1241

Splinting for Carpal Tunnel Syndrome: In Search of The

Optimal Angle
David T. Burke, MD, Maureen McHale Burke, OTRL, Gregory W. Stewart, MD, Antoinette Cambre’

ABSTRACT. Burke DT, Burke MM, Stewart GW, CambrC A. Splinting for carpal tunnel syndrome: in search
of the optimal angle. Arch Phys Med Rehabil 1994;75:1241-4.
a Carpal tunnel syndrome (CTS) is the most common of the compression neuropathies. Several studies have
demonstrated the efficacy of wrist splinting in relieving the symptoms of CTS; however, the chosen angle of
immobiition has varied. Wick catheter measurements of carpal tunnel pressures suggest that the neutral
position has less pressure and, therefore, greater potential to provide relief from symptoms. This study is a
prospectively gathered, blind trial comparing the symptom relief experienced by wearers of splints immobiied
at 20” extension and at neutral. The results indicate that the neutral angle provided superior symptom relief, and
that the relief did not often improve between 2 weeks and 2 months of wear. Relief of symptoms was not related
to the length of time that the patient had experienced of CTS symptoms. The results also indicate that the results
of the electromyography/nerve conduction study (EMGINCS) do not provide information about the subjects’
likely response to splinting.
0 1994 by the American Congress of Rehabilitution Medicine and the American Academy of Physical Medicine and
Rehabilitation

Carpal tunnel syndrome (CTS) is the name commonly
given to compression neuropatbies of the median nerve at
the wrist. CTS is the most common of the compression
neuropathies and the incidence of reported cases is increas-
ing annually. It is usually the suspected diagnosis in anyone
who has hypesthesia or paresthesia in the median nerve in
the hand, and/or in any patient who has weakness or atrophy
in the abductor pollicis brevis or opponens pollicis.‘**
Treatments for CTS have included hand splinting, steroid
injection in the carpal tunnel, and surgical relief of the apo-
neurosis that forms the roof of the carpal tunneL3 Whereas
several studies4*5have demonstrated the efficacy of the splint
in relieving symptoms of carpal tunnel syndrome, the angle
of wrist immobilization has varied. Phalen described the
cock up splint as being one with the wrist in slight extension.*
In 1990, Baxter-Petralin concluded that the cock up splint
should be made with 20” of extension.6 Terrey in 1986 de-
scribed the splint as being in 20 to 30” of extension.7 Other
studies, however, demonstrated that placing the wrist in a
high degree of flexion or extension may greatly increase the
pressure within the carpal tunnel.’ Kruger and others have
suggested that placing the wrist in the neutral position when
immobilizing in a splint may provide the optimal reduction
in pressure, and therefore the optimal relief when using this
mode of therapy.5
There has been no prospective study demonstrating the
clinical utility of placing the wrist in neutral as opposed to
From the Department of Medicine (Drs. Burke, Stewart), Section of Physical Medi-
cine & Rehabilitation, Louisiana State University Medical Center; Occupational Ther-
apy Department (Ms. Burke, Ms. Cambr6). Medical Center of Louisiana at New
Orleans, New Orleans, LA.
Submitted for publication June 17, 1993. Accepted in revised form February 21.
1994.
No commercial party having a direct financial interest in the results of the research
supporting this article has or will confer a benefit upon the authors or upon any
organization with which the authors are associated.
Reprint requests to David T. Burke, MD, Louisiana State University Medical Cen-
ter, Department of Medicine, Section of PM&R, 1.542 Tulane Avenue, Suite 602,
New Orleans, LA 70112.
0 1994 by the American Congress of Rehabilitation Medicine and the American
Academy of Physical Medicine and Rehabilitation
0003~9993/94/751 l-2348$3.00/0
extension. This study reviewed the difference in symptom
relief experienced by individuals placed in a 20” cock up
splint and individuals placed in a neutral carpal tunnel splint.
MATERIALS AND METHODS
Subjects in this study were referred for splinting to the
occupational therapy (OT) department by physicians in the
rheumatology, orthopaedics, and neurology clinics at our
medical center. Fifty-nine patients with a history consistent
with CTS were referred during the study period. Patients
were included if they reported a clinical history consistent
with CTS including hypesthesia or paresthesia in the distri-
bution of the median nerve of the hand, and/or weakness or
atrophy in the abductor pollicis brevis or opponens pollicis.
Subjects were excluded if they reported a history of surgery,
injection at the wrist, or previous splint use. Many individu-
als had bilateral carpal tunnel syndrome and all wrists were
reviewed separately, giving a total of 90 wrists. Because
both neutral and extension splints were used in the OT de-
partment, the therapist began to alternate between neutral
and 20” extension as a quality control review. Splinting was
completed by alternating between extension and neutral. The
order of splinting was dominate then nondominate hand.
Thus, if the next splint on the alternating list was for neutral,
the dominate hand would receive the neutral splint, and the
nondominate hand would then receive the extension splint.
Both splints were attached in the same way, and patients
were not told of the difference in angle. No patients ex-
pressed an awareness of a difference between the two splints.
All splints were custom made volar cock-up style splints
constructed of thermoplastic splinting material. The angle
of the splint was verified with a goniometer after the material
cooled. The splints were fastened with velcro and beta pile
straps.
At the initial appointment, all patients were asked to de-
scribe their symptoms and their duration, their hand domi-
nance, and any surgical and trauma history to the wrists or
hand. Results of any electromyographic or nerve conduction

Arch Phys Med Rehabll Vol75, November 1994

1242 SPLINTING FOR CARPAL TUNNEL SYNDROME, Burke
Table 1: Collapsed ,$ of Subjective Relief Versus
Splinting Angle at 2 Weeks
Splint Angle Not at All/A Little A Lot/Completely
Neutral 28 17
Extension 38 7 Extension
x2 value: p = ,017.
studies were recorded. With studies having been done at
several different laboratories, the data were reviewed for any
indication of nerve entrapment of the wrist consistent with
carpal tunnel syndrome. The minimum criteria for a positive
nerve entrapment at the wrist was a motor distal latency of
greater than or equal to 4.4msec and a sensory distal latency
of greater than or equal to 3.8msec.
Subjects were instructed to return to the clinic if they have
any difficulty with the splints. After 2 weeks, the patients
were contacted by telephone and asked (1) had their symp-
toms improved overall; (2) had their symptoms improved at
night; and (3) had their symptoms improved during the day.
They were asked to respond “Not at all,” “A little,” “A
lot,” or “Completely.” They were also asked “Did you
wear your splint?” and asked to respond “Every night,”
“Most nights, ” “Some nights,” or “Never.” Finally, they
were asked if they also wore the splint during the day, with
possible answers being “None, Some, Most, or All” of the
time. All patients were contacted again after 2 months and
asked the same questions. The information was prospectively
collected as a component of the institutions’ Quality Assur-
ance Program; Institutional Review Board approval was ob-
tained to use the results.
RESULTS
All 59 subjects (90 wrists) were contacted at 2 weeks,
with 12 subjects (19 wrists) lost to long-term follow-up. The
data were analyzed using the 2-week follow-up question-
naire. Both groups contained 45 wrists for analysis. The
average length of symptoms for the neutral group was 25.2
months and the average length of symptoms for the extension
group was 27.6 months. Of the 45 wrists placed at neutral,
5 reported “no” relief, 23 reported “some” relief, 16 re-
ported “a lot” of relief, and 1 reported “complete” relief.
Of the 45 wrists placed in extension, 7 reported “no” relief,
31 reported “some” relief, 7 reported “a lot” of relief and
none reported “complete” relief. The neutral and extension
groups were compared on the basis of subjective relief with
each response given a numerical value (not at all = 1, a
little = 2, a lot = 3, and completely = 4). The results were
analyzed by x2. Because of the low numbers in the extreme
ends of the x2 tables, the data were analyzed by collapsing
responses one and two, and by collapsing the responses three
and four to increase the power of the statistic. With these
Table 2: ,$ of Subjective Relief Versus Nighttime
Splinting Angle at 2 Weeks
Splint Angle Not at AWA Little A Lot/Completely
Neutral 22 20
Extension 21 6 Complete relief
xz value: p = .034.
Arch Phys Med Rehabil Vol75, November 1904
Table 3: ,$ of Subjective Relief Versus Splinting
During the Day at 2 Weeks
Splint Angle Not at AWA Little A Lot/Completely
Neutral 30 10
19 3
x2 value: p = 0.35.
collapsed for a two by two x2 analysis, the results indicated
that neutral was significantly better (p = .017) in overall
symptom relief (table 1).
These data were again analyzed to determine whether the
angle of the splint affected the nighttime symptom relief
experienced by the subjects. Again a problem with statistical
power was found because there were few responses at the
extreme ends of the response scales, and responses one and
two were collapsed as were responses three and four, into
a two by two x2 (table 2). The results again indicated that
neutral provided significantly better relief than extension
splints (p = .034). These data were analyzed for daytime
symptom relief and revealed no difference (p = .345) be-
tween the splints (table 3).
The data were analyzed by x2 to determine whether the
length of time that a person had the symptoms of carpal
tunnel syndrome was correlated to the symptom relief pro-
vided by splinting (table 4). x2 was completed on these data,
which indicated no relationship (p = .32) between the length
of time that the symptoms were experienced prior to splint-
ing and the degree of relief that splinting would provide.
Because of the low values in the extreme ends of the cells,
a Pearson correlation was also completed on these data. The
subjective relief was again given a numerical value on a one
to four scale, and these values were analyzed to detect a
correlation with the number of months that a patient had
experienced symptoms and subjective relief. This statistic
revealed no correlation (p = .202) between the number of
months that the symptoms were present, and the subjective
relief by splinting.
Among those wrists that still remained within the study
at 2 months, a comparison was made between the 2-week and
2-month subjective ratings of symptom relief. Any change in
symptoms was noted (fig). There was no change in 59% of
the cases, and improvement of one rank in 11% and by two
ranks in 6%. Eighteen percent of the patients experienced
symptom improvement of one rank and 6% experienced im-
provement by two ranks.
Finally, for those 62 wrists for which NCYEMG results
Table 4: Subjective Splint Relief at 2 Weeks Compared
With Length of Symptom Complaint
Months Patient Showed CTS
Symptoms
O-6 6-12 12-24 24-48 >48
Subjective response
to splinting No relief 3 4 2 2 1
A little relief 11 19 3 11 7
A lot of relief 9 5 6 2 2
0 1 0 0 0
x2 value: p = ,432.
 SPLINTING FOR CARPAL TUNNEL SYNDROME, Burke

Table 5: 2 Analysis Comparing Splint Response and Table 6: Collapsed 2 Analysis Comparing Splint
EMG/NCS Results Response and EMG/NCS Rasults
Subjective Response to Wrist Splinting Subjective Response to Wrist Splinting
Not at All A Little A Lot Completely Not At ARIA Little A L&Completely
EMG EMG
positive 8 35 6 1 positive 43 7
EMG EMG
negative 1 5 2 0 negative 6 2
x2 value: p = ,773. x2 value: p = ,425.

were available, a x2 analysis was completed to assess the
correlation between the electrophysiological results and the
response to splints. These data (table 5) indicate no signifi-
cant difference in splint response between those with EMG/
NCS positive for CTS and those with EMG/NCS negative
for CTS (p = .425). Because of the low numbers in the
cells, these data were collapsed into a two by two x2 (table
6) with the results again indicating no correlation between
EMG results and response to splinting (p = .425).
DISCUSSION
These data indicate that the angle of the splint does make
a difference in subjective relief of the symptoms of carpal
tunnel syndrome, and that this difference is apparent after
wearing the splints for only 2 weeks.
This study is the first clinical trial that indicates that the neutral
angle wrist splint will provide better symptom relief than the
traditional 20” extension “cock-up” wrist splint. This is consis-
tent with previous studies that found that the pressure within the
carpal tunnel is significantly less when the wrist is in neutral
than when it is flexed or extended?.’ This study provides clinical
evidence that even this relatively small wrist angle difference
will allow for detectably superior symptom relief.
Though it would have been interesting to analyze the data
at 2 months, 19 of the 90 wrists were lost to follow-up.
Among those 73 contacted, 9 had discontinued splint wear.
Seven of the 9 were neutral angle splints and 2 were exten-
sion splints. All the initial responses of those two groups
were “a little” and “a lot.” The data shown in the figure
are interesting, even with the loss of 19 wrists to follow-up.
These data suggest that continuation of splinting beyond 2
weeks would result in either no improvement in symptoms
or a worsening of symptoms (in 76% of the patients). There
is strong evidence that splint use longer than 2 weeks may
not be warranted if the symptom relief is not satisfactory to
the patient. It seems unlikely from these data that a patient’s
symptoms will improve with splint use extended beyond 2
weeks.
The greatest relief in symptoms occurred at night, with
38% of the patients noting good or complete relief at that
time as compared to 2 1% of the patients experiencing relief
during the day. Many patients indicated that wearing the
splints during the day seemed restrictive, making it difficult
to continue wearing. Many patients reported that nighttime
symptoms were the most troublesome, and were pleased
with the relief that these splints afforded. Comfort and utility

-2 (6,0X)

2 (6*OX)

No change (59.0%)

1 (1&OX Change in subjective

symptom relief comparing
2 weeks follow-up with
that at 2 months. Positive
numbers indicate improve-
ment in symptom relief.

Arch Fhys MadR&WI Vol75, Nouumbw 1094

1244 SPLINTING FOR CARPAL TUNNEL SYNDROME, Burke
of splinting obviously is an issue for patients and can affect
the amount of time they are willing to engage in this thera-
peutic modality. However, this result is suspect because our
instructions emphasized night use of splints. It is possible
that if the patients were instructed to always wear their
splints during the day, these results would have been dif-
ferent.
These data also suggest that the amount of time patients
had experienced symptoms prior to splinting does not corre-
late with symptom relief provided by wrist splints. This was
surprising because symptom duration is often thought to
correlate with a poorer conservative treatment response.
These data suggest that a 2-week trial of wrist splints is
warranted regardless of how long patients have had symp-
toms.
In summary, this study verifies that the neutral splint is
superior to the traditional 20” cock-up splint. For the majority
of patients, the overall relief afforded by splinting may be
apparent at 2 weeks. Finally, neither the length of symptoms
Arch Phys Med Rehabil Vol75, November 1994
nor the results of the EMG/NCS are factors that should
discourage this mode of treatment.
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