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Journal of Back and Musculoskeletal Rehabilitation 28 (2015) 761–767 DOI 10.3233/BMR-140580 IOS Press
Comparison of static wrist splint with static wrist and metacarpophalangeal splint in carpal tunnel syndrome Gul Tugba Buluta , Nil Sayiner Caglarb , Ebru Aytekinb , Levent Ozgoneneld, Sule Tutunb and Saliha Eroglu Demirc,∗ a
Physical Medicine and Rehabilitation Clinic, Ministry of Health, Gebze Fatih State Hospital, Izmit, Turkey Physical Medicine and Rehabilitation Clinic, Ministry of Health, Istanbul Research and Training Hospital, Istanbul, Turkey c Physical Medicine and Rehabilitation Department, Medical Faculty, Bezmialem Vakif University, Istanbul, Turkey d Department of Physical Medicine and Rehabilitation, Nightingale Hospital, Istanbul Bilim University Florence, Istanbul, Turkey b
Abstract. BACKGROUND: The position of metacarpophalangeal (MCP) joints may be an important factor affecting the efficacy of splinting in patients with carpal tunnel syndrome (CTS). OBJECTIVE: The aim of the present study was to compare the efficacy of a neutral volar static wrist splint with a neutral volar static wrist and MCP splint in patients with CTS. METHODS: Fifty-four hands were included into the study. A neutral volar static wrist splint was given to the symptomatic hands of the patients in group 1 while a neutral volar static wrist and MCP splint was given to the symptomatic hands of the patients in group 2. Evaluation parameters were Visual Analog Scale for pain severity (VASp), grip strength, pinch strength, electrophysiologic tests and CTS Questionnaire (CTSQ) at baseline and four weeks later. RESULTS: At baseline there was no difference between groups. The intergroup comparison of the improvement showed significant differences in VASp at rest, grip strength, pinch strength and CTSQ functional capacity scores between groups in favor of wrist MCP splint. Although there were significant improvements with regard to sensory amplitude and motor latency in both groups after therapy, the differences between groups were not at the level of significance. CONCLUSIONS: The position of MCP joints seems to be an important factor for the treatment of CTS and should be considered while prescribing a splint to the patients with CTS. Keywords: Carpal tunnel syndrome, splint, electrophysiological tests, wrist joint, metacarpophalangeal joint
1. Introduction Carpal tunnel syndrome (CTS) is the most common form of entrapment neuropathies occuring due to compression of the median nerve at the wrist. This syn∗ Corresponding author: Saliha Eroglu Demir, Physical Medicine and Rehabilitation Department, Medical Faculty, Bezmialem Vakif University, Adnan Menderes Bulvarı Vatan Cad. Fatih, Istanbul, Turkey. Tel.: +90 212 523 37 19; Fax: +90 212 533 23 26; E-mail: [email protected].
drome leads to pain, paresthesia, numbness and weakness in the median nerve distribution of the hand. The carpal tunnel is a passageway through which nine flexor tendons and the median nerve pass. The reported prevalence of CTS is 6% in the general population [1]. Increased pressure within the carpal tunnel of patients with idiopathic CTS and disturbance in the blood flow to the median nerve were reported [2,3]. Flexion and extension of the wrist increases carpal tunnel pressure. Immobilization of the hand in a splint may prevent the elevation of carpal tunnel pressure [4]. Splinting is one
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of the most commonly used conservative treatment options in CTS [5,6]. The aim of splinting is to immobilize the wrist a neutral position in order to avoid flexion or extension of the wrist [3]. It was reported that patients using a neutral wrist splint will report higher symptom relief than patients who receive a wrist splint in extension [7]. The effectiveness of neutral wrist splinting has been validated in the previous studies [8–10]. However, wrist position may not be the only factor affecting the efficacy of splinting [11]. Forceful contraction of the lumbrical muscles within the carpal tunnel may be another factor [12]. When the hand is used actively and the fingers, especially the metacarpophalangeal (MCP) joints, are flexed, the lumbrical muscles migrate proximally into the carpal tunnel. This leads to increased pressure within the carpal tunnel [11]. In a recent study showed that compared with fingers extended pinch and grip activities caused significant increases in pressure at hook of hamate where the tunnel is most constricted and the median nerve is most compressed in CTS [12]. It seems important to consider the MCP joint position while splinting for the treatment of CTS. There are a few studies evaluating the effects of a neutral wrist MCP splint in patients with CTS [11,13, 14]. These studies reported a significant improvements in symptoms and functional status. However, wrist was positioned in different angles in these studies. One of them, wrist splint positioned the wrist in 20◦ of extension while the wrist-MCP splint positioned the wrist in neutral (0◦ ) and the MCP joints from 0◦ to 10◦ of flexion [11]. In their study, Zinnuroglu et al. adjusted wrist angle to be in 15 degrees of extension in wrist splint group. The splint they used to immobilize the wrist and MCP joints also immobilized forearm [14]. Because splinting the wrist in a neutral position was reported to be more effective then splinting the wrist in extension, new studies to compare the effficacy of splinting wrist and MCP joints with wrist splint in a neutral position are necessary. The aim of the present study was to compare the efficacy of a neutral volar static wrist splint with a neutral volar static wrist and MCP splint in CTS.
2. Materials and methods Patients who were diagnosed as having CTS according to subjective symptoms, physical examination and electrophysiologic findings were recruited from the Physical Medicine and Rehabilitation Outpatient
Clinic. All individuals gave informed consent and a local ethics approved the study. Participants were questioned about their demographic characteristics (age, gender, body mass index (BMI) (kg/m2 )) and medical history including systemic diseases and chronic use of drugs. Dominant hand, symptomatic hand, subjective symptoms of CTS (tingling, numbness, burning, weakness, pain, nocturnal pain), the symptom duration, smoking history and alcohol consumption were questioned. Dominant hand was defined as the one preferred for daily activities like writing and eating and for handling heavy objects. All participants were eligible to participate in the program if their age were above 18 years, and they were able to understand the content of questionnaires. All the patients were examined by the same physician including systemic, musculoskeletal and neurolgical examinations. Exclusion criteria were underlying metabolic disorders that cause secondary CTS such as diabetes mellitus, thyroid disease, chronic kidney disease, rheumatological disorders; being pregnant; history of steroid injection to the carpal tunnel within previous three months; having thenar muscle atrophy; history of splint use; history of traumatic or inflammatory events affecting hand region such as wrist fractures, tenosynovitis, surgery; other disorders of upper extremities or cervical region such as epicondylitis, disc herniation; patients with electrophysiologically severe CTS; clinical or electrophysiologic evidence of accompanying conditions that mimic CTS or interfere with its evaluation, such as proximal median neuropathy, cervical radiculopathy, polyneuropathy, brachial plexopathy, or thoracic outlet syndrome. The patients were randomly divided into two groups. Bilaterally affected wrists were allocated to the same intervention. After satisfying inclusion criteria, patients were admitted to the study and assigned a number. Odd numbers used to indicate allocation to Group 1 and even numbers to indicate allocation to Group 2. A neutral volar static wrist splint was given to the symptomatic hands of the patients in group 1. The angle of the wrist was adjusted to be in 0–5 degrees of extension. MCP joints as well as the fingers and the elbow were free to move. Cotton–polyester material was used in the construction of this splint. A neutral volar static wrist and MCP splint adjusting MCP joints and wrist in neutral position was given to the symptomatic hands of the patients in group 2. Thermoplastic material was used in the construction of this splint. The angle of the wrist was adjusted to be in 0–5 degrees of extension. The angle of MCP joints was
G.T. Bulut et al. / Comparison of static wrist splint with static wrist and metacarpophalangeal splint in CTS
adjusted to be in 0–10 degrees of flexion. This support restricted MCP and the wrist movements, but allowed the finger and the elbow movements. The patients were instructed to wear their splints continuously all night for 4 weeks. All the patients were individually educated on the disease and preventive measures for the disease were explained. Three patients from Group 1 and two patients from Group II who did not comply with splint use as requested were excluded from the study. A total of 33 patients (29 women and 4 men) were included into the study. Their mean age was 44.27 ± 9.4 years, with a range of 24–59. CTS was bilateral in 21 patients. The hand involvement had the following distribution: dominant hand 30.3% (10 patients), nondominant hand 6.1% (2 patients) and bilateral hand 63.6% (21 patients). Evaluations were performed at baseline and repeated at the end of 4 weeks by the same clinician. Electrophysiological evaluation of all the patients was carried out at baseline and at the end of 4 week by the same physician who was not aware of the splint allocated to the patient. All evaluation parameters were as follows: Severity of pain was evaluated using the 0–10 mm Visual Analog Scale (VASp) as VASp activity (VASpa) and VASp resting (VASpr). Grip strength and pinch strength: Grip strength and pinch strength was measured (in kilograms) using a Saehan Hydraulic Hand Dynamometer. Three measurements were taken for each parameter, and the mean of the values was calculated [13]. Electrophysiologic Tests: Electrophysiological studies before and after the treatment were performed with R Alpine Biomed Keypoint Portable Classic 5.11 device by the same physician who was blind to treatment. All studies were performed in a room with the temperature kept at 25◦ C. Median sensory and motor nerve conduction studies were recorded on the painful arm. Median distal motor latencies and median motor nerve conduction velocity were measured. Compound muscle action potentials (CMAP) were recorded with surface electrodes from the abductor policis brevis muscle for the median nerve. Sensory nerve action potentials (SNAP) were obtained ortodromically. The distance between the stimulator and recording electrode was 14 cm. Distal sensory latency and sensory nerve conduction velocity were measured. CTS Questionnaire (CTSQ): CTSQ is a self-administered disease-specific questionnaire for assessing severity of symptoms, functional impairment and the outcome of treatment in CTS. It consists of two scales.
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The symptom severity scale (CTSQ-S) consists of 11 items concerning pain, nocturnal symptoms, numbness, tingling and weakness. Each item of this scale offers five responses of increasing severity and is scored from 1 (no symptoms) to 5 (very severe symptoms). The functional status scale (CTSQ-F) has eight items assessing difficulty in writing, buttoning clothes, opening jars, holding a book, gripping of a telephone handle, household chores, carrying of grocery bags, bathing, and dressing. The eight responses are scored on a five-point scale (1 to 5) [15]. This scale also referred to as the Boston Carpal Tunnel Questionnaire, the Levine scale, Brigham and Womens’Carpal Tunnel Questionnaire and Carpal Tunnel Syndrome Instrument [16]. The questionnaire has previously been utilized with a Turkish population to, evaluate treatment responses [17,18]. Power analysis was performed retrospectively, and the value was found to be 85%. The minimum sample size required for 80% statistical power and 5% significance level was 23 for each group. Data were analyzed with the use of Epi Info Version 3.5.1. Descriptive data were presented as mean ± standard deviation (SD). Demographic characteristics were compared using the Chi-squared and Fisher’s exact tests. As variables did not show normal distribution, Mann-Whitney U test was used for the comparison of pretreatment and posttreatment values between groups. Wilcoxon’s signed Rank test was used to analyze the differences between pretreatment and posttreatment values within groups. The intergroup comparison of the improvement (differences of pre-post scores) between groups was also evaluated with Mann-Whitney U tests. Correlations between study parameters were evaluated by the Spearman’s correlation test. A p value less than 0.05 was considered as statistically significant.
3. Results Fifty-four hands were included in the study. Demographic characteristics of both groups are presented in Table 1. At baseline, the main demographic and clinical features of the groups except phalen test were similar. Phalen test positivity were significantly higher in Group 1 (p:0.041). No statistically significant difference was found in terms of VASpa, VASpr, grip strength, pinch strength, CTSQ-S and CTSQ-F scores at baseline (Table 2). A statistically significant improvement was observed in the values of VASpa, VASpr, grip strength, pinch strength, CTSQ-S and
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G.T. Bulut et al. / Comparison of static wrist splint with static wrist and metacarpophalangeal splint in CTS Table 1 Demographic characteristics of both groups Gender (Female/Male) (n) Bilateral CTS (n) Age (years) (mean ± SD) BMI (kg/m2 ) (mean ± SD) Symptom duration (months) (mean ± SD) CTS (mild/moderate) (n) Dominant hand (right/left) (n) Numbness n (%) Burning n (%) Clumsiness n (%) Pain causing awakening during the night n (%) Tinel test n (%) Phalen test n (%)
Wrist splint (n:16) 13/3 11 42.4 ± 10.1 29.8 ± 4.7 10.2 ± 4.6 11/5 15/1 16 (100) 10 (62.5) 10 (62.5) 8 (50) 14 (87.5) 13 (81.3)
Wrist MCP splint (n:17) 17/0 10 46.4 ± 7.8 29.6 ± 6.3 13.2 ± 10.6 11/6 15/2 16 (94.1) 14 (82.4) 11 (64.7) 9 (52.9) 15 (88.2) 8 (47.1)
P 0.061 0.554 0.460 0.518 0.193 0.805 0.582 0.325 0.201 0.895 0.866 0.948 0.041
n: number of patients, SD Standard Deviation, BMI Body Mass Index, CTS Carpal Tunnel Syndrome, VASpa Visual Analog Scale pain activity, VASpr Visual Analog Scale pain resting. Table 2 Symptomatic and functional parameters of groups before and after therapy
VASpa p (within groups) VASpr p (within groups) Grip strength p (within groups) Pinch strength p (within groups) CTSQ-S p (within groups) CTSQ-F p (within groups)
Wrist splint (27 hands) Baseline After therapy 3.74 ± 2.88 3.85 ± 3.11 0.113 1.19 ± 2.06 0.67 ± 1.73 0.066 20.59 ± 11.40 22.05 ± 10.80 0.025 5.72 ± 1.74 5.75 ± 1.56 0.747 2.50 ± 0.83 1.79 ± 0.71 0.000 2.14 ± 0.70 2.08 ± 0.84 0.108
Wrist MCP splint (27 hands) Baseline After therapy 2.89 ± 3.13 1.52 ± 2.23 0.001 2.04 ± 2.61 0.30 ± 0.82 0.005 20.06 ± 6.96 24.24 ± 7.36 0.000 5.56 ± 1.60 6.67 ± 1.79 0.000 2.58 ± 0.86 1.55 ± 0.63 0.000 2.15 ± 0.61 1.54 ± 0.52 0.000
p (between groups) Baseline After therapy 0.880 0.085 0.176
0.867
0.598
0.098
0.795
0.065
0.835
0.164
0.808
0.012
Data are expressed as means ± SD. CTSQ Carpal Tunnel Syndrome Questionnaire, VASpa Visual Analog Scale pain activity, VASpr Visual Analog Scale pain resting.
CTSQ-F scores in Group 2 (wrist MCP splint) after therapy. In Group 1 (neutral wrist splint) we found statistically significant improvements in grip strength (p:0.025) and CTSQ-S score (p:0.000) after therapy. A statistically significant difference between the two groups after therapy was only found in CTSQ-F score in favor of wrist MCP splint (p:0.012). No statistically significant difference was found in terms of measured electrophysiological parameters at baseline (Table 3). Although there were significant improvements with regard to sensory amplitude and motor latency in both groups after therapy, the differences between groups were not at the level of significance (Table 3). The intergroup comparison of the improvement showed a significant difference in VASpr, grip strength, pinch strength and CTSQ-F scores between groups in favor of wrist MCP splint (Table 4). There was not a significant correlation between symptom duration and CTSQ-S and CTSQ-F scores and electrophysiological
parameters of groups before and after therapy (p > 0.05). There was no significant correlation between electrophysiological parameters and CTSQ-S scores in both groups. There was also no significant correlation between electrophysiological parameters and CTSQ-F scores in neutral wrist splint group (p > 0.05). CTSQF scores were significantly correlated with motor latency at baseline (p: 0.025, r: 0.431) and motor amplitude after therapy (p: 0.027, r: 0.425) in neutral wrist MCP splint group. Other electrophysiological parameters was not correlated with CTSQ-F scores in neutral wrist MCP splint group (p > 0.05).
4. Discussion Splinting is one of the most frequently reported treatments of CTS [19]. The efficacy of several splints were investigated in the previous studies. It was re-
G.T. Bulut et al. / Comparison of static wrist splint with static wrist and metacarpophalangeal splint in CTS
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Table 3 Electrophysiological parameters of groups before and after therapy
Sensory latency (ms) p (within groups) Sensory amplitude(mV) p (within groups) Sensory velocity (m/s) p (within groups) Motor latency (ms) p (within groups) Motor amplitude (mV) p (within groups) Motor velocity (m/s) p (within groups)
Wrist splint (27 hands) Baseline After therapy 2.83 ± 0.31 2.78 ± 0.29 0.327 10.23 ± 4.78 12.35 ± 5.51 0.003 48.59 ± 5.76 50.18 ± 6.39 0.104 3.73 ± 0.49 3.64 ± 0.45 0.038 8.55 ± 1.55 8.59 ± 1.91 0.656 56.10 ± 4.93 56.64 ± 4.13 0.493
Wrist MCP splint (27 hands) Baseline After therapy 2.85 ± 0.37 2.79 ± 0.44 0.057 11.44 ± 4.11 13.96 ± 5.35 0.000 50.39 ± 5.41 50.83 ± 7.05 0.197 3.57 ± 0.64 3.45 ± 0.64 0.008 7.83 ± 2.03 8.60 ± 2.21 0.052 56.83 ± 4.53 58.76 ± 4.65 0.133
p (between groups) Baseline After therapy 0.951 0.917 0.446
0.181
0.317
0.827
0.181
0.096
0.128
1.00
0.055
0.128
Data are expressed as means ± SD. MCP Metacarpophalangeal. Table 4 Intergroup comparison of the improvement (pre-post scores) of clinical and electrophysiological parameters among three groups VASpa VASpr Grip strength Pinch strength CTSQ-S CTSQ-F Sensory latency (ms) Sensory amplitude (mV) Sensory velocity(m/s) Motor latency (ms) Motor amplitude (mV) Motor velocity(m/s)
Wrist splint 0.9 ± 2.7 0.5 ± 1.4 −1.5 ± 3.1 −0.02 ± 0.8 0.7 ± 0.8 0.05 ± 0.8 0.04 ± 0.2 −2.1 ± 3.2 −1.6 ± 3.8 0.08 ± 0.2 −0.03 ± 1.7 −0.5 ± 4.9
Wrist MCP splint 2.2 ± 2.4 1.8 ± 2.6 −4.3 ± 3.6 −1.1 ± 0.7 1.0 ± 0.6 0.6 ± 0.5 0.06 ± 0.2 −2.6 ± 2.4 −0.4 ± 3.6 0.1 ± 0.2 −0.7 ± 1.9 −1.5 ± 5.9
P 0.053 0.029 0.001 0.000 0.086 0.002 0.879 0.435 0.443 0.389 0.243 0.511
Data are expressed as means ± SD.
ported that limited evidence supports the use of a wrist splint in neutral position than an extended wrist position of 20◦ in patients with CTS [7,19]. The effect of the time of splint use was also investigated in the previous studies and night-only wrist splint use was reported to be equally effective as full-time wrist splint use in a review study [7]. The results of the present study suggest that a neutral wrist MCP splint is more effective to improve pain, to reduce symptoms and recover functions than a neutral wrist splint. However, no statistically significant differences were found between these splints according to electrophysiological parameters. In a previous study flexor retinaculum and median nerve characteristics were measured during fingers extended and fingers in an isometric squeeze grip using MRI. They reported that performing an isometric squeeze grip resulted in statistically significant variations within the carpal tunnel area and they suggested that fabricating a splint which prevents the fingers from flexing may be more successful in alleviating the symptoms of CTS than the currently prescribed
splint which only restricts wrist movements (C) [20]. It seems important to consider the MCP joint position while splinting for the treatment of CTS. Currently available data do not adequately address that the immobilization of MCP joints could enhance the efficacy of a neutral wrist splinting in patients with CTS. There are few studies investigating the efficacy of a splint immobilising both the wrist and the MCP joints [11,13,14]. However, these previous studies did not allow for direct comparison with our results because each of them had different methodology. One of these studies investigated the clinical and electrophysiological effects of the carpal lock comparing with a conventional volar-supporting orthosis. The angle of the wrist was adjusted to be in 15 degrees of extension and the forearm was in neutral position in this previous study. The volar-supporting orthosis restricted MCP, wrist, and forearm movements, but MCP joints were in approximately 10–15 degrees of flexion. They prescribed a splinting program of 2 weeks of continuous use followed by 2.5 months of nightly use to affected
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hands of patients with CTS. They found statistically significant improvements in both groups at 3 months. But no statistically significant difference was found between the two groups [14]. In their study Brininger et al. compared the efficacy of a neutral wrist MCP splint (the wrist in neutral (0◦ ) and the MCP joints from 0◦ to 10◦ of flexion) with wrist cock-up splint (the wrist in 20◦ of extension) with and without tendon and nerve gliding exercises in the treatment of CTS. They instructed patients to wear the splint during their sleep time. They found that both splints significantly reduced CTS symptoms and improved functional status and there was a significant difference between two groups in favor of the neutral wrist and MCP splint group [11]. In another study, Baker et al. compared the efficacy of cock-up splint (wrist 0◦ of extension) and lumbrical splint (wrist at 0◦ of extension and the MCP joints at 0◦ to 10◦ of flexion) with different exercises (lumbrical stretch or general stretch exercises) in four groups. They instructed subjects to wear their splint when sleeping. They reported that all splint/stretch combinations were essentially equally effective four weeks later and subjects in the lumbrical splint/general stretch group and the general splint/lumbrical stretch group demonstrated continued and significant improvements in function at 12 weeks [13]. In the present study, we investigated the additional effects of the immobilization of the MCP joints in neutral position (in 0–10 degrees of flexion) to the neutral wrist splinting (in 0–5 degrees of extension). Patients wore their splints continuously all night for 4 weeks. There were significant improvements with regard to grip strength, CTSQ-S scores, sensory amplitude and motor latency in both groups after therapy. Additionally, significant improvements were observed in the values of VASpa, VASpr, pinch strength, CTSQF scores in the patients using a neutral wrist MCP splint at the end of 4 weeks. These improvements point to additional effects of immobilization of MCP joints. Idiopathic CTS generally occurs bilaterally and the dominant hand of patients with CTS is more frequently affected [21]. In the present study, the majority of the patients presented with bilateral CTS (63.6%). Of patients with unilateral CTS 30.3% had dominant hand involvement. CTS is usually diagnosed based on the history and physical examination. Electrophysiological studies are important to confirm the diagnosis [22]. However, a recent study reported that electrodiagnostic tests do not change the probability of diagnosing CTS to an extent that is clinically relevant for the majority
of patients who are considered to have this syndrome on the basis of their history and physical examination alone [23]. Chan et al. reported that electrodiagnostic findings and CTS symptoms and functions of patients with CTS do not appear to be related and both of these parameters should be assessed by clinicians and also researchers [24]. In the present study we only detected a significant correlation between CTSQ-F scores and motor latency at baseline, CTSQ-F scores and motor amplitude after therapy in neutral wrist MCP splint group. We thought that the short-term evaluation of patients in the current study (at 4 weeks) was the reason of insignificance in most parameters of electrophysiological studies. The results of this study showed that a splint which prevents MCP joints from flexing in addition to wrist is more successful in alleviating symptoms of CTS and improving functional status than a splint which only restricts wrist movements. The position of MCP joints should be considered while prescribing a splint to the patients with CTS.
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Journal of Back and Musculoskeletal Rehabilitation 28 (2015) 761–767 DOI 10.3233/BMR-140580 IOS Press
Comparison of static wrist splint with static wrist and metacarpophalangeal splint in carpal tunnel syndrome Gul Tugba Buluta , Nil Sayiner Caglarb , Ebru Aytekinb , Levent Ozgoneneld, Sule Tutunb and Saliha Eroglu Demirc,∗ a
Physical Medicine and Rehabilitation Clinic, Ministry of Health, Gebze Fatih State Hospital, Izmit, Turkey Physical Medicine and Rehabilitation Clinic, Ministry of Health, Istanbul Research and Training Hospital, Istanbul, Turkey c Physical Medicine and Rehabilitation Department, Medical Faculty, Bezmialem Vakif University, Istanbul, Turkey d Department of Physical Medicine and Rehabilitation, Nightingale Hospital, Istanbul Bilim University Florence, Istanbul, Turkey b
Abstract. BACKGROUND: The position of metacarpophalangeal (MCP) joints may be an important factor affecting the efficacy of splinting in patients with carpal tunnel syndrome (CTS). OBJECTIVE: The aim of the present study was to compare the efficacy of a neutral volar static wrist splint with a neutral volar static wrist and MCP splint in patients with CTS. METHODS: Fifty-four hands were included into the study. A neutral volar static wrist splint was given to the symptomatic hands of the patients in group 1 while a neutral volar static wrist and MCP splint was given to the symptomatic hands of the patients in group 2. Evaluation parameters were Visual Analog Scale for pain severity (VASp), grip strength, pinch strength, electrophysiologic tests and CTS Questionnaire (CTSQ) at baseline and four weeks later. RESULTS: At baseline there was no difference between groups. The intergroup comparison of the improvement showed significant differences in VASp at rest, grip strength, pinch strength and CTSQ functional capacity scores between groups in favor of wrist MCP splint. Although there were significant improvements with regard to sensory amplitude and motor latency in both groups after therapy, the differences between groups were not at the level of significance. CONCLUSIONS: The position of MCP joints seems to be an important factor for the treatment of CTS and should be considered while prescribing a splint to the patients with CTS. Keywords: Carpal tunnel syndrome, splint, electrophysiological tests, wrist joint, metacarpophalangeal joint
1. Introduction Carpal tunnel syndrome (CTS) is the most common form of entrapment neuropathies occuring due to compression of the median nerve at the wrist. This syn∗ Corresponding author: Saliha Eroglu Demir, Physical Medicine and Rehabilitation Department, Medical Faculty, Bezmialem Vakif University, Adnan Menderes Bulvarı Vatan Cad. Fatih, Istanbul, Turkey. Tel.: +90 212 523 37 19; Fax: +90 212 533 23 26; E-mail: [email protected].
drome leads to pain, paresthesia, numbness and weakness in the median nerve distribution of the hand. The carpal tunnel is a passageway through which nine flexor tendons and the median nerve pass. The reported prevalence of CTS is 6% in the general population [1]. Increased pressure within the carpal tunnel of patients with idiopathic CTS and disturbance in the blood flow to the median nerve were reported [2,3]. Flexion and extension of the wrist increases carpal tunnel pressure. Immobilization of the hand in a splint may prevent the elevation of carpal tunnel pressure [4]. Splinting is one
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of the most commonly used conservative treatment options in CTS [5,6]. The aim of splinting is to immobilize the wrist a neutral position in order to avoid flexion or extension of the wrist [3]. It was reported that patients using a neutral wrist splint will report higher symptom relief than patients who receive a wrist splint in extension [7]. The effectiveness of neutral wrist splinting has been validated in the previous studies [8–10]. However, wrist position may not be the only factor affecting the efficacy of splinting [11]. Forceful contraction of the lumbrical muscles within the carpal tunnel may be another factor [12]. When the hand is used actively and the fingers, especially the metacarpophalangeal (MCP) joints, are flexed, the lumbrical muscles migrate proximally into the carpal tunnel. This leads to increased pressure within the carpal tunnel [11]. In a recent study showed that compared with fingers extended pinch and grip activities caused significant increases in pressure at hook of hamate where the tunnel is most constricted and the median nerve is most compressed in CTS [12]. It seems important to consider the MCP joint position while splinting for the treatment of CTS. There are a few studies evaluating the effects of a neutral wrist MCP splint in patients with CTS [11,13, 14]. These studies reported a significant improvements in symptoms and functional status. However, wrist was positioned in different angles in these studies. One of them, wrist splint positioned the wrist in 20◦ of extension while the wrist-MCP splint positioned the wrist in neutral (0◦ ) and the MCP joints from 0◦ to 10◦ of flexion [11]. In their study, Zinnuroglu et al. adjusted wrist angle to be in 15 degrees of extension in wrist splint group. The splint they used to immobilize the wrist and MCP joints also immobilized forearm [14]. Because splinting the wrist in a neutral position was reported to be more effective then splinting the wrist in extension, new studies to compare the effficacy of splinting wrist and MCP joints with wrist splint in a neutral position are necessary. The aim of the present study was to compare the efficacy of a neutral volar static wrist splint with a neutral volar static wrist and MCP splint in CTS.
2. Materials and methods Patients who were diagnosed as having CTS according to subjective symptoms, physical examination and electrophysiologic findings were recruited from the Physical Medicine and Rehabilitation Outpatient
Clinic. All individuals gave informed consent and a local ethics approved the study. Participants were questioned about their demographic characteristics (age, gender, body mass index (BMI) (kg/m2 )) and medical history including systemic diseases and chronic use of drugs. Dominant hand, symptomatic hand, subjective symptoms of CTS (tingling, numbness, burning, weakness, pain, nocturnal pain), the symptom duration, smoking history and alcohol consumption were questioned. Dominant hand was defined as the one preferred for daily activities like writing and eating and for handling heavy objects. All participants were eligible to participate in the program if their age were above 18 years, and they were able to understand the content of questionnaires. All the patients were examined by the same physician including systemic, musculoskeletal and neurolgical examinations. Exclusion criteria were underlying metabolic disorders that cause secondary CTS such as diabetes mellitus, thyroid disease, chronic kidney disease, rheumatological disorders; being pregnant; history of steroid injection to the carpal tunnel within previous three months; having thenar muscle atrophy; history of splint use; history of traumatic or inflammatory events affecting hand region such as wrist fractures, tenosynovitis, surgery; other disorders of upper extremities or cervical region such as epicondylitis, disc herniation; patients with electrophysiologically severe CTS; clinical or electrophysiologic evidence of accompanying conditions that mimic CTS or interfere with its evaluation, such as proximal median neuropathy, cervical radiculopathy, polyneuropathy, brachial plexopathy, or thoracic outlet syndrome. The patients were randomly divided into two groups. Bilaterally affected wrists were allocated to the same intervention. After satisfying inclusion criteria, patients were admitted to the study and assigned a number. Odd numbers used to indicate allocation to Group 1 and even numbers to indicate allocation to Group 2. A neutral volar static wrist splint was given to the symptomatic hands of the patients in group 1. The angle of the wrist was adjusted to be in 0–5 degrees of extension. MCP joints as well as the fingers and the elbow were free to move. Cotton–polyester material was used in the construction of this splint. A neutral volar static wrist and MCP splint adjusting MCP joints and wrist in neutral position was given to the symptomatic hands of the patients in group 2. Thermoplastic material was used in the construction of this splint. The angle of the wrist was adjusted to be in 0–5 degrees of extension. The angle of MCP joints was
G.T. Bulut et al. / Comparison of static wrist splint with static wrist and metacarpophalangeal splint in CTS
adjusted to be in 0–10 degrees of flexion. This support restricted MCP and the wrist movements, but allowed the finger and the elbow movements. The patients were instructed to wear their splints continuously all night for 4 weeks. All the patients were individually educated on the disease and preventive measures for the disease were explained. Three patients from Group 1 and two patients from Group II who did not comply with splint use as requested were excluded from the study. A total of 33 patients (29 women and 4 men) were included into the study. Their mean age was 44.27 ± 9.4 years, with a range of 24–59. CTS was bilateral in 21 patients. The hand involvement had the following distribution: dominant hand 30.3% (10 patients), nondominant hand 6.1% (2 patients) and bilateral hand 63.6% (21 patients). Evaluations were performed at baseline and repeated at the end of 4 weeks by the same clinician. Electrophysiological evaluation of all the patients was carried out at baseline and at the end of 4 week by the same physician who was not aware of the splint allocated to the patient. All evaluation parameters were as follows: Severity of pain was evaluated using the 0–10 mm Visual Analog Scale (VASp) as VASp activity (VASpa) and VASp resting (VASpr). Grip strength and pinch strength: Grip strength and pinch strength was measured (in kilograms) using a Saehan Hydraulic Hand Dynamometer. Three measurements were taken for each parameter, and the mean of the values was calculated [13]. Electrophysiologic Tests: Electrophysiological studies before and after the treatment were performed with R Alpine Biomed Keypoint Portable Classic 5.11 device by the same physician who was blind to treatment. All studies were performed in a room with the temperature kept at 25◦ C. Median sensory and motor nerve conduction studies were recorded on the painful arm. Median distal motor latencies and median motor nerve conduction velocity were measured. Compound muscle action potentials (CMAP) were recorded with surface electrodes from the abductor policis brevis muscle for the median nerve. Sensory nerve action potentials (SNAP) were obtained ortodromically. The distance between the stimulator and recording electrode was 14 cm. Distal sensory latency and sensory nerve conduction velocity were measured. CTS Questionnaire (CTSQ): CTSQ is a self-administered disease-specific questionnaire for assessing severity of symptoms, functional impairment and the outcome of treatment in CTS. It consists of two scales.
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The symptom severity scale (CTSQ-S) consists of 11 items concerning pain, nocturnal symptoms, numbness, tingling and weakness. Each item of this scale offers five responses of increasing severity and is scored from 1 (no symptoms) to 5 (very severe symptoms). The functional status scale (CTSQ-F) has eight items assessing difficulty in writing, buttoning clothes, opening jars, holding a book, gripping of a telephone handle, household chores, carrying of grocery bags, bathing, and dressing. The eight responses are scored on a five-point scale (1 to 5) [15]. This scale also referred to as the Boston Carpal Tunnel Questionnaire, the Levine scale, Brigham and Womens’Carpal Tunnel Questionnaire and Carpal Tunnel Syndrome Instrument [16]. The questionnaire has previously been utilized with a Turkish population to, evaluate treatment responses [17,18]. Power analysis was performed retrospectively, and the value was found to be 85%. The minimum sample size required for 80% statistical power and 5% significance level was 23 for each group. Data were analyzed with the use of Epi Info Version 3.5.1. Descriptive data were presented as mean ± standard deviation (SD). Demographic characteristics were compared using the Chi-squared and Fisher’s exact tests. As variables did not show normal distribution, Mann-Whitney U test was used for the comparison of pretreatment and posttreatment values between groups. Wilcoxon’s signed Rank test was used to analyze the differences between pretreatment and posttreatment values within groups. The intergroup comparison of the improvement (differences of pre-post scores) between groups was also evaluated with Mann-Whitney U tests. Correlations between study parameters were evaluated by the Spearman’s correlation test. A p value less than 0.05 was considered as statistically significant.
3. Results Fifty-four hands were included in the study. Demographic characteristics of both groups are presented in Table 1. At baseline, the main demographic and clinical features of the groups except phalen test were similar. Phalen test positivity were significantly higher in Group 1 (p:0.041). No statistically significant difference was found in terms of VASpa, VASpr, grip strength, pinch strength, CTSQ-S and CTSQ-F scores at baseline (Table 2). A statistically significant improvement was observed in the values of VASpa, VASpr, grip strength, pinch strength, CTSQ-S and
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G.T. Bulut et al. / Comparison of static wrist splint with static wrist and metacarpophalangeal splint in CTS Table 1 Demographic characteristics of both groups Gender (Female/Male) (n) Bilateral CTS (n) Age (years) (mean ± SD) BMI (kg/m2 ) (mean ± SD) Symptom duration (months) (mean ± SD) CTS (mild/moderate) (n) Dominant hand (right/left) (n) Numbness n (%) Burning n (%) Clumsiness n (%) Pain causing awakening during the night n (%) Tinel test n (%) Phalen test n (%)
Wrist splint (n:16) 13/3 11 42.4 ± 10.1 29.8 ± 4.7 10.2 ± 4.6 11/5 15/1 16 (100) 10 (62.5) 10 (62.5) 8 (50) 14 (87.5) 13 (81.3)
Wrist MCP splint (n:17) 17/0 10 46.4 ± 7.8 29.6 ± 6.3 13.2 ± 10.6 11/6 15/2 16 (94.1) 14 (82.4) 11 (64.7) 9 (52.9) 15 (88.2) 8 (47.1)
P 0.061 0.554 0.460 0.518 0.193 0.805 0.582 0.325 0.201 0.895 0.866 0.948 0.041
n: number of patients, SD Standard Deviation, BMI Body Mass Index, CTS Carpal Tunnel Syndrome, VASpa Visual Analog Scale pain activity, VASpr Visual Analog Scale pain resting. Table 2 Symptomatic and functional parameters of groups before and after therapy
VASpa p (within groups) VASpr p (within groups) Grip strength p (within groups) Pinch strength p (within groups) CTSQ-S p (within groups) CTSQ-F p (within groups)
Wrist splint (27 hands) Baseline After therapy 3.74 ± 2.88 3.85 ± 3.11 0.113 1.19 ± 2.06 0.67 ± 1.73 0.066 20.59 ± 11.40 22.05 ± 10.80 0.025 5.72 ± 1.74 5.75 ± 1.56 0.747 2.50 ± 0.83 1.79 ± 0.71 0.000 2.14 ± 0.70 2.08 ± 0.84 0.108
Wrist MCP splint (27 hands) Baseline After therapy 2.89 ± 3.13 1.52 ± 2.23 0.001 2.04 ± 2.61 0.30 ± 0.82 0.005 20.06 ± 6.96 24.24 ± 7.36 0.000 5.56 ± 1.60 6.67 ± 1.79 0.000 2.58 ± 0.86 1.55 ± 0.63 0.000 2.15 ± 0.61 1.54 ± 0.52 0.000
p (between groups) Baseline After therapy 0.880 0.085 0.176
0.867
0.598
0.098
0.795
0.065
0.835
0.164
0.808
0.012
Data are expressed as means ± SD. CTSQ Carpal Tunnel Syndrome Questionnaire, VASpa Visual Analog Scale pain activity, VASpr Visual Analog Scale pain resting.
CTSQ-F scores in Group 2 (wrist MCP splint) after therapy. In Group 1 (neutral wrist splint) we found statistically significant improvements in grip strength (p:0.025) and CTSQ-S score (p:0.000) after therapy. A statistically significant difference between the two groups after therapy was only found in CTSQ-F score in favor of wrist MCP splint (p:0.012). No statistically significant difference was found in terms of measured electrophysiological parameters at baseline (Table 3). Although there were significant improvements with regard to sensory amplitude and motor latency in both groups after therapy, the differences between groups were not at the level of significance (Table 3). The intergroup comparison of the improvement showed a significant difference in VASpr, grip strength, pinch strength and CTSQ-F scores between groups in favor of wrist MCP splint (Table 4). There was not a significant correlation between symptom duration and CTSQ-S and CTSQ-F scores and electrophysiological
parameters of groups before and after therapy (p > 0.05). There was no significant correlation between electrophysiological parameters and CTSQ-S scores in both groups. There was also no significant correlation between electrophysiological parameters and CTSQ-F scores in neutral wrist splint group (p > 0.05). CTSQF scores were significantly correlated with motor latency at baseline (p: 0.025, r: 0.431) and motor amplitude after therapy (p: 0.027, r: 0.425) in neutral wrist MCP splint group. Other electrophysiological parameters was not correlated with CTSQ-F scores in neutral wrist MCP splint group (p > 0.05).
4. Discussion Splinting is one of the most frequently reported treatments of CTS [19]. The efficacy of several splints were investigated in the previous studies. It was re-
G.T. Bulut et al. / Comparison of static wrist splint with static wrist and metacarpophalangeal splint in CTS
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Table 3 Electrophysiological parameters of groups before and after therapy
Sensory latency (ms) p (within groups) Sensory amplitude(mV) p (within groups) Sensory velocity (m/s) p (within groups) Motor latency (ms) p (within groups) Motor amplitude (mV) p (within groups) Motor velocity (m/s) p (within groups)
Wrist splint (27 hands) Baseline After therapy 2.83 ± 0.31 2.78 ± 0.29 0.327 10.23 ± 4.78 12.35 ± 5.51 0.003 48.59 ± 5.76 50.18 ± 6.39 0.104 3.73 ± 0.49 3.64 ± 0.45 0.038 8.55 ± 1.55 8.59 ± 1.91 0.656 56.10 ± 4.93 56.64 ± 4.13 0.493
Wrist MCP splint (27 hands) Baseline After therapy 2.85 ± 0.37 2.79 ± 0.44 0.057 11.44 ± 4.11 13.96 ± 5.35 0.000 50.39 ± 5.41 50.83 ± 7.05 0.197 3.57 ± 0.64 3.45 ± 0.64 0.008 7.83 ± 2.03 8.60 ± 2.21 0.052 56.83 ± 4.53 58.76 ± 4.65 0.133
p (between groups) Baseline After therapy 0.951 0.917 0.446
0.181
0.317
0.827
0.181
0.096
0.128
1.00
0.055
0.128
Data are expressed as means ± SD. MCP Metacarpophalangeal. Table 4 Intergroup comparison of the improvement (pre-post scores) of clinical and electrophysiological parameters among three groups VASpa VASpr Grip strength Pinch strength CTSQ-S CTSQ-F Sensory latency (ms) Sensory amplitude (mV) Sensory velocity(m/s) Motor latency (ms) Motor amplitude (mV) Motor velocity(m/s)
Wrist splint 0.9 ± 2.7 0.5 ± 1.4 −1.5 ± 3.1 −0.02 ± 0.8 0.7 ± 0.8 0.05 ± 0.8 0.04 ± 0.2 −2.1 ± 3.2 −1.6 ± 3.8 0.08 ± 0.2 −0.03 ± 1.7 −0.5 ± 4.9
Wrist MCP splint 2.2 ± 2.4 1.8 ± 2.6 −4.3 ± 3.6 −1.1 ± 0.7 1.0 ± 0.6 0.6 ± 0.5 0.06 ± 0.2 −2.6 ± 2.4 −0.4 ± 3.6 0.1 ± 0.2 −0.7 ± 1.9 −1.5 ± 5.9
P 0.053 0.029 0.001 0.000 0.086 0.002 0.879 0.435 0.443 0.389 0.243 0.511
Data are expressed as means ± SD.
ported that limited evidence supports the use of a wrist splint in neutral position than an extended wrist position of 20◦ in patients with CTS [7,19]. The effect of the time of splint use was also investigated in the previous studies and night-only wrist splint use was reported to be equally effective as full-time wrist splint use in a review study [7]. The results of the present study suggest that a neutral wrist MCP splint is more effective to improve pain, to reduce symptoms and recover functions than a neutral wrist splint. However, no statistically significant differences were found between these splints according to electrophysiological parameters. In a previous study flexor retinaculum and median nerve characteristics were measured during fingers extended and fingers in an isometric squeeze grip using MRI. They reported that performing an isometric squeeze grip resulted in statistically significant variations within the carpal tunnel area and they suggested that fabricating a splint which prevents the fingers from flexing may be more successful in alleviating the symptoms of CTS than the currently prescribed
splint which only restricts wrist movements (C) [20]. It seems important to consider the MCP joint position while splinting for the treatment of CTS. Currently available data do not adequately address that the immobilization of MCP joints could enhance the efficacy of a neutral wrist splinting in patients with CTS. There are few studies investigating the efficacy of a splint immobilising both the wrist and the MCP joints [11,13,14]. However, these previous studies did not allow for direct comparison with our results because each of them had different methodology. One of these studies investigated the clinical and electrophysiological effects of the carpal lock comparing with a conventional volar-supporting orthosis. The angle of the wrist was adjusted to be in 15 degrees of extension and the forearm was in neutral position in this previous study. The volar-supporting orthosis restricted MCP, wrist, and forearm movements, but MCP joints were in approximately 10–15 degrees of flexion. They prescribed a splinting program of 2 weeks of continuous use followed by 2.5 months of nightly use to affected
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hands of patients with CTS. They found statistically significant improvements in both groups at 3 months. But no statistically significant difference was found between the two groups [14]. In their study Brininger et al. compared the efficacy of a neutral wrist MCP splint (the wrist in neutral (0◦ ) and the MCP joints from 0◦ to 10◦ of flexion) with wrist cock-up splint (the wrist in 20◦ of extension) with and without tendon and nerve gliding exercises in the treatment of CTS. They instructed patients to wear the splint during their sleep time. They found that both splints significantly reduced CTS symptoms and improved functional status and there was a significant difference between two groups in favor of the neutral wrist and MCP splint group [11]. In another study, Baker et al. compared the efficacy of cock-up splint (wrist 0◦ of extension) and lumbrical splint (wrist at 0◦ of extension and the MCP joints at 0◦ to 10◦ of flexion) with different exercises (lumbrical stretch or general stretch exercises) in four groups. They instructed subjects to wear their splint when sleeping. They reported that all splint/stretch combinations were essentially equally effective four weeks later and subjects in the lumbrical splint/general stretch group and the general splint/lumbrical stretch group demonstrated continued and significant improvements in function at 12 weeks [13]. In the present study, we investigated the additional effects of the immobilization of the MCP joints in neutral position (in 0–10 degrees of flexion) to the neutral wrist splinting (in 0–5 degrees of extension). Patients wore their splints continuously all night for 4 weeks. There were significant improvements with regard to grip strength, CTSQ-S scores, sensory amplitude and motor latency in both groups after therapy. Additionally, significant improvements were observed in the values of VASpa, VASpr, pinch strength, CTSQF scores in the patients using a neutral wrist MCP splint at the end of 4 weeks. These improvements point to additional effects of immobilization of MCP joints. Idiopathic CTS generally occurs bilaterally and the dominant hand of patients with CTS is more frequently affected [21]. In the present study, the majority of the patients presented with bilateral CTS (63.6%). Of patients with unilateral CTS 30.3% had dominant hand involvement. CTS is usually diagnosed based on the history and physical examination. Electrophysiological studies are important to confirm the diagnosis [22]. However, a recent study reported that electrodiagnostic tests do not change the probability of diagnosing CTS to an extent that is clinically relevant for the majority
of patients who are considered to have this syndrome on the basis of their history and physical examination alone [23]. Chan et al. reported that electrodiagnostic findings and CTS symptoms and functions of patients with CTS do not appear to be related and both of these parameters should be assessed by clinicians and also researchers [24]. In the present study we only detected a significant correlation between CTSQ-F scores and motor latency at baseline, CTSQ-F scores and motor amplitude after therapy in neutral wrist MCP splint group. We thought that the short-term evaluation of patients in the current study (at 4 weeks) was the reason of insignificance in most parameters of electrophysiological studies. The results of this study showed that a splint which prevents MCP joints from flexing in addition to wrist is more successful in alleviating symptoms of CTS and improving functional status than a splint which only restricts wrist movements. The position of MCP joints should be considered while prescribing a splint to the patients with CTS.
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