Orthotic Treatment Overview of Carpal Tunnel Syndrome

*Hasan Md Arif Raihan, Poly Ghosh, Prasanna Lenka, Ameed Equbal and Abhishek Biswas*

#### **Abstract**

Carpal tunnel syndrome or median compressive neuropathy at the wrist is the condition of median nerve compression. Most of the CTSs are idiopathic and are provoked by repetitive grasping and manipulating activities, and the exposure can be cumulative. Orthotic splinting is prescribed both pre- and postsurgical but essentially in pre-surgical situation. The importance of wrist orthotic splints in non-operative treatment for carpal tunnel syndrome is a known scenario. Also evidentially it has a standard of care despite having varying rates of success. The aim and objective of orthotic splinting is to immobilize the wrist to stop flexion and maintain low range of wrist motion which help to decrease inflammation. CTS splint may be applied to dorsal side or in volar for maintaining wrist in a neutral position. The general recommendation is to wear a wrist immobilization orthotic splint as night splint. Splint kinematics and kinetics for biomechanical analyzing principles are essential to understand the principles involved in the various standard design, construction, and fitting of CTS splint. Application of orthotic biomechanics is for possessing a specific understanding of orthotic splinting function as per clinical orthotic assessment.

**Keywords:** carpal tunnel syndrome, orthotic splints, CTS biomechanics, CTS orthotic splint biomechanics

#### **1. Introduction**

Compression of the median nerve at the wrist is the most common upper extremity compressive neuropathy known as carpal tunnel syndrome [1–4]. It affects as much as 3% of the population at any one time. Still CTS remains a clinical syndrome, and as many as 15% of patients in some series have clinical evidence. Although surgical relieved for the median nerve compression my processed in the presence of normal severe electro diagnostic results [2, 3].

CTS decreases the cross-sectional area of the carpal tunnel that produces increased carpal tunnel canal volume content which may result in increased pressure in the carpal canal. Secondarily intracarpal tunnel pressure may be affected by external pressure to the palm [3].

The value of nonsurgical treatment protocol for mild CTS is a standard option. Conservative management is generally not an ideal option for moderate-to-severe CTS, especially in patients who have signs of muscle atrophy or significant sensory impairment. Non-surgery management options that have been described for CTS include orthosis use, nonsteroidal anti-inflammatory drugs, injection of the carpal tunnel with a corticosteroid, tendon-nerve gliding exercises, iontophoresis, ultrasound, and daily activity site modifications. The importance of CTS orthotic splints is well known in non-operative scenario. The American Academy of Neurology recommends a noninvasive orthotic treatment for the light and moderate CTS pathology. CTS orthotic treatment protocol remains the standard of care even though varying rates of success have been reported in the literature [5–7].

The objective of CTS splinting is immobilizing the wrist motion that decreases inflammation. Increased pressure in the carpal tunnel has been demonstrated with either wrist flexion or extension; therefore splinting of the wrist in a neutral position is recommended. Mild CTS symptoms of short duration are recommended with night splinting. Day and night splinting is recommended when there is mild-tomoderate symptoms during the day or with minimal activity. Also postoperative CTS splinting protects healing structures while allowing the predefined wrist motion.

Other significant objective of CTS splinting is ranging from pain relief and protection to prevention and correction of the wrist deformity.

Clinical orthotic assessment in terms of anatomic, kinesiology, neurology, and functional effects is important for prescribing CTS splint.

CTS and CTS splint's kinetics and kinematics analyses play a key role to understand the principles involved in the various standard design, construction, and fitting of CTS splint.

#### **2. Orthotic assessment for CTS**

Orthotic assessment includes the use of a variety of clinical qualitative and quantitative evaluation methods and instruments whose subsequent data is integrated to produce a clearly defined picture of CTS and its patho-biomechanics.

Points are essential for orthotic prescription.


**33**

*Orthotic Treatment Overview of Carpal Tunnel Syndrome*

• Soft tissue condition (check pressure tolerance capacity. Creep, stress-relax-

• Pain scale (VAS scale, which type of pain and how to grade pain according to

• EMG test (muscle activity profile, resting potential, neuromuscular junction condition, neuromuscular integration for wrist joint kinetic and kinematic

• NCV-test (median nerve activity profile, resting potential, neuromuscular junction condition, neuromuscular integration for wrist joint kinetic and

• Coordination (central nervous to peripheral nerve activity through wrist joint

• Asking price (appropriate to individual client factors and third-party payers).

• Period of time splint is to be used (temporary, semipermanent, permanent).

• Minimalism (no irrelevant parts, splint is applicable and pertinent to the need).

• Optimum function (splint allows usage and performance without unnecessary

• Optimal sensation (splint permits as much sensory input as possible).

• Application and removal (appropriate to individual client factors).

• Efficient fabrication (no extraneous parts or procedures, such as the use of reinforcement parts instead of curving contour, bonding instead of uninterrupted coalescing of components, straps instead of contiguous fit, inappropri-

• Client suggestions (requested adaptations that would not alter or jeopardize

• Attaining purpose (immobilize, mobilize, restrict motion, or transmit torque).

• Effect on joints not included in splint; kinetic effects (avoids application of

• Influencing primary and secondary joints (motion allowed or restricted

appropriately; components accomplish intended functions).

contraindicated forces to no splinted joints).

• Clinical test related to CTS (diagnosis of abnormal motion and pain).

• X-ray finding (structure of carpal tunnel and any other involvement).

• Swelling (orthotic splint material for low-grade swelling).

kinematics for various activity of daily living).

• Dexterity (power and precision grip strength).

*DOI: http://dx.doi.org/10.5772/intechopen.85101*

ation, stress rate sensitivity, etc.).

splint pressure system applied).

condonation).

kinematic condonation).

reduction of motion).

ate use of padding).

splint function).


*Peripheral Nerve Disorders and Treatment*

fitting of CTS splint.

**2. Orthotic assessment for CTS**

dynamic condition).

pressure system).

patho-kinetics).

tunnel with a corticosteroid, tendon-nerve gliding exercises, iontophoresis, ultrasound, and daily activity site modifications. The importance of CTS orthotic splints is well known in non-operative scenario. The American Academy of Neurology recommends a noninvasive orthotic treatment for the light and moderate CTS pathology. CTS orthotic treatment protocol remains the standard of care even though varying rates of success have been reported in the literature [5–7].

The objective of CTS splinting is immobilizing the wrist motion that decreases inflammation. Increased pressure in the carpal tunnel has been demonstrated with either wrist flexion or extension; therefore splinting of the wrist in a neutral position is recommended. Mild CTS symptoms of short duration are recommended with night splinting. Day and night splinting is recommended when there is mild-tomoderate symptoms during the day or with minimal activity. Also postoperative CTS splinting protects healing structures while allowing the predefined wrist motion. Other significant objective of CTS splinting is ranging from pain relief and

Clinical orthotic assessment in terms of anatomic, kinesiology, neurology, and

CTS and CTS splint's kinetics and kinematics analyses play a key role to understand the principles involved in the various standard design, construction, and

Orthotic assessment includes the use of a variety of clinical qualitative and quantitative evaluation methods and instruments whose subsequent data is integrated to produce a clearly defined picture of CTS and its patho-biomechanics.

• Demographic data and individual client factors (age, motivation, intelligence,

• Chief complaint (type of pain during hand and wrist activity in static or

• Previous orthotic treatment history (type of orthotic splint, function, and

• Other treatment plans (postoperative, what are other medical conditions).

• Manual muscle testing (minimum gravity control muscle power for wrist

• Active range of motion (check the wrist patho-kinematics).

• Passive range of motion (check the wrist patho-kinematics).

• Upper extremity reflexes (check wrist pathophysiology).

• Body temperature (orthotic splint material and design).

• Perspiration (providing hole over orthotic splint).

• Skin condition (orthotic splint material).

protection to prevention and correction of the wrist deformity.

functional effects is important for prescribing CTS splint.

Points are essential for orthotic prescription.

vocation/avocation, clinic proximity).

**32**


Orthotic assessment is essential for the splinting design program and instructions for the wearing times and exercise regimen, donning and doffing, and precautions.

#### **3. CTS-ASHT orthotic splint nomenclature**

American Society of Hand Therapists, ASHT (SCS) (1989), developed a universal splint nomenclature. It is based on splint function rather than splint design.

CTS splint classification also follows this classification. SCS components consist of identification of articular/nonarticular, location, direction, purpose (immobilization, mobilization, restriction, torque transmission), type, and the total number of joints. All splints have inherent mechanical characteristics that combine to a series of predictable patterns [1–3].

#### **3.1 Articular/nonarticular orthotic splint**

The principal division is given below (**Tables 1**–**6**).

Articular splints for CTS follow three-point/four-point or two-point pressure systems to affect the wrist joint by immobilizing, mobilizing, restricting, or transmitting torque. Nonarticular splints for CTS mainly obey the two-point pressure forces to stabilize or immobilize the wrist joint.

ESCS splint classification system (ESCS) for CTS splint groupings of primary and secondary joints, when a primary joint is linked with its potential secondary joint partners, a predictable linear pattern (**Table 2**).

#### *3.1.1 Examples*

Joints = [elbow level] = type 1 Total joints = [wrist + elbow = 2 joints] = (2)


#### **Table 1.**

*Principal classification of orthotic splint.*


**35**

**4. Orthotic treatments for CTS**

*Minimum wrist pressure for CTS and wrist motion.*

**With splint** **Without splint**

*Pressure of flexible wrist splint on carpal tunnel during repetitive hand activity.*

conservative splinting.

Orthotic splinting for CTS still remains the standard option [8–10]. CTS splint is mainly prescribed before surgery including muscle atrophy or continuous sensory impairment. Patients who present with mild symptoms will have the best option to

*Orthotic Treatment Overview of Carpal Tunnel Syndrome*

*10–15, and 15–20. Wrist extension (degree) had 0–50, 5–10, 10–15, and 15–20.*

**Study Patients with CTS**

**Neutral position (mmHg)**

*Reviewed report for wrist pressure in normal position, flexion position, and extension position.*

**Force (KP) Wrist flexion (degree) Wrist extension (degree)**

*In force (KP) the resultant tendon force was 0–10, 10–20, 20–30, and 30–40. Wrist flexion (degree) had 0–5, 5–10,* 

Gelberman et al. (1981) 32 ± 4.27 94 ± 12.53 110 ± 14.66 Werener et al. (1983) 31 ± 4.13 75 ± 10 105 ± 14 Szabo and Chidgey (1989) 10 ± 1.33 32 ± 4.27 51 ± 6.80 Okutsu et al. (1989) 43 ± 5.73 192 ± 25.60 222 ± 29.60 Luchetti et al. (1989) 26 ± 3.47 — — Rojviroj et al. (1990) 12 ± 1.60 27 ± 3.60 33 ± 4.40 Graham et al. (1991) 20 ± 2.67 — —

**Wrist position (sagittal and frontal planes) with minimum pressure (mmHg) in CTS splint**

**Carpal tunnel pressure (mmHg) data for subjects performing a repetitive material handling Task with and without a wrist splint Pre activity baseline During activity Post activity baseline During activity**

6 5 13 12 6 5 12 13

**Without splint**

**With splint**

**First minute of activity**

**Last minute of activity**

**With splint**

CTS 19 ± 1.5 Flexion 2 ± 0.7 ulnar deviation 1 ± 0.4 Normal/CTS splint 8 ± 0.75 Extension 2 ± 0.7 ulnar deviation 2 ± 1

**Minimum pressure Wrist motion**

**Flexion (mmHg) Extension (mmHg)**

0–10 0–5 0–5 10–20 5–10 5–10 20–30 10–15 10–15 30–40 15–20 15–20

*DOI: http://dx.doi.org/10.5772/intechopen.85101*

*Resultant tendon force on wrist sagittal plane motion.*

**Table 3.**

**Table 4.**

**Table 5.**

**Without splint**

**Table 6.**

#### **Table 2.**

*CTS orthotic splint classification.*

#### *Orthotic Treatment Overview of Carpal Tunnel Syndrome DOI: http://dx.doi.org/10.5772/intechopen.85101*


*In force (KP) the resultant tendon force was 0–10, 10–20, 20–30, and 30–40. Wrist flexion (degree) had 0–5, 5–10, 10–15, and 15–20. Wrist extension (degree) had 0–50, 5–10, 10–15, and 15–20.*

#### **Table 3.**

*Peripheral Nerve Disorders and Treatment*

exercises).

and precautions.

*3.1.1 Examples*

• Patient education.

• Anatomical variables (surface of application appropriate, healing structures

• Exercise routine (permits efficient execution of prescribed therapeutic

Orthotic assessment is essential for the splinting design program and instructions for the wearing times and exercise regimen, donning and doffing,

American Society of Hand Therapists, ASHT (SCS) (1989), developed a univer-

CTS splint classification also follows this classification. SCS components consist of identification of articular/nonarticular, location, direction, purpose (immobilization, mobilization, restriction, torque transmission), type, and the total number of joints. All splints have inherent mechanical characteristics that combine to a

Articular splints for CTS follow three-point/four-point or two-point pressure systems to affect the wrist joint by immobilizing, mobilizing, restricting, or transmitting torque. Nonarticular splints for CTS mainly obey the two-point pressure

ESCS splint classification system (ESCS) for CTS splint groupings of primary and secondary joints, when a primary joint is linked with its potential secondary

Nonarticular Those that affect an anatomic segment or structure but do not

affect joint motion or cross a joint

sal splint nomenclature. It is based on splint function rather than splint design.

protected as necessary, external hardware considered).

**3. CTS-ASHT orthotic splint nomenclature**

series of predictable patterns [1–3].

Joints = [elbow level] = type 1

**Articular/nonarticular orthotic splint**

*Principal classification of orthotic splint.*

**3.1 Articular/nonarticular orthotic splint**

forces to stabilize or immobilize the wrist joint.

joint partners, a predictable linear pattern (**Table 2**).

Total joints = [wrist + elbow = 2 joints] = (2)

Articular Those that affect articular structures

**Primary joints Secondary joints Total joint involvement/splint**

Wrist joint DIP PIP MP Design and tramline of CTS splint (0 type, 1 type, 2 type, etc.)

The principal division is given below (**Tables 1**–**6**).

**34**

**Table 2.**

**Table 1.**

*CTS orthotic splint classification.*

*Resultant tendon force on wrist sagittal plane motion.*


#### **Table 4.**

*Reviewed report for wrist pressure in normal position, flexion position, and extension position.*


#### **Table 5.**

*Minimum wrist pressure for CTS and wrist motion.*


#### **Table 6.**

*Pressure of flexible wrist splint on carpal tunnel during repetitive hand activity.*

#### **4. Orthotic treatments for CTS**

Orthotic splinting for CTS still remains the standard option [8–10]. CTS splint is mainly prescribed before surgery including muscle atrophy or continuous sensory impairment. Patients who present with mild symptoms will have the best option to conservative splinting.

Hence orthotic CTS splint is prescribed for mild-to-moderate and postoperative conditions.

Numerous customized design orthotic splints are commercially available. On the other hand, custom-fit CTS orthosis may be made for individual patients for minimizing external pressure over the median nerve.

Customized volar or dorsal orthotic splints are provided with neutral position over wrist joint. Dorsal-based splint Carpal Lock CTS splint applied for restricting kinematic external pressure over the carpal tunnel with thin straps over the palm leave the palmar surface free. It is indicated for mild CTS patient.

The general principle for orthotic splint application which maintains the wrist in a neutral position is that pressure on the median nerve as it passes through the carpal tunnel is amplified in positions of wrist flexion and extension (Gelberman 1984). Neutral wrist joint position (loose pack position) is the clinical condition for orthotic splinting to hold the wrist even when the patient is asleep and likely to flex their wrist without being able to correct themselves. The wrist angle in CTS splint and altering the shape of the carpal tunnel are moving the lumbricals distally out of the carpal tunnel to decrease pressure on the median nerve (Manente et al. 2001).

Manente et al. (2001) expressed a compared report for night CTS splint (4 weeks) with no treatment group. Premoselli et al. (2006) performed a quasirandomized trial that compared a CTS splint worn at night for 6 months with no treatment group. Both studies concluded that orthotic splinting has a significant impact on CTS.

#### **4.1 Static CTS wrist hand orthosis**

WHO is the standard design option used in CTS. Wrist joint is one of the key elements for upper extremity splinting. Fine tune position of wrist splint maintains powerful extrinsic tendon, finger, and hand digital posture and motion. Static is indicated to make the wrist static and restrict sagittal and coronal plane motions.

Many plastics and metallic standard CTS-WHO splint are designed for orthotic treatment by various universities and institutes as the Institute in Chicago, the Institute for Rehabilitation and Research in Houston, and the Institute of Rehabilitation Medicine at New York University.

#### **4.2 CTS immobilization splints**

Wrist immobilization orthotic splint for CTS aimed to allow healing of injured or inflamed wrist. This splint can restrict sagittal and coronal plane motions. The correct application can provide significant result in mild-to-moderate CTS. For increasing mechanical advantage, two-thirds the length of the forearm extension may be added in CTS splint.

#### *4.2.1 CTS immobilization splint type 0*


**37**

*Orthotic Treatment Overview of Carpal Tunnel Syndrome*

• Type 1 wrist immobilization splint indicates the presence of one secondary joint level included in the splint in addition to the primary joint, the wrist.

• The secondary joint most often included in a wrist immobilization splint, type 1 (2), is the thumb CMC joint, which is held motionless by a carefully fitted

• Type 1 wrist immobilization splints that include the thumb CMC may be used

• Because mechanical purchase on the first metacarpal is challenging, complete immobilization of the CMC joint is difficult to achieve with a type 1 wrist

• Type 2 wrist immobilization splints incorporate two secondary joint levels in addition to the wrist the primary joint. Secondary joint(s) may be situated either proximal or distal to the wrist depending on the specific purpose of the splint.

• For example, splints may include both the thumb CMC and MP as distally located secondary joint levels, or they may include the forearm and elbow as

• Type 2 wrist immobilization splints that incorporate the thumb are sometimes used to provide additional stabilization for partial fusions or fractures on the radial side of the wrist including scaphoid fractures or radial wrist ligament

• Stiff wrists with the limited passive range of motion. For the most part, flaccid wrists lacking full or partial active motion require simple mobilization splints that facilitate and improve hand function. Occasionally, more complicated splinting utilizing torque transmission may be required to substitute for absent movement in supple wrists. Types of CTS splints are type 0, type 1, and type 3.

Restriction CTS orthotic splints are prescribed to acute mild CTS patients for daytime use for restricting or where defined arcs of active wrist motion are

Wrist sagittal and coronal plane motion restriction is controlled by inflexible materials like thermoplastic, metal, etc. Less rigid materials like neoprene, leather, vinyl, and tape are used for some allowing some degree of wrist range of motion.

*DOI: http://dx.doi.org/10.5772/intechopen.85101*

first metacarpal bar component.

immobilization splint.

*4.2.3 CTS immobilization splint type 2*

proximal secondary level joints.

• Supple wrists that lack active motion.

CTS restriction splints are type 0 and type 2.

**4.3 CTS mobilization splints**

**4.4 CTS restriction splints**

injuries where thumb IP joint motion is permitted.

Generally prescribe for the postoperative CTS patients.

required. Prescribe for the pre- and postoperative CTS patients.

to help control and/or decrease wrist pain.

*4.2.2 CTS immobilization splint type 1*

#### *4.2.2 CTS immobilization splint type 1*

*Peripheral Nerve Disorders and Treatment*

minimizing external pressure over the median nerve.

leave the palmar surface free. It is indicated for mild CTS patient.

conditions.

et al. 2001).

impact on CTS.

motions.

**4.1 Static CTS wrist hand orthosis**

**4.2 CTS immobilization splints**

may be added in CTS splint.

itself.

*4.2.1 CTS immobilization splint type 0*

neutral immobilization splint, type 0.

Rehabilitation Medicine at New York University.

Hence orthotic CTS splint is prescribed for mild-to-moderate and postoperative

Numerous customized design orthotic splints are commercially available. On the other hand, custom-fit CTS orthosis may be made for individual patients for

Customized volar or dorsal orthotic splints are provided with neutral position over wrist joint. Dorsal-based splint Carpal Lock CTS splint applied for restricting kinematic external pressure over the carpal tunnel with thin straps over the palm

The general principle for orthotic splint application which maintains the wrist in a neutral position is that pressure on the median nerve as it passes through the carpal tunnel is amplified in positions of wrist flexion and extension (Gelberman 1984). Neutral wrist joint position (loose pack position) is the clinical condition for orthotic splinting to hold the wrist even when the patient is asleep and likely to flex their wrist without being able to correct themselves. The wrist angle in CTS splint and altering the shape of the carpal tunnel are moving the lumbricals distally out of the carpal tunnel to decrease pressure on the median nerve (Manente

Manente et al. (2001) expressed a compared report for night CTS splint (4 weeks) with no treatment group. Premoselli et al. (2006) performed a quasirandomized trial that compared a CTS splint worn at night for 6 months with no treatment group. Both studies concluded that orthotic splinting has a significant

WHO is the standard design option used in CTS. Wrist joint is one of the key elements for upper extremity splinting. Fine tune position of wrist splint maintains powerful extrinsic tendon, finger, and hand digital posture and motion. Static is indicated to make the wrist static and restrict sagittal and coronal plane

Many plastics and metallic standard CTS-WHO splint are designed for orthotic

Wrist immobilization orthotic splint for CTS aimed to allow healing of injured or inflamed wrist. This splint can restrict sagittal and coronal plane motions. The correct application can provide significant result in mild-to-moderate CTS. For increasing mechanical advantage, two-thirds the length of the forearm extension

• Here the primary joint of a type 0 wrist immobilization splint is the wrist

• There are no secondary joints included in a type 0 wrist splint. Neutral wrist position is also used frequently, and, in this instance, the splint is called a wrist

treatment by various universities and institutes as the Institute in Chicago, the Institute for Rehabilitation and Research in Houston, and the Institute of

**36**


#### *4.2.3 CTS immobilization splint type 2*


#### **4.3 CTS mobilization splints**

Generally prescribe for the postoperative CTS patients.


#### **4.4 CTS restriction splints**

Restriction CTS orthotic splints are prescribed to acute mild CTS patients for daytime use for restricting or where defined arcs of active wrist motion are required. Prescribe for the pre- and postoperative CTS patients.

Wrist sagittal and coronal plane motion restriction is controlled by inflexible materials like thermoplastic, metal, etc. Less rigid materials like neoprene, leather, vinyl, and tape are used for some allowing some degree of wrist range of motion. CTS restriction splints are type 0 and type 2.

#### *4.4.1 CTS restriction splints type 0*


#### *4.4.2 CTS restriction splints type 2*


#### **4.5 CTS torque transmission splints**

These are usually prescribed in postoperative CTS patients. Dynamic splinting is not recommended for CTS patients. Postoperative CTS patients may be prescribed who are having patho-kinematics in the transverse plane (wrist rotation). Also it is used for the therapeutic approach for contracture release for CTS.

#### *4.5.1 CTS torque transmission splints type 3 and type 4*


#### *4.5.2 CTS dynamic splinting application*

Berner et al. (2008) studied with dynamic splint application for a modality that treats CTS using low-load, prolonged duration stretch to reduce contracture, which contributes to median nerve compression. Dynamic splinting reduced experimental patients' symptoms and improved electrodiagnostic parameters [11] (**Figures 1–7**).

**39**

**Figure 3.**

*CTS wrist hand orthosis with thumb extension.*

**Figure 2.** *CTS dorsal splint.*

**Figure 1.** *CTS volar splint.*

*Orthotic Treatment Overview of Carpal Tunnel Syndrome*

*DOI: http://dx.doi.org/10.5772/intechopen.85101*

*Orthotic Treatment Overview of Carpal Tunnel Syndrome DOI: http://dx.doi.org/10.5772/intechopen.85101*

**Figure 1.** *CTS volar splint.*

*Peripheral Nerve Disorders and Treatment*

*4.4.1 CTS restriction splints type 0*

in other directions.

*4.4.2 CTS restriction splints type 2*

activities.

fabric.

activities.

respectively.

• Type 0 wrist restriction splints control motion at one primary joint the wrist.

• Restriction splints may be designed and fit to allow full or limited wrist extension/flexion while preventing radial and ulnar deviation or vice versa, or they may simply limit motion in one direction while allowing increments of motion

• Wrist circumduction restriction splints allow varying degrees of overall wrist mobility while providing external support for sports, work, and/or avocational

• These splints are constructed in softer materials including tape neoprene or

• Type 2 wrist restriction splints limit gradations of wrist motion and are used with a variety of diagnoses. They are often worn during sports or work

extension and/or flexion or in radial and/or ulnar deviation.

used for the therapeutic approach for contracture release for CTS.

thumb CMC and MP as secondary joints.

*4.5.1 CTS torque transmission splints type 3 and type 4*

focused exclusively on the wrist joint.

*4.5.2 CTS dynamic splinting application*

**4.5 CTS torque transmission splints**

• Generally, these splints allow normal motion while limiting extreme motion in

• One of the most commonly used type 2 wrist restriction splints includes the

These are usually prescribed in postoperative CTS patients. Dynamic splinting is not recommended for CTS patients. Postoperative CTS patients may be prescribed who are having patho-kinematics in the transverse plane (wrist rotation). Also it is

• Torque transmission splints affecting the wrist joint may have three or four secondary joint levels incorporated and are categorized as type 3 or type 4,

• These splints function longitudinally by controlling finger joint motion to transmit torque to the wrist joint proximally so that extrinsic muscle power is

Berner et al. (2008) studied with dynamic splint application for a modality that treats CTS using low-load, prolonged duration stretch to reduce contracture, which contributes to median nerve compression. Dynamic splinting reduced experimental patients' symptoms and improved electrodiagnostic parameters [11] (**Figures 1–7**).

There are no secondary joints included in type 0 restriction splints.

**38**

**Figure 2.** *CTS dorsal splint.*

**Figure 3.** *CTS wrist hand orthosis with thumb extension.*

**Figure 4.** *CTS carpal lock splint.*

**Figure 5.** *CTS thumb spica.*

**41**

*Orthotic Treatment Overview of Carpal Tunnel Syndrome*

not shift inappropriately on extremity).

• Contiguous fit of components on extremity.

**6. Classical mechanical theories for CTS splint**

• Good overall esthetic appearance.

**5. Orthotic clinical checkout guidelines for CTS orthotic splinting**

Given the diagnostic requirements the splint has been fitted appropriately to

• Anatomical structure (bony prominences, arches, dual obliquity, skin creases).

• Ligamentous stress (immobilization, mobilization, restriction, or torque transmission forces correctly applied to avoid damage or attenuation).

• Joint alignment (anatomical axes aligned with splint articulation; splint does

• Kinematic changes (splint does not inappropriately inhibit motion of unrestricted or partially restricted joints; splint does not inappropriately transmit torque).

• Corners rounded, edges and surfaces smooth and flanged appropriately.

• Ventilation (appropriately placed, splint strength not jeopardized).

Most splints used in upper extremity clinical practice apply consistent, linear-oriented, three-point pressure systems to affect joint motion. These splints incorporate three parallel reciprocal forces with the proximal and distal forces oriented in the same direction and the middle reciprocal force oriented in the

The diagnostic requirements, does the splint meet mechanical criteria, including

• Joined surfaces stable and finished (bonds solid, securing devices of sufficient number and correctly applied; internal edges smoothed, securing devices

*DOI: http://dx.doi.org/10.5772/intechopen.85101*

adapt to the following:

*Three-dimensional model of CTS hand.*

**Figure 7.**

finished).

opposite [6, 7, 12].

adaptation.

**Figure 6.** *CTS thumb spica.*

**Figure 7.** *Three-dimensional model of CTS hand.*

*Peripheral Nerve Disorders and Treatment*

**Figure 4.**

**Figure 5.** *CTS thumb spica.*

*CTS carpal lock splint.*

**40**

**Figure 6.** *CTS thumb spica.*

## **5. Orthotic clinical checkout guidelines for CTS orthotic splinting**

Given the diagnostic requirements the splint has been fitted appropriately to adapt to the following:


#### **6. Classical mechanical theories for CTS splint**

Most splints used in upper extremity clinical practice apply consistent, linear-oriented, three-point pressure systems to affect joint motion. These splints incorporate three parallel reciprocal forces with the proximal and distal forces oriented in the same direction and the middle reciprocal force oriented in the opposite [6, 7, 12].

The diagnostic requirements, does the splint meet mechanical criteria, including adaptation.

#### **6.1 Increase the area of force application**

Pressure = total force/area of force application. Splinting materials are, to varying degrees, rigid; their improper application to the extremity may cause damage to the cutaneous surface and underlying soft tissue as a result of excessive pressure. Splint applies over bony prominences or in areas where the inherent structure of the splint influences to increase the pressure of mechanical counterforces.

#### **6.2 Increase mechanical advantage**

Splinting is acting like the lever system. Splint provides more mechanical advantage by the use of favorable force systems. The design and construction of splints significantly provide the mechanical advantages.

#### **6.3 Use optimum rotational force**

Splint restricts the compressive or tensile force through the mobilization (90° angle of approach to segments mobilized, perpendicular to joint axes) splint in stiffened joints through traction. Splint must be achieved without generating patient frustration or increased tissue damage. Two dimensions and three dimensions of force resolution are used for minimizing force load by the splint.

#### **6.4 Consider the torque effect**

Torque equals the product of the force times the length of the arm on which it acts. Patients may be taught to use the torque phenomenon advantageously by advancing their finger cuffs distally as their pain tolerance permits. The splint should be provided opposite torque for neutralization of torque effect.

#### **6.5 Consider the relative degree of passive mobility of successive joints**

Primary and secondary joints are responsible for maintaining static and dynamic equilibrium. When motion is limited or stopped at a given articulation, the remaining mobile joints are moved in the direction of the force with minimal motion occurring at the restricted.

#### **6.6 Control reaction effect at secondary joints**

The amount of stiffness between primary and secondary joints within the same longitudinal segment is marked; as a mobilization force is directed to a stiff joint and reciprocal force secondary joint motion is controlled, the end of the stabilized segment may have a tendency to displace or sublux at the level of the secondary joint.

#### **6.7 Consider the effects of reciprocal parallel forces**

The use of three parallel forces in equilibrium is achieved in the splint by twopoint, three-point, or four-point pressure system.

#### **6.8 Increase material strength by providing contour**

Proper contour of splinting provides better controls of forces equilibrium in 3 dimensional plane.

**43**

*Orthotic Treatment Overview of Carpal Tunnel Syndrome*

damage may occur on either side or on both sides.

ity as active movement occurs, causing shear forces and friction.

The important terms describe the material behavior of soft tissues.

nerve condition, and ligament tendon pathological changes.

Parallel to providing elements of control and motion, articulated splints defend healing of soft tissue structures and improve function. Articulated splint mechanisms must be accurately aligned with anatomical joint axes. If a splint articulation is not aligned with its anatomical joint, the splint tends to the piston on the extrem-

Kinetic friction develops when surfaces in contact with each other move relative to one another. If a difference in density exists between the surfaces, the harder surface may begin to erode the softer, less dense surface. If the surfaces are similar,

Quantitative biomechanical analysis of CTS is for finding how internal external forces/pressure inside flexed and extended wrists is related to wrist size hand force and hand position. Analyzing pathological condition of CTS is helpful for finding causes of wrist deformity and wrist pain. Biomechanics analysis is involved for finding deformed boney three-dimensional alignment, muscle devotion, deformed

Biomechanics of CTS is playing an important role for proper application of CTS splinting. Here some kinematics and kinetic are discussed as per previous analysis. Muscle force of extrinsic finger flexor muscles and flexor digitorum profundus and superficial and the flexor pollicis longus muscles that are providing effort force to the hand. Additionally forearm muscle forces are acting to the fingers with long tendons that pass through the carpal tunnel. Flexor retinaculum reinforced to wrist tendons in wrist flexion condition and in wrist extension condition tendons are

Armstrong and Chaffin, 1978, found that the deviation of the wrist from the straight position causes the extrinsic finger flexor tendons to be displaced against,

Le Veau et al. 1974 also found that the tendon sliding over a curved surface is

The force FL, exerted on a pulley, is a function of the belt tension Ft; the radius of the pulley curvature, r; the coefficient of friction between the pulley and the belt, μ; and the included angle of pulley-belt contact, α, and is expressed.

FL Force (force/Arch length) = Fte μ α/r (1)

*DOI: http://dx.doi.org/10.5772/intechopen.85101*

**6.9 Appropriate components**

**6.10 Eliminate friction**

**6.11 Avoid high shear stress**

**7. Biomechanics of CTS**

reinforced by carpal bones.

**7.2 Kinetic model of CTS wrist**

**7.1 Biomechanical reflection for CTS**

and past, the adjacent walls of the carpal tunnel.

analogous to a belt draped around a pulley.

#### **6.9 Appropriate components**

*Peripheral Nerve Disorders and Treatment*

**6.2 Increase mechanical advantage**

**6.3 Use optimum rotational force**

**6.4 Consider the torque effect**

occurring at the restricted.

**6.6 Control reaction effect at secondary joints**

**6.7 Consider the effects of reciprocal parallel forces**

**6.8 Increase material strength by providing contour**

point, three-point, or four-point pressure system.

significantly provide the mechanical advantages.

**6.1 Increase the area of force application**

Pressure = total force/area of force application. Splinting materials are, to varying

Splinting is acting like the lever system. Splint provides more mechanical advantage by the use of favorable force systems. The design and construction of splints

Splint restricts the compressive or tensile force through the mobilization (90° angle of approach to segments mobilized, perpendicular to joint axes) splint in stiffened joints through traction. Splint must be achieved without generating patient frustration or increased tissue damage. Two dimensions and three dimensions of

Torque equals the product of the force times the length of the arm on which it acts. Patients may be taught to use the torque phenomenon advantageously by advancing their finger cuffs distally as their pain tolerance permits. The splint

Primary and secondary joints are responsible for maintaining static and dynamic equilibrium. When motion is limited or stopped at a given articulation, the remaining mobile joints are moved in the direction of the force with minimal motion

The amount of stiffness between primary and secondary joints within the same longitudinal segment is marked; as a mobilization force is directed to a stiff joint and reciprocal force secondary joint motion is controlled, the end of the stabilized segment may have a tendency to displace or sublux at the level of the secondary joint.

The use of three parallel forces in equilibrium is achieved in the splint by two-

Proper contour of splinting provides better controls of forces equilibrium in 3

degrees, rigid; their improper application to the extremity may cause damage to the cutaneous surface and underlying soft tissue as a result of excessive pressure. Splint applies over bony prominences or in areas where the inherent structure of the

splint influences to increase the pressure of mechanical counterforces.

force resolution are used for minimizing force load by the splint.

should be provided opposite torque for neutralization of torque effect.

**6.5 Consider the relative degree of passive mobility of successive joints**

**42**

dimensional plane.

Parallel to providing elements of control and motion, articulated splints defend healing of soft tissue structures and improve function. Articulated splint mechanisms must be accurately aligned with anatomical joint axes. If a splint articulation is not aligned with its anatomical joint, the splint tends to the piston on the extremity as active movement occurs, causing shear forces and friction.

#### **6.10 Eliminate friction**

Kinetic friction develops when surfaces in contact with each other move relative to one another. If a difference in density exists between the surfaces, the harder surface may begin to erode the softer, less dense surface. If the surfaces are similar, damage may occur on either side or on both sides.

#### **6.11 Avoid high shear stress**

The important terms describe the material behavior of soft tissues.

## **7. Biomechanics of CTS**

Quantitative biomechanical analysis of CTS is for finding how internal external forces/pressure inside flexed and extended wrists is related to wrist size hand force and hand position. Analyzing pathological condition of CTS is helpful for finding causes of wrist deformity and wrist pain. Biomechanics analysis is involved for finding deformed boney three-dimensional alignment, muscle devotion, deformed nerve condition, and ligament tendon pathological changes.

#### **7.1 Biomechanical reflection for CTS**

Biomechanics of CTS is playing an important role for proper application of CTS splinting. Here some kinematics and kinetic are discussed as per previous analysis.

Muscle force of extrinsic finger flexor muscles and flexor digitorum profundus and superficial and the flexor pollicis longus muscles that are providing effort force to the hand. Additionally forearm muscle forces are acting to the fingers with long tendons that pass through the carpal tunnel. Flexor retinaculum reinforced to wrist tendons in wrist flexion condition and in wrist extension condition tendons are reinforced by carpal bones.

Armstrong and Chaffin, 1978, found that the deviation of the wrist from the straight position causes the extrinsic finger flexor tendons to be displaced against, and past, the adjacent walls of the carpal tunnel.

#### **7.2 Kinetic model of CTS wrist**

Le Veau et al. 1974 also found that the tendon sliding over a curved surface is analogous to a belt draped around a pulley.

The force FL, exerted on a pulley, is a function of the belt tension Ft; the radius of the pulley curvature, r; the coefficient of friction between the pulley and the belt, μ; and the included angle of pulley-belt contact, α, and is expressed.

$$\text{FL Force (force/Arch length)} = \text{Fte } \mu \text{\(\sigma\)}\tag{1}$$

**Figure 8.** *2D force calculation for CTS.*

Linn et al. (1968) and Linn and Radin et al. (1968) found that the coefficient of tendon-trochlear friction has not been measured directly; however, friction measurements of surfaces lubricated with bovine synovial fluid indicate that the coefficient would be in the range of 0.01–0.1.

For coefficients of friction in this range, friction can be neglected without greatly affecting force estimates; thus Eq. (1) can be approximated by

$$\mathbf{FL} = \mathbf{Ft}/\mathbf{r} \tag{2}$$

**45**

*Orthotic Treatment Overview of Carpal Tunnel Syndrome*

which in turn leads to compression of the median nerve inside the carpal tunnel (Yamaguchi et al., 1965; Phalen, 1966, 1972; Tichauer, 1966, 1975, 1976).

• Armstrong et al. (1979) suggest that the resultant force is exerted by a tendon on adjacent wrist structures as a function of wrist angle and tendon load. The

• Thomas J. et al. (1979) found that the CTS resultant force is exerted by a tendon on adjacent wrist structures as a function of wrist angle and tendon load.

Biomechanics of CTS splint is for analyzing the kinematics and kinetics of wrist with splinting. Kinematics analysis signifies the wrist range of motion, and kinetics analysis signifies wrist pressures with splinting. Many studies were performed on kinematics and kinetics of CTS splint. Here we summarized the previous results for

Keir et al. (1999) found the direction of determining MRI for tendon paths has provided new insight into the relationships between the finger flexor tendons and

Weiss et al. (1995) reviewed the wrist pressure in the normal position, flexion

• Weiss ND and Gordon et al. (1995) also found that the minimum wrist pressure for CTS is to be maintained in CTS splint with limited range of motion (**Table 5**).

• Di Domizio et al. (2008) found that when the splint was used, there was a significant reduction in extensor carpi radialis ECR and flexor carpi radialis FCR activity. That was presumably due to participants' use of the splint to support some of the load that would be expected in the radial muscles to counteract gravity given that the standard posture required a neutral forearm and no

• Rempel et al. (1994) found the pressure of flexible wrist splint on carpal tunnel

Authors would like to thank Mr. Ananda Poddar, Project Assistance, Department

SamirSamanta (MPO), Miss RashmitaDash (MPO), Miss Smurti Sahoo (MPO), Mr. HarshKumar (MPO), Miss Subhlata (MPO), Miss Shaliny (MPO), Mr. Subhasish (MPO), Mr. Mirtunjay (MPO), and Mr. Aryan (MPO), Department of Prosthetics

No conflict of interest. Authors are donning clinical practice and clinical

of Rehabilitation Engineering; and also thank Mr. B.B.Bharti (MPO), Mr.

The resultant force is independent of tendon and wrist size (**Table 3**).

resultant force is independent of tendon and wrist size [13].

finding range of motion and wrist pressure with splinting condition.

**8. Kinematics and kinetics of orthotic CTS splint**

other structures at the wrist [14].

radioulnar deviation [16].

**Acknowledgements**

and Orthotics, NILD, Kolkata.

research for updated teaching.

**Conflict of interest**

position, and extension position [15] (**Table 4**).

during repetitive hand activity [17] (**Table 6**).

*DOI: http://dx.doi.org/10.5772/intechopen.85101*

Equation (2) indicates that the tendon load is approximately uniformly distributed over the trochlea.


It has been suggested that force between the extrinsic finger flexor tendons and the trochlea in the flexed wrist compresses the median nerve and is a factor of carpal tunnel syndrome (Brain et al., 1949; Robbins, 1963; Phalen, 1966).


*Peripheral Nerve Disorders and Treatment*

coefficient would be in the range of 0.01–0.1.

1976; Armstrong, 1976) (**Figures 7** and **8**).

and by Smith et al. (1977).

uted over the trochlea.

*2D force calculation for CTS.*

**Figure 8.**

Linn et al. (1968) and Linn and Radin et al. (1968) found that the coefficient of tendon-trochlear friction has not been measured directly; however, friction measurements of surfaces lubricated with bovine synovial fluid indicate that the

For coefficients of friction in this range, friction can be neglected without

FL = Ft/r (2)

Equation (2) indicates that the tendon load is approximately uniformly distrib-

• It can be seen that the contact force between the tendons and trochlea increases directly with tendon tension and inversely with the radius of tendon curvature.

(Armstrong and Chaffin, 1978); the tendon tension can be estimated for given positions of given sized hands (Dempster, 1961; Smith et al., 1964; Chao et al.,

• Tendon load per unit length as a function of tendon curvature and load.

• The radius of curvature can be estimated for different wrist thicknesses

It has been suggested that force between the extrinsic finger flexor tendons and the trochlea in the flexed wrist compresses the median nerve and is a factor of

• Compression of the median nerve by adjacent tendons has been confirmed by direct pressure measurements at the site of the median nerve by Tanzer (1959)

• In addition to the median nerve, the synovial membranes of the radial and ulnar bursas that surround the extrinsic finger flexor tendons are compressed by forces in both flexed and extended wrists. It has been suggested that repeated compression can lead to synovial inflammation and swelling,

carpal tunnel syndrome (Brain et al., 1949; Robbins, 1963; Phalen, 1966).

greatly affecting force estimates; thus Eq. (1) can be approximated by

**44**

which in turn leads to compression of the median nerve inside the carpal tunnel (Yamaguchi et al., 1965; Phalen, 1966, 1972; Tichauer, 1966, 1975, 1976).


#### **8. Kinematics and kinetics of orthotic CTS splint**

Biomechanics of CTS splint is for analyzing the kinematics and kinetics of wrist with splinting. Kinematics analysis signifies the wrist range of motion, and kinetics analysis signifies wrist pressures with splinting. Many studies were performed on kinematics and kinetics of CTS splint. Here we summarized the previous results for finding range of motion and wrist pressure with splinting condition.

Keir et al. (1999) found the direction of determining MRI for tendon paths has provided new insight into the relationships between the finger flexor tendons and other structures at the wrist [14].

Weiss et al. (1995) reviewed the wrist pressure in the normal position, flexion position, and extension position [15] (**Table 4**).


#### **Acknowledgements**

Authors would like to thank Mr. Ananda Poddar, Project Assistance, Department of Rehabilitation Engineering; and also thank Mr. B.B.Bharti (MPO), Mr. SamirSamanta (MPO), Miss RashmitaDash (MPO), Miss Smurti Sahoo (MPO), Mr. HarshKumar (MPO), Miss Subhlata (MPO), Miss Shaliny (MPO), Mr. Subhasish (MPO), Mr. Mirtunjay (MPO), and Mr. Aryan (MPO), Department of Prosthetics and Orthotics, NILD, Kolkata.

#### **Conflict of interest**

No conflict of interest. Authors are donning clinical practice and clinical research for updated teaching.

*Peripheral Nerve Disorders and Treatment*

### **Author details**

Hasan Md Arif Raihan\*, Poly Ghosh, Prasanna Lenka, Ameed Equbal and Abhishek Biswas The West Bengal University of Health Sciences, National Institute for Locomotor Disabilities, Kolkata, India

\*Address all correspondence to: arifraihan7@gmail.com

© 2019 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

**47**

1975

*Orthotic Treatment Overview of Carpal Tunnel Syndrome*

dynamic splinting: A randomized controlled trial. PM&R. 2008;**1**(1):1

[12] Brand PW, Hollister A. Clinical Mechanics of the Hand. 3rd ed. St.

[13] Armstrong TJ, Chaffin DB. Some biomechanical aspects of the carpal tunnel. Journal of Biomechanics.

[14] Keir PJ, Wells RP. Changes in geometry of the finger flexor tendons in the carpal tunnel with wrist posture and tendon load: An MRI study on normal wrists. Clinical Biomechanics.

[15] Weiss ND, Gordon L, Bloom T, So Y, Rempel DM. Position of the wrist associated with the lowest carpal-tunnel pressure: implications for splint design. Journal of Bone and Joint Surgery.

[16] Wade A. A Physiological and Performance Comparison between a Traditional and Novel Tennis Grip; 2015

[17] Rempel D, Manojlovic R, Levinsohn DG, Bloom T, Gordon L. The effect of wearing a flexible wrist splint on carpal tunnel pressure during repetitive hand activity. The Journal of Hand Surgery. 1994;**19**(1):1, 106-110

Louis: Mosby; 1999

1979;**12**(7):567-570

1999;**14**(9):635-645

1995;**77**(11):1695-1699

*DOI: http://dx.doi.org/10.5772/intechopen.85101*

[1] Mansivias JJ, Bucher PA, Monsvias DB. Nonsurgically treated carpal tunnel syndrome in the manual worker. Plastic and Reconstructive Surgery.

[2] Rempel D, Maojilovic R, Levinsohn DG, Bloom T, Gordon L. The effect of wearing a flexible wrist splint on carpal tunnel pressure during repetitive hand activities. The Journal of Hand Surgery.

[3] Sailer SM. The role of splinting and rehabilitation in the treatment of carpal and cubital tunnel syndromes. Hand

**References**

1994;**94**:695-699

1994;**19A**:106-110

Clinics. 1996;**12**:223-241

[4] Available from: http://

and-p.aspx

System; 1991

www.360oandp.com/about-360-o-

[6] Fess EE, Gettle KS, Strickland JW. Hand Splinting: Principles and Methods.

[7] Fess EE, Philips CA. Hand Splinting: Principles and Methods. ed 2 ed.

[9] Brand PW. Clinical Mechanics of the

[10] Brand PW, Hollister A. Clinical Mechanics of the Hand. 2nd ed. St.

[11] Berner SH, Willis FB, Martinez J. Treating carpal tunnel syndrome with

[8] Brand PW. Repetitive Stress on Insensitive Feet. Carville, LA: United States Public Health Service Hospital;

Hand. St. Louis: Mosby; 1985

Louis: Mosby; 1993

1st ed. St. Louis: Mosby; 1981

St. Louis: Mosby; 1987

[5] Fess EE. Splint Mechanical Patterns©, Presented to the ASHT Splint Nomenclature Task Force, January, 1991. American Society of Hand Therapists Splint Classification *Orthotic Treatment Overview of Carpal Tunnel Syndrome DOI: http://dx.doi.org/10.5772/intechopen.85101*

#### **References**

*Peripheral Nerve Disorders and Treatment*

**46**

**Author details**

and Abhishek Biswas

Disabilities, Kolkata, India

provided the original work is properly cited.

© 2019 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium,

The West Bengal University of Health Sciences, National Institute for Locomotor

Hasan Md Arif Raihan\*, Poly Ghosh, Prasanna Lenka, Ameed Equbal

\*Address all correspondence to: arifraihan7@gmail.com

[1] Mansivias JJ, Bucher PA, Monsvias DB. Nonsurgically treated carpal tunnel syndrome in the manual worker. Plastic and Reconstructive Surgery. 1994;**94**:695-699

[2] Rempel D, Maojilovic R, Levinsohn DG, Bloom T, Gordon L. The effect of wearing a flexible wrist splint on carpal tunnel pressure during repetitive hand activities. The Journal of Hand Surgery. 1994;**19A**:106-110

[3] Sailer SM. The role of splinting and rehabilitation in the treatment of carpal and cubital tunnel syndromes. Hand Clinics. 1996;**12**:223-241

[4] Available from: http:// www.360oandp.com/about-360-oand-p.aspx

[5] Fess EE. Splint Mechanical Patterns©, Presented to the ASHT Splint Nomenclature Task Force, January, 1991. American Society of Hand Therapists Splint Classification System; 1991

[6] Fess EE, Gettle KS, Strickland JW. Hand Splinting: Principles and Methods. 1st ed. St. Louis: Mosby; 1981

[7] Fess EE, Philips CA. Hand Splinting: Principles and Methods. ed 2 ed. St. Louis: Mosby; 1987

[8] Brand PW. Repetitive Stress on Insensitive Feet. Carville, LA: United States Public Health Service Hospital; 1975

[9] Brand PW. Clinical Mechanics of the Hand. St. Louis: Mosby; 1985

[10] Brand PW, Hollister A. Clinical Mechanics of the Hand. 2nd ed. St. Louis: Mosby; 1993

[11] Berner SH, Willis FB, Martinez J. Treating carpal tunnel syndrome with dynamic splinting: A randomized controlled trial. PM&R. 2008;**1**(1):1

[12] Brand PW, Hollister A. Clinical Mechanics of the Hand. 3rd ed. St. Louis: Mosby; 1999

[13] Armstrong TJ, Chaffin DB. Some biomechanical aspects of the carpal tunnel. Journal of Biomechanics. 1979;**12**(7):567-570

[14] Keir PJ, Wells RP. Changes in geometry of the finger flexor tendons in the carpal tunnel with wrist posture and tendon load: An MRI study on normal wrists. Clinical Biomechanics. 1999;**14**(9):635-645

[15] Weiss ND, Gordon L, Bloom T, So Y, Rempel DM. Position of the wrist associated with the lowest carpal-tunnel pressure: implications for splint design. Journal of Bone and Joint Surgery. 1995;**77**(11):1695-1699

[16] Wade A. A Physiological and Performance Comparison between a Traditional and Novel Tennis Grip; 2015

[17] Rempel D, Manojlovic R, Levinsohn DG, Bloom T, Gordon L. The effect of wearing a flexible wrist splint on carpal tunnel pressure during repetitive hand activity. The Journal of Hand Surgery. 1994;**19**(1):1, 106-110

**49**

**Chapter 5**

**Abstract**

would be carried out.

**1. Introduction**

minimally invasive surgery, scalpel

Biological and Preclinical

Carpal Tunnel Syndrome

*Ching-Cheng Huang and Ming-Che Chiang*

Evaluations of Designed Optically

Treatment and Surgical Procedure

A novel technique and product applied to carpal tunnel microscopic surgical procedures through the designed medical devices were prepared and studied. The novel design of the medical device could be developed and applied for new carpal tunnel microscopic surgical procedures instead of the traditional carpal tunnel surgical procedures. Also, a new medical device with optical LLLT module was designed for wound healing in carpal tunnel syndrome treatments. Furthermore, assistive surgical healing dressings for carpal tunnel syndrome treatments via minimally invasive surgery (MIS) such as air-foam soft cleaning sponges and hydrogel surgical dressings with polymeric films were designed for more comfortable treatments. Biological and clinical evaluations of carpal tunnel surgical procedure using the new designed medical devices are studied. For commercialized reasons, guidance such as ISO 10993-1:2009(E) for biological evaluation of medical devices must be considered. Furthermore, the clinical evaluation of modified medical devices

**Keywords:** clinical evaluation, carpal tunnel syndrome, surgical procedure,

Novel optically guided medical devices were designed for the clinical needs of carpal tunnel surgical procedure. The word "carpus" means "wrist." The wrist is the joint between your hand and the lower part of your arm and is surrounded by a band of fibrous tissue as a support for the joint. The tight space between the wrist bone and the fibrous band is called the carpal tunnel. The median nerve could pass through the carpal tunnel to receive any kind of sensations from the thumb, index, and middle fingers of the hand. Hence, any condition that causes swelling or a change in position of the tissue within the carpal tunnel would

Guided Medical Devices with

Light Scattering Modules for

#### **Chapter 5**
