Did you know that the prevalence of Carpal Tunnel Syndrome (CTS) in developed countries is about 50 -160 cases per 1000? It affects women more than men and typically develops between 50 to 54 and 75 to 84 years.
Carpal Tunnel Syndrome affects women more than men and typically develops between 50 to 54 and 75 to 84 years
It is also common during pregnancy affecting up to 50% of pregnant women, the good news for these women is that symptoms often get better within three months of the baby being born.
However I was surprised to learn that carpal tunnel release is one of the most common surgical procedures in the United States. So what non surgical treatments are available for people with mild to moderate symptoms (typically pain, numbness and a burning or tingling sensation in the thumb, index finger, middle finger and half of the ring finger)?
Wrist splints are often recommended but what is the evidence? I was pleased to find that a new Cochrane systematic review addresses this very issue.
Here’s what they did
The authors of this review from Melbourne, Australia compared the effectiveness of splinting for carpal tunnel syndrome with no treatment, placebo, or another non-surgical treatment for improving clinical outcome. They followed Cochrane’s high quality methodology and undertook an extensive search of the literature, up until 10 January 2012, and found 19 studies involving 1190 randomised participants (some studies included people with bilateral CTS thus data were from 1287 wrists). Studies comparing splinting with surgical treatment and studies with participants who had previous surgery for CTS were excluded and the Cochrane Collaboration’s ‘Risk of bias’ tool was applied to the studies they included.
Here’s what they found
- The duration, type and routine of splint wear was varied (the most common was between two and four weeks, and nocturnal wear)
- Only 3 studies reported on short-term overall improvement at three months or less
- One low quality study with 80 wrists found that compared to no treatment, splints worn at night more than tripled the likelihood of reporting overall improvement at the end of four weeks of treatment (RR 3.86, 95% CI 2.29 to 6.51)
- A very low quality quasi-randomised trial with 90 wrists found that wearing a neutral splint more than doubled the likelihood of reporting ‘a lot or complete relief’ at the end of two weeks of treatment compared with an extension splint (RR 2.43, 95% CI 1.12 to 5.28)
- The third study which measured short-term overall improvement did not report outcome data separately per group.
- Nine studies measured adverse effects of splinting and all found either no or few participants reporting discomfort or swelling due to splinting;
- Differences between groups in the secondary outcomes – symptoms, function, and neurophysiologic parameters – were small with 95% CIs incorporating effects in either direction.
The authors concluded
“Overall, there is limited evidence that a splint worn at night is more effective than no treatment in the short term, but there is insufficient evidence regarding the effectiveness and safety of one splint design or wearing regimen over others, and of splint over other non-surgical interventions for CTS. More research is needed on the long-term effects of this intervention for CTS.”
The Musculoskeletal Elf’s views
This high quality Cochrane review could not define the most effective splint design, wrist position or wearing schedule thus making the choice between interventions conceptually difficult for clinicians and patients. The reason for this was that there was significant heterogeneity (variability) in the interventions delivered, risk of bias, and outcomes reported, which prevented any pooling of outcome data.
This review could not define the most effective splint design, wrist position or wearing schedule thus making the choice between interventions conceptually difficult for clinicians and patients.
I entered ‘wrist splints for carpal tunnel’ into Google and got over 320,000 hits, and a quick scroll through revealed that many of these were sales pitches some even indicating ‘Designed and approved by Medical Professionals’. There was even a dedicated site for ‘Carpal Tunnel Brace Reviews’, and after a careful look this did have a ‘**DISCLAIMER** I am NOT a medical doctor, the information on this site should NOT be taken as medical advice’. Clearly more work is needed in this important area.
Do you recommend splinting for your patients? What is your view on this review, will it change your clinical practice? Send us your views on this blog and become part of the Musculoskeletal Elf community.
Links
- Page MJ, Massy-Westropp N, O’Connor D, Pitt V. Splinting for carpal tunnel syndrome. Cochrane Database of Systematic Reviews 2012, Issue 7. Art. No.: CD010003. DOI: 10.1002/14651858.CD010003.
- Higgins JPT, Altman DG, Sterne JAC. Assessing risk of bias in included studies. In: Higgins JPT, Green S editor(s). Cochrane Handbook for Systematic Reviews of Interventions Version 5.1.0 [updated March 2011]. The Cochrane Collaboration, 2011: Available from www.cochranehandbook.org.
I work in Rheumatology in an acute hospital. We routinely fit a Neoprene wrist brace in a neutral wrist position, teach hand exercises for flexor tendon gliding and assess if task modification would be beneficial. I was surprised the evidence was so weak but would not expect measurable positive outcomes within 2-4 weeks for many people. 2-4 months seems a more appropriate time scale to me.
Hi Tracy- this review could not have come at a more opportune time for us as had a huge debate amongst msk physio managers (with no agreement other than need to go off and do a lit search!!) on whether or not we should still fund/order and provide wrist splints for carpal tunnel (and thumb splicas for OA thumb/De Quervain’s). It would appear that the evidence is apparently too weak to support ongoing funding of these for carpal tunnel until a stronger evidence base is available. I suppose now the debate will be whether weak available evidence should be enough to support their provision meantime and is better than no evidence at all!! I presume your advice would be to change clinical practice and stop using splints at present? Thanks again- you have saved me the trouble of a lit search for this condition. Can I just also comment that I think the “elf” is a fantastic site for clinicians and much needed so thanks (you’ve probably already had my comments via Fraser Ferguson but just though I would repoeat them!). Helen
Hi Helen and Tracy,
Thanks for your summary of our review Tracy (and I agree with Helen that your blog is an excellent resource).
I agree that the results of our review makes the choice between use of splinting interventions conceptually difficult for clinicians and patients. However I think it’s important not to confuse “evidence of no effect” with “no evidence of effect”. In other words, the studies in our review were often not able to confirm that one splinting intervention was more effective than another intervention for carpal tunnel syndrome; however we did not find evidence that splinting does not work. So based on this, Helen, I wouldn’t recommend you stop using splints in your practice, but do think it’s important that people with carpal tunnel syndrome are informed of the weak evidence for this treatment (so that they can make an evidence-informed decision).
Matt
These last two comments certainly answer a lot of queries that have been proposed by the budget holders in our trust. The weak evidence in supporting the use of splints is just that, weak but better than none. I agree with the suggestion that its quality and strength be relayed to patients from an education aspect. Thanks for this piece of work.
Hi – I am a Rheumatology OT -Thanks for this very useful review .I agree that while the evidence is weak it at least does give us synthesis of the best evidence to date.
Resources are under scrutiny -but this evidence along with what our patients actually feedback to us about symptom relief needs to be taken into account.
Hi. I am a physio working in orthopaedic clinic and outpatients. Again having just been introduced to the site I’m find ing it very useful especially with the inclusion of a Blog to allow discussion. I have a few questions I’d like to ask.
Do you know when they were looking at the effectivenss of splinting did they take into consideration the grading of carpal tunnel and the duration of symptoms?
Was effectiveness deemed by what happened when the person stopped wearing the spint or lack of effect whilst using the splint?
In my own clinincal practice I often use the splints as part of a diagnositic/ prognostic component. Whilst they may not get sustained or complete relief from wearing splints some change in symptoms may be an indication that the person would benefit from decompression and help comfirm diagnosis.
Working in a private hand therapy physiotherapy practice we see a bucket load of these. Basically people fall into 3 categories: Overuse manual handling, overuse computer, pregnancy related.
Also when this is further investigated many patients do not complain of constant neurological symptoms. The symptoms occur either primarily in the morning (lack of use), or evening (after use).
In regard to their conclusion:
“there is insufficient evidence regarding the effectiveness and safety of one splint design or wearing regimen over others, and of splint over other non-surgical interventions for CTS”
I would think the articles used in this review did not stratify people according to their primary provoking activity (sleep, labouring, typing) and did not splint according to their functional requirement (sleep, labouring, typing). Therefore evidence is weak.
The clients story is much more important. Just throwing splints at people does not do anything!
In addition I’m curious to know if any of these studies had exclusion criteria related to the neck or nerve pains proximal to the carpal tunnel….much reading to be done now…thanks!!!??!?!
Thanks for the post, Elf!
In my experience as a hand physio there is definitely a place for splinting with carpal tunnel syndrome, but it is never going to be the solution for everyone. There are many possible causes for CTS, and often the cause is not identifiable. Splinting is most likely to be effective if the cause is at least partly positional. The tunnel has its largest possible diameter (therefore lowest possible pressure) when the wrist is near neutral. Diameter decreases and pressure increases with greater wrist flexion (eg sleeping in the fetal position) or with wrist extension (eg sleeping on your side with your palm flat on the mattress).
Prolonged/heavy gripping can also cause or aggravate CTS due to incursion of the lumbricals into the tunnel. Splinting to prevent full MCP joint flexion can be helpful in these cases.
Thanks for this information, I am a long time sufferer of Carpal Tunnel and have found that the splint design is the most crucial aspect when figuring out effectiveness. Too short a splint does not give adequate support while many have pinched or rubber in the area between the thumb and hand.
I came to this page looking for recommendations and was not surprised to see studies lacking, longer terms are needed for this type of look into effectiveness of splints, years is more appropriate for effectiveness not months.