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Running Head: WS FOR CTS

Evaluating the effects of wrist splinting in individuals with carpal tunnel syndrome

Todd Banks, Gareth Loosle and Lexi Sybrowsky

University of Utah


Carpal tunnel syndrome (CTS) is a condition where the median nerve is compressed or

inflamed and causes numbness, tingling, and other symptoms in the arm and hand (Mayo clinic,

2017). Irritated tendons or a thickening of the lining of the tunnel itself can cause compression.

Certain underlying medical conditions can also cause swelling in the wrist including diabetes,

thyroid problems, high blood pressure, arthritis or previous trauma to the wrist (Hall, 2013).

Women are three times more likely than men to develop CTS, probably due to the fact that the

actual carpal tunnel structure in the wrist is smaller in women than it is in men (“Carpal Tunnel

Syndrome Fact Sheet,” 2017). Carpal tunnel syndrome affects 2.7 to 5.8 percent of the adult

population. This diagnosis is often associated with overuse injuries that can be repetitive in

nature (Cestia, 2011) such as typing, repeated exposure to vibration (such as power tools) or

poor positioning of the wrist or hand for long periods of time.

Carpal tunnel syndrome ranges in cost for those affected by it. In terms of non-surgical

treatments, things like splints, braces, medication and therapy can vary in cost. In more severe

cases, surgery can cost someone between $1,500 and $12,000 depending on insurance

coverage (“What is the cost of surgery,” n.d.). Additionally, the pain from CTS can interfere with

work, school or home responsibilities and prevent those people from participating in certain

activities. Symptoms may interfere at work, which could lead to decreased productivity and

potentially unemployment. Carpal tunnel syndrome can have a significant impact on a person’s

quality of life. Pain or muscle weakness may prevent someone from doing important everyday

occupations and activities. This can lead to depression or low self-esteem (“Can carpal tunnel

syndrome cause anxiety and depression,” 2017). Though CTS may seem like it is localized to

the wrist and arm, it can have widespread effects on many parts of a person’s life.

With proper treatment, people with CTS can reduce their symptoms and live more

normal lives. As occupational therapist, we will be able to assess people with carpal tunnel

syndromeCTS and provide them with education, symptom management, modification or

adaptive equipment in order to improve their quality of life and increase their engagement in

occupations. A person’s hands and wrists are important for many of the occupations and

activities that people chose to do, so it is an occupational therapist's job to help maximize

function and reduce symptoms like pain.

Current therapy for carpal tunnel syndrome can range from non-surgical techniques like

splinting, medication, and exercise to surgery for more severe cases. Most patients are treated

non-surgically (Verdugo, Salinas, Castillo, & Cea, 2003). Piazzini et al. (2007) conducted a

systematic review that looked at the effectiveness of the current conservative therapy

treatments. They evaluated different treatments including local injections, splints, physical

therapies, and therapeutic exercises and found various levels of evidence that correlated with

each treatment. Among the evidence that was presented in this systematic review, there was

level 2 evidence that showed that splints were an effective treatment, especially if they are used

full time. We chose to focus our attention on splinting because it is one of the most common

forms of conservative treatment for CTS. As noted by Piazzini et al. (2007), there is a hole gap

in our knowledge about the effectiveness of some of these conservative treatments like

splinting. As such, we systematically reviewed the literature to see if splinting is an effective

treatment on its own or if additional treatments were required to reduce pain in individuals with

CTS. Commented [AT1]: nice job on your intro

Methods Commented [AT2]: bold

For this systematic review, online databases were searched for studies that utilized CTS

and pain management. The databases used were Medline, Cochrane Database, Google

Scholar, CINAHL Database, and PubMed. The University of Utah’s Eccles Library was also

used. Keywords used included carpal tunnel syndrome, CTS, splinting, pain and splint. These

keywords were not all used at once, but in various combinations to achieve accurate and broad

searches. We searched for articles that compared splinting in carpal tunnel for pain to another

form of treatment or no treatment. This includes no treatment, surgery, different splinting

techniques, and splinting plus other treatment such as steroid injections or education. Overall,

there were a combined 643 articles available to review based on our keyterms using the key

terms listed earlier in this section. This large number of articles can be attributed to the

prevalence of carpal tunnel syndrome as well as the large amount of research that has been

done on the effectiveness of splinting as a form of therapy. We found articles about CTS back to

dating back to the 1960’s.

Each of us originally found, read, and reviewed five articles each for a total of 15 articles.

The selection criteria used to find articles was that they were recently published and had high Commented [AT3]: meaning?

levels of evidence, including criteria such as a control and/or a study group. We ended up with a

handful of systematic reviews and RCTs. Then those articles were analyzed for our final review.

For our final review, some articles were omitted due to being more irrelevant and not

addressing pain, for having lower PeDRO scores, low validity, or for overlapping with other

articles. We settled on using nine different articles for this review. We wanted articles that had

no lower than a 5 on the PeDRO scale. We wanted to keep high levels of evidence so all of our

articles are either randomized clinical trials or systematic reviews. We also wanted articles that

took various perspectives on CTS treatment for pain. To keep up with leading research, articles

between 2003 and 2017 were exclusively used in this review. Commented [AT4]: ok here it is. Probably would have
been better to organize it so it is closer to the earlier

Results Commented [AT5]: bold

Study size and quality: Commented [AT6]: should make these AP style
For this evidence- based review, there were nine articles included. Eight of the nine

articles were randomized controlled trials (RCTs). The ninth article used was a systematic

review. Six of the RCTs used a two group design (Gerritsen, 2003; Angelis et al., 2009; Yagci et Commented [AT7]: write out

Commented [AT8]: these should be in alphabetical

al., 2009; Hall et al., 2013; Khosrawi, Emadi, & Mahmoodian, 2016; Bulut et al., 2015) one used order

a four group design (Brininger et al., 2007), and one used a three group design (Dincer et al., Commented [AT9]: write out

2009). The range of the sample sizes in the RCT”s was from 33 to 176. The mean sample size

was 76. The sample size for the systematic review was 1,190. All of the articles qualified as

level 1 evidence. The PeDRO scores for the articles ranged from 5/10 to 8/10 with a PeDRO

score average of PeDRO score of 6/10.

Study design: Commented [AT10]: make it APA style

Brininger et al. (2007) examined the efficacy of customized splints and tendon nerve

gliding exercises used to treat CTS in a randomized control trial. This study looked at

conservative interventions like splinting for mild to moderate CTS in regards to overall

symptoms, though pain was not specifically mentioned. Limitations in this study included the

potential use of medication or injections, which makes it difficult to determine whether

improvement resulted solely from the intervention process. The main outcome validated the use

of splints for conservative CTS treatments and further mentioned certain types of splints were

more effective than others.

Angelis, Pierfelice, Giovanni, Staniscia, and Uncini (2009) examined the efficacy of a Commented [AT11]: since you mentioned Angelis
earlier, you’d be able to just write Angelis et al. (2009)
wrist splint versus a soft hand brace for CTS treatment. This study specifically mentioned the

measurement of pain and paresis so it was important to include this article because it directly

related to our research question. There were no limitations mentioned by the authors of this

article, but the study population was predominantly female which could have had an impact on

the overall outcome. The outcomes of this study show that both hand braces and wrist splints

show a reduction in symptoms, specifically the pain scores were significantly reduced post


Yagci et al. (2009) looked to compare the short-term efficacy of splinting alone versus

splinting with low-level laser therapy to treat carpal tunnel. This study showed that splinting is an

effective treatment but splinting with another form of therapy (low-level laser therapy in this

case) is a more beneficial treatment. This study noted many limitations including a lower

baseline symptom severity for the group that received the laser therapy. This could not have

been predicted before the study due to the randomization of assignment to groups, but both

treatments were proven to show symptomatic improvement. Another limitation of this study was

the sample size. The sample was large enough to use the specific assessments and

questionnaires that the authors chose but may have been limited to statistical comparison of


Khosrawi, Emadi, and Mahmoodian (2016) is a RCT looking to compare comparing

splinting as a conservative treatment for CTS to splinting in conjunction with steroid injections.

This study used both clinical measures and client questionnaires to measure the treatment

effectiveness. The results of this study show that only conservative treatment is not as effective

as splinting with steroid injections. In both nerve conduction and client questionnaires, the

steroid injection group scored higher. This study noted some limitations including the low

amount of participants (N=43), limited age range (51-52 years), and the large participation of


Page, Massy-Westropp, O'Connor, and Pitt (2012) is a systematic review that looked at

19 articles regarding CTS treatment. This review noted that most of the studies used different

outcome measures, but the majority of them dealt with a reduction of symptoms either

measured or via questionnaire. This systematic review concluded that there is evidence that

splinting is more effective than no treatment. Limitations of this review are limited evidence and

high ration of women to men.

Gerritsen (2003) is conducted a RCT that compared wrist splinting at night for six weeks

to open carpal tunnel release surgery. They measured effectiveness by how many times

participants woke up during the night due to pain and client questionnaires at specified times

during the study. This study concluded that while more invasive, the open carpal tunnel release

surgery showed more reduced pain and symptoms. Noted limitations of this study are the lack

of clinical or physiological measurement of pain or symptoms. Instead, this study was based

entirely on self-reported measures. It also noted a high level of women to men.

Dincer, Cakar, Kiralp, Kilac, and Dursun (2009) looked at the effectiveness of splinting

coupled with other treatments in treating symptoms of carpal tunnel syndrome. The treatments

that were compared were splinting alone, splinting with low-level laser (Lll) therapy, and

splinting with ultrasound (US) therapy. This study found that all of the interventions were

effective at relieving symptoms, but splinting coupled with Lll therapy was the most effective

treatment, followed by splinting with US therapy, and lastly splinting alone. The authors state a

few limitations for this study. One was the short duration of the follow-up. This could have

affected the overall outcome of the study. Another limitation noted is that it was impossible for

the authors to guarantee the compliance of participants.

Hall et al. (2013) compared full-time wrist splinting alone with full-time wrist splinting.

Splinting combined with an education program. The study found that 8 week full-time splinting

with an education program was more effective at relieving symptoms including pain, than the

control group of full-time splinting alone. A limitation of this study is that the results could not

completely be attributed to the difference in intervention. The interventions were completed by

occupational therapists of different skill levels and the difference in skill could have had an

impact on the amount of symptom improvement. The study also had a smaller sample size, but

the article stated that the size was determined by previous studies to be sufficient.

Bulut et al. (2015) looked at the effectiveness of wrist splinting alone compared with the

wrist splinting combined with metacarpophalangeal joint splints. The results of this study show

that a splint that prevents MCP joints from flexing combined with a wrist splint is more effective

than a wrist splint that restricts wrist movements alone. A limitation noted by the authors is that

there is a large variety of MCP splints and wrist splints and how much movement is restricted by

each of them may have influenced the results. More studies need to be conducted on these

variations to be able to better support the findings of this study. Commented [AT12]: great job on your results!

Discussion Commented [AT13]: bold

The general population in our studies was female with an age range of 50-55 years old.

The participants had mild to moderate carpal tunnel syndrome and were seeking conservative

treatments for their symptoms. We were able to find nine different articles related to our

question. Seven of the articles were specific to our question regarding pain symptoms. Four of

the nine studies found compared splinting alone versus splinting combined with another

treatment. One study compared splinting at night with surgery and two studies compared

treatment using different kinds of splints. The systematic review looked at 19 studies that

compared various carpal tunnel treatments.

The findings of the articles show that wrist splinting is an effective conservative

treatment for the treatment of carpal tunnel syndrome in reducing pain. This may be one of the

reasons that wrist splinting alone was used a control group against other treatments. Although

splinting is effective, four of our studies that compared splinting alone with splinting combined

with another treatment (Yagci et al., 2009; Hall et al., 2013; Khosrawi, Emadi, & Mahmoodian,

2016; Bulut et al., 2015) found that splinting combined with another treatment was generally

more effective than splinting alone. Furthermore, these studies show that customized splints

may be more effective than off the shelf splints. Overall findings show that splinting significantly

reduced symptoms, including pain, and improved function.

A common limitation mentioned throughout these articles is that the participant number

was sufficient to run the trials but was still considered small sample sizes. The studies selected

for our review also mentioned having a limited age range, with the mean age being between 50-

55 years old. An additional limitation in these articles was that there were much higher numbers

of women used as participants than men. Khosrawi, Emadi and Mahmoodian (2016) specifically

mentioned the higher number of women selected for their study than men. Though the general

population shows that women are more likely to develop CTS than men, this is still considered a

limitation because the information may not be generalizable to men with carpal tunnel


According to the American Heart Association, splinting would be considered between the

levels of A and B and a class IIa benefit (AHA levels of evidence, 2010). We classified our

research as IIa and between A and B because of the limited population in our articles and the

multiple RCTs we found that were positively correlated with our research question. This is a

reasonable treatment to use for CTS to address pain. Based on the articles researched,

splinting would be more effective as a part of a conservative treatment regimen. It is important

to note that there was conflicting evidence found in a few of the RCTs stating that surgery was a

more effective treatment than splinting but these articles were largely disregarded due to

surgery being considered a more invasive approach to CTS. Our review focused on

conservative treatments and how they compared with splinting. Overall, splinting is an effective

conservative treatment but as stated above, it is more beneficial to use splinting in conjunction

with additional treatments.

As occupational therapists, we will often come into contact with clients affected by carpal

tunnel syndrome. Although splinting is effective treatment for OT practice in reducing pain,

findings show that splinting coupled with other treatments is more effective at relieving

symptoms. Knowing this information, we will be able to make better recommendations for our

clients and utilize a larger base of treatment to alleviate pain in individuals with carpal tunnel

syndrome. Commented [AT14]: very nice!



AHA Levels of Evidence. (2010). Retrieved April 14, 2017, from

Angelis, M. V., Pierfelice, F., Giovanni, P. D., Staniscia, T., & Uncini, A. (2009). Efficacy of a soft

hand brace and a wrist splint for carpal tunnel syndrome: a randomized controlled study.

Acta Neurologica Scandinavica, 119(1), 68-74. doi:10.1111/j.1600-0404.2008.01072.x

Brininger, T. L., Rogers, J. C., Holm, M. B., Baker, N. A., Li, Z., & Goitz, R. J. (2007). Efficacy of

a fabricated customized splint and tendon and nerve gliding exercises for the treatment

of carpal tunnel syndrome: a randomized controlled trial. Archives of Physical Medicine

and Rehabilitation, 88(11), 1429-1435. doi:10.1016/j.apmr.2007.07.019

Bulut, G. T., Caglar, N. S., Aytekin, E., Ozgonenel, L., Tutun, S., & Demir, S. E. (2015).

Comparison of static wrist splint with static wrist and metacarpophalangeal splint in

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Gerritsen, A. A. (2003). Splinting vs. Surgery for Carpal Tunnel Syndrome. JAMA: The Journal

of the American Medical Association, 289(4). doi:10.1001/jama.289.4.421-c

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448–459. https:/

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splinting and splinting plus low-level laser therapy in idiopathic carpal tunnel syndrome.

Clinical Rheumatology, 28(9), 1059-1065. doi:10.1007/s10067-009-1213-0


Table 1. Overview of articles chosen to use in our review Commented [AT18]: chart looks great!
Study Design Population Outcome Measures Findings

Brininger, T. L., Rogers, Four groups N=61 subjects Focused on varying Splinting was reported by 62.7%
J. C., Holm, M. B., Baker, randomly (14 men, 47 kinds of splints and of the subjects to be the most
N. A., Li, Z., & Goitz, R. assigned Groups women) looking at their beneficial intervention.
J. (2007). were to receive Mean age of 50 overall
varying kinds of years old with effectiveness for Results suggest that certain
splints, exercises mild to moderate CTS. kinds of splints were more
and amounts of carpal tunnel Assessments used: effective than others.
time. syndrome CTS Symptom
Level of Inclusion criteria: Severity Scale Customized splints may be more
evidence: 1 18 years old, (SSS) and the effective than off the shelf splints.
PeDRO score: positive Tinel sign Functional Status
5/10 or Phalen's Scale (FSS) used Wrist splinting significantly
maneuver and to assess CTS reduces symptoms and improves
complaints of symptoms and function short term.
nocturnal functional status
numbness. Measured at
baseline and 8
weeks post

Gerritsen, A. (2003) Two groups N=176 patients Number of nights Surgery reduced pain and
randomly (143 women, 4 waking up due to symptoms more than splinting.
assigned to men) pain and severity of
either receive Mean age: 49 symptoms.
wrist splinting at Inclusion criteria: Measured via
night for six Pain, questionnaires
weeks or open paresthesia, or given by trained
carpal tunnel hypoesthesia in therapists at the
release surgery. hand innervated baseline and at 3,
Level of by median nerve. 6, and 12 months
evidence: 1 Clinically after randomization
PeDRO score: confirmed CTS. began.

Angelis, M. V., Pierfelice, Two groups N=91 patients Looked at the Both hand and wrist splinting
F., Giovanni, P. D., randomly (79 females, 12 efficacy of wrist were found to be effective
Staniscia, T., & Uncini, A. assigned to use males) splinting versus a treatments for reducing CTS
(2009) either a soft hand Mean age: 46 soft hand brace. symptoms.
brace or a wrist Inclusion criteria: Assessments used:
splint. pain, numbness The Italian version Average pain and paresis scores
Level of and abnormal of the Boston for VAS scale were reduced
evidence: 1 sensation in the Carpal Tunnel
PeDRO score: median nerve. Questionnaire: Symptomatic relief seems to fade
5/10 Exclusion criteria: used to evaluate and improvement in functionality
previous CTS symptomatic and does not persist, may need to
surgeries, steroid functional scores. repeat treatment periodically.
injections, The Visual
rheumatoid Analogical Scale
arthritis or signs (VAS): measures
of neuropathy. changes in pain
and paresis.
Measured at
baseline, 3 and 9
months post

Page, M. J., Massy- Systematic N=1,190 (179 Many different Evidence supporting splinting is
Westropp, N., O'Connor, review that men, 839 women, outcome measures an effective treatment compared

D., & Pitt, V. (2012). looked at 19 97 undescribed were used across to not splinting.
studies with no gender) the studies. Many
time limits that Mean age range: of them dealt with a
compared carpal 40-50 years reduction of CTS
tunnel symptoms such as

Yagci, I., Elmas, O., Two groups N= 45 (all Compared the Both splinting and splinting with
Akcan, E., Ustun, I., randomly females) efficacy of splinting laser therapy (SLLLT) provided
Gunduz, O. H., & Guven, assigned to Mean age: 50 and splinting plus improvements in clinical
Z. (2009) either splinting Inclusion criteria: low-level laser parameters but SLLLT is
group or splinting mild or moderate therapy for CTS superior to splinting.
plus low-level patients with CTS treatment.
laser therapy Exclusion criteria: Assessments used:
group. patients with Nerve conduction
Level of fibromyalgia, study (NCS),
evidence: 1 diabetes, radial Boston
PeDRO score: fractures, Questionnaire
7/10 pregnancy, (BQ), grip strength,
rheumatoid and clinical
arthritis or prior response criteria to
CTS treatment or measure function.
surgery. Measured at
baseline and 3
months after

Hall, B., Lee, H. C., Two groups N=62 Compared the Results suggest that splinting
Fitzgerald, H., Byrne, B., randomly (71% women) effectiveness of with an education program on
Barton A., & Lee, A. H. assigned to Mean age: 53.8 splinting to splinting how to use the wrist splint
(2013) either control Inclusion criteria: with an education reduced pain symptoms more
group (splinting) Age ≥ 18 yr., program. than splinting alone. This
or treatment Assessment used: suggests Splinting is an effective
group (splinting paresthesia in the The Boston Carpal treatment for pain when
with education). median nerve Tunnel completed properly.
Level of Questionnaire:
evidence: 1 night or day, measured function
PeDRO score clumsiness, grasp and symptom
5/10 severity. The Visual
weakness, sleep Analog Scale (VAS:
disturbance, no measured pain.
Dynamometer: grip
medical strength. Purdue
intervention, no Pegboard Test: for
finger dexterity:
conservative Semmes–
treatments in the Weinstein
Monofilament: for
past 6 mo. light touch. The
Phalen’s test: for

Khosrawi, S., Emadi, M., Two groups, N=43 (37 female, Questionnaire Steroids plus splinting showed
& Mahmoodian, A. E. randomly 6 male) evaluating better recovery results versus
(2016). assigned into Mean age range: satisfaction splinting only
either 51-52 Nerve conduction
conservative Inclusion criteria: items.
treatment Confirmed CTS Measured at

(splinting) or via electro baseline, at four

splinting diagnostic and weeks and 12
combined with observation of weeks after
steroid injections. symptoms. intervention
Level of
evidence: 1
PeDRO: 6/10

Bulut, G. T., Caglar, N. Two groups, N=33 (30 Effectiveness of The study suggests that splinting
S., Aytekin, E., randomly females, 3 males) splinting with MCP with MCP splinting improves pain
Ozgonenel, L., Tutun, S., assigned into 11 bilateral CTS splinting compared symptoms more than splinting
& Demir, S. E. (2015). either in group 1 to splinting alone. alone. No statistically significant
conservative 10 bilateral CTS Assessments used: differences were found between
treatment, in group 2 Visual Analog these splints according to
Neutral volar Mean age: 44.4: Scale (VAS): electrophysiological testing.
static wrist splint, Exclusion criteria: subjective pain,
or neutral volar Underlying Saehan Hydraulic
static wrist splint disorders that Hand
with cause secondary Dynamometer: grip
metacarpophalan CTS; pregnancy;; strength.
geal splint. hx of steroid Electrophysiological
Level of injection to the Test Alpine Biomed
evidence: 1 carpal tunnel; Key point,
PeDRO score: thenar muscle CTS questionnaire:
6/10 atrophy; hx of severity of
traumatic or symptoms
events of hand;
other UE
patients with
severe CTS

Dincer, U., Cakar E., Three groups N=100 hands (50 Assessments used: The study suggests that splinting
Kiralp M. Z., Kilac H., & randomly women w/ Boston with ultrasound (US) and
Dursun H. (2009) assigned into bilateral CTS) Questionnaire, splinting with low level laser
three different Mean age: 51.2 patient satisfaction (LLL) therapy were more
conservative Exclusion criteria: inquiry, Visual effective at reducing symptoms
interventions; severe CTS, Analogue Scale than splinting alone. Splinting
splinting only, underlying (VAS) for pain, and with LLL therapy reduced
splinting plus US, disorders,, ENMG. symptoms more than the other
& splinting plus malignancy, two treatments.
LLL therapy. fractures, cervical
Level of radiculopathy,
evidence: 1 brachial
PeDRO score: plexopathy,
6/10 tenosynovitis,
pregnancy, other
CTS treatment or
procedure within
the past year