to the editor: Thank you for this review on carpal tunnel syndrome. However, several points in this article regarding splinting are potentially misleading. First, the authors assert that “there is good evidence supporting the use of neutral and cock-up wrist splints, with similar symptom relief outcomes with both styles.” Although neutral and cock-up splints have been shown to relieve symptoms of carpal tunnel syndrome, two studies directly comparing neutral and cock-up splints showed superior improvement with neutral position splints.^1,2 Because neutral and cock-up splints are commercially available and similarly priced, family physicians should prescribe the best available product: the neutral position splint.

Second, the review states that “there is good evidence supporting the use of splints 24 hours a day (full-time) over night-only use.” However, the referenced study showed improvement only in nerve conduction study results, a disease-oriented outcome.³ There were no differences in clinical symptoms or functional status between the 24-hours-a-day and night-only groups. In fact, patients in the night-only group reported a much higher functional status than those in the 24-hour-a-day group. The study has other important limitations, including a small cohort size consisting mostly of men (carpal tunnel syndrome has a strong female predilection) who exhibited significant issues with brace-wear compliance. Although 85 to 100 percent of patients studied were compliant with night-only bracing, only 27 percent were even moderately compliant with 24-hour wear. This confirms our own experience that most patients will not wear splints 24 hours a day despite our best urging. We conclude that the best available patient-oriented evidence actually supports recommending night-only splint use, rather than wearing splints for 24 hours a day.

in reply: We would like to thank Drs. Beutler and Stephens for their thoughtful letter. A primary goal of our article was to highlight the effectiveness of splints and to advocate their use for the conservative management of carpal tunnel syndrome. Through experience, we have found that physicians and patients tend to use the splint that is most available to them at the time. Both cock-up and neutral wrist splints have been shown to be effective for symptom relief. We appreciate the clarification that neutral position splints do indeed show some statistical superiority over cock-up splints when measuring symptom relief, and should be used when available.¹ However, it is reasonable to use a cock-up splint if it is the one available to the physician and patient.

Regarding night-only versus 24-hours-a-day splint use, we highlighted end points, namely sensory distal latency, that have noted improvement when splints are worn beyond the nighttime period. This being said, all other end points were similar between the two groups.² Therefore, recommendations for splint use beyond the nighttime period should be made on an individual basis, taking into account the patient's motivation, symptom severity, and tolerance of the splint.