation and the environement. Surely by providing a splint you are helping ‘adjust’ (i cant think of the right word!) the person which in turn helps with occupations? Its certainly helped with me! what do you think? It would be great to hear whether practising OT’s think iv ‘got the right end of the stick!’

    Reply

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