Splinting and Hand Therapy Principles

Synopsis

This chapter presents information to guide hand therapists in providing care on international short-term medical missions. It reviews principles of hand therapy evaluation and treatment in this setting with recommendations to guide instruction to local therapists in host countries. The goal is to impart hand therapy knowledge and skills to local therapists, in particular splint/orthosis fabrication, promotion of independence, and facilitation of ongoing patient care.

Clinical Issues

Opportunities are expanding for hand therapists to participate in international short-term medical missions (STMMs). From Guatemala to Southeast Asia, lower- and middle-income countries (LMICs) welcome medical teams from more developed countries. These visiting medical teams (VMTs) offer expertise and instruction and introduce materials and resources. As part of the team, hand therapists share their knowledge and skills as they discover new cultures and health care systems. In the process, the therapists' abilities and creativity are stretched as they provide care in a culture and environment vastly different from their own.

There are several agencies that have established STMMs around the world. The United States–based American Society of Hand Therapists (ASHT) website maintains a list that includes: Guatemala Healing Hands, Health Volunteers Overseas, International Medical Volunteers Association, ReSurge International, United Kingdom–based Sierra Leone, Hands Across Borders, and Medical Teams International.

The Visiting Medical Team

The VMT may include plastic and/or orthopedic surgeons, anesthesiologists, nurses, translators, and a hand therapist. Sometimes the team may be smaller with only surgeons and a therapist. The roles of each team member are not as delineated as they are in hospitals in more developed countries. The team members work closely together and need to be flexible. Hand therapists may be involved in casting, taking photos, transporting patients, and gathering supplies in addition to providing hand therapy.

The relationships that are formed between the VMT and the host medical staff are critical to facilitate the successful exchange of ideas, information, and skills. The receiving hospital typically has a host or point person. Communicating with this person before going on the mission is helpful to establish initial contact, learn about the basic setup of the facility, determine the makeup of the patient list, and find out whether there is a local therapist on staff.

Due to the small window of time that the VMT is at the site, the ability to take care of acutely injured patients is limited. Adult patients may present with healed trauma-related injuries, amputations, burns, arthritis, stroke, nonunion or malunion of fractures, and sub-acute tendon and nerve injuries. In the pediatric population, the team may encounter congenital contractures, cerebral palsy, thumb hypoplasia with radial longitudinal deficiency, burn scars, syndactyly, and polydactyly.

The short-term goals for the VMT include:

• 1.

  Providing quality care to as many patients as possible during the 1 to 2 weeks at the host hospital.

• 2.

  Teaching and equipping the local staff by transfer of knowledge and skills that can be used to deliver care to the community once the VMT departs.

The effect of the VMT in each of these areas depends on the availability of personnel and physical resources.

The long-term goal of the VMT is to decrease dependency on visiting STMMs and to empower the local health care team to address the needs of its patients.

Hand Therapy in the Developing World

The primary role of the visiting hand therapist includes instructing local therapists and providing evaluation and treatment to both surgical and nonsurgical patients.

The presence of a local physical or occupational therapist or other health care provider interested in serving in the therapist's role is vital for the transfer of hand therapy techniques and the development of local resources. Both textbooks and lectures that provide visual explanations of therapy intervention can serve as useful resources. However, the hands-on experience, such as working with patients side by side, is instrumental in solidifying the delivery of care in a safe and effective manner. The local practitioners are able to observe hand therapy assessment and treatment, as well as practice splint/orthosis fabrication.

A patient list is created by the host hospital before the visiting team arrives. The VMT typically begins its work with a clinic to evaluate all of the potential patients. Some of the patients will require surgery, and others may be referred for hand therapy intervention only.

Surgical patients may require hand therapy intervention both in the operating room and post-operatively. The VMT surgeons and hand therapist determine whether the patient would benefit from a splint in the operating room to allow more optimal positioning than a cast, as well as early wound monitoring and dressing changes. The splint can be modified after wound healing is complete to maintain optimal positioning.

Post-operative hand therapy includes evaluation, wound care, and treatment including range-of-motion (ROM) exercises, splint fabrication, and home program instruction.

Some of the patients assessed in the initial clinic will not be surgical candidates but will need hand therapy. For example, patients with congenital contractures, arthritic patients with joint stiffness, pain, and weakness, and patients with spasticity may require exercises and splint intervention only.

In general, patients may be seen one to three times by the visiting therapist, depending on how long the VMT is in the country. It is possible for patients to have longer follow-up if there is a competent local therapist. However, this depends on the ability of the patients to travel back to the hospital, the length of time patients can stay in the hospital, and the parameters of the health care system.

Most likely there will be limited therapist-patient face-to-face time. As a result, a good home program is crucial. It is recommended that the therapist bring exercise sheets with illustrations of the most common upper limb exercises to prescribe to patients. If the patients have access to a cell phone with a camera, they can photograph exercises for reference. If there is a language barrier, having an interpreter is critical, though illustrations and demonstration are needed regardless. Patients or caregivers of young children should demonstrate exercises with the therapist to ensure understanding. Fig. 5.10.1 shows sample illustrations of upper limb ROM exercises that are suitable to use with patients.

Visiting therapists should be culturally sensitive to the norms that influence patient care, communication, and interactions between local therapists and other medical staff. For example, in most developed countries therapists and surgeons work closely together. In other cultures, the surgeons may not work as closely with the therapists; there may be hierarchical norms that influence working relationships.