comparison of range-of-motion constraints provided by

JHT READ FOR CREDIT ARTICLE #040

Comparison of Range-of-Motion ConstraintsProvided by Splints Used in the Treatment of

Cubital Tunnel Syndrome—A Pilot Study

SCIENTIFIC/CLINICAL ARTICLES

Eileen Apfel, OTR/L, CHTDepartment of Rehabilitation MedicineDivision of Occupational and Hand TherapyVA Healthcare System, San DiegoCalifornia

Gloria T. Sigafoos, PT, OCS, CHTUniversity City Physical TherapySan Diego, California

Cubital tunnel syndrome (CBTS) is the secondmost common peripheral compression neuropathy.1

It occurs when a combination of factors, which arestill not well understood, produce ischemia of, anddamage to the ulnar nerve. The symptoms of CBTSmay consist of sensory and/or motor dysfunction.Pain quality can be sharp or aching in nature andcan be located primarily on the medial side of theproximal forearm, or can be diffuse and radiate prox-imally and distally in the arm. Paresthesias, dysesthe-sias, decreased sensation, a feeling of coldness,muscle weakness, and atrophy may be present alongthe ulnar nerve distribution.2

Correspondence and reprint requests to Gloria T. Sigafoos, PT,OCS, CHT, University City Physical Therapy, 5190 GovernorDrive, Suite 107, San Diego, CA 92122; e-mail: <[email protected]>.

0894-1130/$ e see front matter � 2006 Hanley & Belfus, an imprintof Elsevier Inc. All rights reserved.

doi:10.1197/j.jht.2006.07.028

384 JOURNAL OF HAND THERAPY

ABSTRACT: Nocturnal splinting of the elbow is commonly usedto treat cubital tunnel syndrome (CBTS). Rationales are based onseveral studies, which suggest that proper nocturnal positioningof the elbow during sleep contributes to decreased cubital tunnelsymptoms. Currently there is limited scientific evidence support-ing the rationale for specific splinting protocols. Splints may becustom or prefabricated. The purpose of this article is to assessthe range-of-motion constraints of five nighttime elbow orthosescommonly used in the treatment of CBTS. This preliminary studywas conducted using a cadaveric model, using three arms to rep-resent three human arm sizes, and compared five different splints,and no splint. Range-of-motion testing was performed usinggravity alone and then testing was repeated using gravity plus a1-pound weight in a standardized fashion. Results showed thatall splints restricted elbow flexion significantly more than the un-splinted extremity. Of the five splints, the AliMed splint allowedthe most elbow flexion both in the gravity assisted, and gravityplus a 1-pound weight assisted conditions. The only splint that re-stricted elbow extension was the Hely & Weber splint. The Pil-O-Splint Elbow Support with stay, Hely & Weber and the FoldedTowel all restricted elbow flexion to less than 908 under all studyconditions. The information provided may be helpful in makingclinical decisions regarding splinting for CBTS.

J HAND THER. 2006;19:384–92.

In recent years, there has been limited discussionand research regarding the best conservative tech-niques for the treatment of CBTS, and debate con-tinues within the literature. Rationales for overnightelbow splinting are based on several studies, whichsuggest that passively and actively sustained posi-tions of the wrist, elbow, and shoulder assumedduring nighttime positioning, can contribute to ele-vated cubital tunnel pressures and strain on the ulnarnerve.1e4 Although many causes and treatmentshave been described, nocturnal splinting of the elbowto restrict the elbow from acute elbow flexion remainsa standard component of nonsurgical intervention.There are many splints available, commercial andcustom made, and almost as many factors to considerwhen prescribing a particular product or immobiliza-tion technique. Some authors have suggested that re-stricting elbow flexion to between 308 and 908 ishelpful in managing CBTS.2e6 However, the basisof these recommendations remains questionable.When prescribing and fitting any orthotic device, itis important to understand its performance

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characteristics and properties. The primary purposeof this study is to evaluate the abilities of five suchsplints for their effectiveness in restricting elbowflexion.

For research purposes, our null hypothesis wasthat the five splints evaluated would perform equallywell to restrict elbow range of motion (ROM).

MATERIALS

Three cadaver arms were selected to representthree human arm sizes: small, small/medium, andmedium. Gender, size, and best cadaver choice weredetermined by the availability of cadaveric extremi-ties. The arms were harvested to include the scapula,shoulder, elbow, wrist, and fingers. Size criteria werebased on a synthesis of commercial splint manufac-turer recommendations, and best overall splint fitbased on therapist clinical judgment. The criteria forsize for each anatomical location were determined bycircumferential measurements as presented below ininches:

The sizes of the extremities accepted for inclusionin the study were measured in inches and were asfollows:

All the cadaver arms had normal ROM except forthe small cadaver arm, which had an elbow flexioncontracture of 158. We included the only small armavailable for harvest despite the 158 contracture,because the contracture was determined to be irrel-evant to the outcome of the study because ourprimary focus was the amount of elbow flexioneach splint would restrict.

A 16-inch extremity positioning jig was fabricatedfrom Polyform and made to fit over a wooden dowelmeasuring 2 3 4 3 37 inches. The jig flared out at thebottom into a 2½-inch-deep shelf upon which eachcadaver scapula was supported. The purpose of thisapparatus was to ensure consistent positioning ofthe subjects. The jig was attached with large stripsof 2-inch-wide sticky back hook and loop Velcro tothe underlying wooden dowel. The upper armswere supported by 2-inch Velfoam strips attachedby Velcro as close to the elbow as possible without in-terfering with free flexion. The wooden block, in turn,

Foreman Biceps

Small #9 #11Medium 9e10.5 11.5e13

Forearm Biceps

Small 6.25 6.50Small/medium 8.75 11.00Medium 9.50 11.50

was attached with a clamp to a rigid vertical post.Forearm rotation was not restricted by the jig(Figure 1).

Five splints and methods for restricting elbowflexion were evaluated and compared to a non-splinted elbow. The five splints evaluated in thisstudy were (Figure 2)

� A large bath towel, applied circumferentiallyaround the elbow joint as shown in Figure 3.� IMAK Corp. Pil-O-Splint Elbow Support, adjust-

able with rigid plastic stay.� IMAK Corp. Pil-O-Splint Elbow Support, adjust-

able with rigid plastic stay removed.� Hely & Weber Cubital Tunnel Splint (Prototype)

(Body Glove Corp., CA).� AliMed Cubital Tunnel Syndrome Support.

Splints were chosen for inclusion in the studybecause they represented a wide spectrum of splintstyles and immobilization designs. Descriptions ofthese are listed below. The Pil-O-Splint Elbow Supportwas measured with the rigid plastic stay inserted andthen repeated with the stay removed. This splintalteration was also evaluated because patients areroutinely advised of the option to remove the stay ifthey find the splint too rigid or uncomfortable. Thisoption is offered at this treatment facility with the aimof improving compliance with nightwear.

The only ‘‘custom splint’’ evaluated was a largebath towel fastened circumferentially around the

FIGURE 1. Extremity testing of jig.

OctobereDecember 2006 385

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elbow, and secured with duct tape. Sailer3 describessuch a splint: ‘‘A small pillow or folded towel canbe secured into the antecubital fossa to effectivelylimit flexion greater than 458.’’ The towel that westudied was moderately thick and soft. It was48 3 30 inches, folded three times lengthwise to awidth of 10 inches, wrapped circumferentiallyaround a medium arm and fastened with duct tape(Figure 3). Once donned, its thickness was 4 inches.It was noted that although the procedure of wrappingand taping was somewhat time consuming, once thesplint was formed for the individual, it could bedonned and doffed easily.

METHODS

Each cadaver arm was placed in a clear long plasticshower glove to contain blood, protect the splints,and preserve the cadaver prior to testing. The plasticglove did not restrict ROM. A Futuro Wrist Splint wasplaced on each cadaver wrist to stabilize and

AliMed Cubital TunnelSyndrome Support

Made with soft, beige tricot laminated topolyethylene foam, with firm, butnonrigid bilateral foam inserts(Figure 4).

Hely & Weber CubitalTunnel Splint(Prototype)

Made with neoprene, stockinette, Velcroand plastic. It is a lined, semirigiddorsal elbow support molded intoapprox 158 of flexion with three volarstraps (Figure 5).

Pil-O-Splint With Stay Made with breathable foam coveredwith soft fabric for cushioned supportwith a removable plastic stay(Figure 6).

Pil-O-SplintWithout Stay

Same as above, with rigid longitudinalplastic stay removed (Figure 7).

Custom CircumferentialTowel Support

Trifolded 48 3 30 inches bath towel,circumferentially wrapped andfastened with duct tape (Figure 8).

FIGURE 2. Splints evaluated in this study.


standardize wrist positioning during elbow ROMtesting. Two experienced hand therapists performedROM testing.

Testing of gravity only assisted elbow extensionwas obtained. The cadaver arm was allowed to lie ona table in a gravity-assisted position of completeextension, with the disarticulated proximal armsupported by a helper in a standardized fashion. Agoniometric measurement of elbow extension wastaken. This was then repeated with a 1-pound weightoverlying the wrist.

The cadaver arm was fastened to a verticalPolyform jig with the scapula supported on a2½-inch-deep shelf with the upper arm supportedby 2-inch Velfoam strips. The forearm was allowed tohang freely in flexion to simulate gravity onlyassisted flexion of the elbow. This was then repeatedwith a 1-pound weight overlying the wrist.

Goniometric testing protocol deviated fromAmerican Society of Hand Therapists recommendedtechnique by consistently lining up the long arms ofthe goniometer parallel to the medial aspect of thehumerus and the ulna instead of the lateral side, toobtain both elbow flexion and extension measure-ments.9 This approach was used because the disar-ticulated arm could most reliably be measured fromthis side. A conventional 12-inch, 3608, plastic goni-ometer with two rigid arms, was used (Figure 1).

Prior to collection of study data, assessment relia-bility was established by paired measurements in 12practice ROM trials. The first examiner placed thegoniometer. The second examiner located 2 feet away,confirmed proper goniometric placement and alsophotographed the process. This was repeated withthe two examiners trading roles. The data obtainedby the examiners for the preliminary test subject werecompared. Differences between paired goniometric

FIGURE 3. Custom circumferential towel support.

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observations never exceeded 58 and were deemed tobe sufficiently reliable and repeatable.

One therapist measured the ROM while the secondexaminer was 2 feet away, confirming the goniometerplacement and photographing the process. A thirdtherapist was always required when measuring el-bow extension to stabilize the extremity. After initialROM testing without an elbow splint, each of the fiveelbow orthoses was donned in sequence. ROM elbowextension and flexion measurements were taken witheach splint, with and then without a 1-pound weight.The technique described above was then repeated forall three cadaver subjects. All goniometric measure-ments were rounded to the nearest 58 during studytesting (Figures 4e8).

RESULTS

ROM measurements are reported in Table 1 asextension/flexion. The elbow flexion contracture ofthe small left arm appears as a positive number forstatistical purposes. It should be noted that the exten-sion measurements do not reflect any movement pastneutral. All positive extension numbers indicate de-grees of restriction (Table 1).

RESULTS

The AliMed splint allowed the most elbow flexionwith an average 1108 flexion without the weight and

FIGURE 4. AliMed Cubital Tunnel Syndrome Support.

1208 flexion with weight. The Hely & Weber splintallowed the least flexion (averaging 538 withoutweight and 688 with weight). All of the tested splintsallowed full extension except the Hely & Weber,which restricted full extension, averaging 178 without

FIGURE 5. Hely & Weber Cubital Tunnel Splint.

FIGURE 6. Pil-O-Splint with stay.


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weight and 158 with the 1-pound weight. The Pil-O-Splint Elbow Support with stay, Hely & Weber splint,and the Folded Towel, all restricted elbow flexion toless than the 908 criteria, both with and withoutweight applied. These same splints were also the onlyones to meet a flexion criterion of less than 100e1108

(Figure 9).

Inferential Analysis

The null hypothesis was that there would be nodifference in the splints’ ability to restrict ROM underthe specific laboratory conditions. Analysis of vari-ance (ANOVA) and Tukey post hoc tests were used toevaluate the differences among splints both with andwithout weights. Both flexion ANOVAs were signif-icant (p¼ 0.001), while differences were not signifi-cant for extension.

DISCUSSION

All of the splints failed a 40e508 range criteria forthe lowest mean extraneural and intraneural pres-sures described by Gelberman et al.6 Because all the

FIGURE 7. Pil-O-Splint without stay.

FIGURE 8. ‘‘Homemade’’ folded towel support.


splints evaluated in this study also failed the 30e708

range criteria defined as being significantly lowerthan full extension, a different criteria statementwas considered. Gelberman et al. also describedgreater than 100e1108 as the point at which themost significant pressure increases occurred.

Several studies investigated elevated cubital tun-nel pressure as a factor in the development of CBTS.Increased traction on the ulnar nerve is also cited as asignificant contributor to ulnar nerve compromise.Studies show that increasing pressure and tractiondevelop with positions of increasing elbow flex-ion.1,5,6,8,10,11 Bozentka1 noted that, ‘‘As the elbow isbrought into full flexion there is a 55% decrease incanal volume.’’ Manicol examined extraneuralpressures affecting the ulnar nerve at the elbow invarious degrees of flexion using cannulae connected

NO SPLINT ALIMED HELY-WEBBER

PIL-OW/ STAY

TOWEL PIL-OW/O STAY

AVERAGESW/O WEIGHT 148º 110º 53º 62º 57º 92º

W / WEIGHT 152º 120º 68º 85º 73º 108º

Flex

ion

(Deg

rees

)

0102030405060708090

100110120130140150160

Without WeightWith Weight

FIGURE 9. Statistical analysis.

TABLE 1. Range-of-motion Measurements

Without Weight With Weight

Small ArmNo splint 15/160 15/160AliMed 15/125 15/135Hely-Webber 15/50 15/60Pil-O-Splint with stays 15/70 15/100Pil-O-Splint without stays 15/110 15/120Folded towel 15/80 15/90

Small-Medium ArmNo splint 0/150 0/150AliMed 0/115 0/125Hely-Webber 20/65 10/75Pil-O-Splint with stays 0/80 0/105Pil-O-Splint without stays 0/100 0/115Folded towel 0/55 0/70

Medium ArmNo splint 0/135 0/145AliMed 0/90 0/100Hely-Webber 15/45 15/70Pil-O-Splint with stays 0/35 0/50Pil-O-Splint without stays 0/65 0/90Folded towel 0/35 0/60

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to a pressure transducer using a closed, oil filled sys-tem. Pressure measurements were obtained from tenfresh cadaveric arms with the shoulders in 08, 908, and1358 of abduction. He took pressure readings of theulnar nerve at the cubital tunnel, the postcondylargroove and the medial intermuscular septum. Hefound that, ‘‘Significant pressure increases occurredwhen the elbow was flexed beyond a right angle,and concomitant shoulder abduction further raisedthe pressures recorded at the cubital tunnel and post-condylar groove.’’ ‘‘Further flexion of the elbow (1508

with the shoulder at 908) produced highly significantrises in pressure at all three sites and almost doubledpressures recorded in the groove and at the septumwhen the shoulder was not abducted.’’10

Penchan and Julis measured intraneural pressureof the ulnar nerve in cadavers. Their objective was,‘‘To analyze the two most conspicuous mechanismsof ulnar nerve damage, i.e., the stretch of the nerveand its compression by the aponeurosis of the flexorcarpi ulnaris.’’ They found that, ‘‘In elbow extension,the tissue pressure in the ulnar nerve in the cubitaltunnel was found to be about 7 mm Hg. In elbowflexion at a right angle, this pressure rose on an aver-age to 11e24 mm Hg, according to the position of thewrist and shoulder. In the position of the ulnar nervemaneuver [full elbow flexion], pressure averaging46 mm Hg was found in the ulnar nerve. This intra-neural hypertension is apt to disturb capillary circu-lation and to directly damage nerve fibers of theulnar nerve.’’5

Gelberman et al. used magnetic resonance imagingand pressure catheters to determine compression andstrain on the ulnar nerve along with visualization ofthe cubital tunnel with increasing elbow flexion in108 increments from 08 to 1308 of flexion. They con-cluded that, ‘‘The lowest mean intraneural pressurewas recorded with the elbow flexed 508, and the low-est mean extraneural pressure was recorded with theelbow flexed 408.’’ He also found that the greatestamount of pressure was seen with the elbow at 1308

of elbow flexion. He concluded that, ‘‘The cubitaltunnel is a dynamic region morphologically. Boththe cubital tunnel and the ulnar nerve change in thearea by as much as 50% as the normal elbow is flexedand extended, with substantial flattening of the ulnarnerve but no evidence of direct, focal compression.These morphological findings corresponded wellwith measurements of interstitial pressure, whichdemonstrated an initial increase in intraneural pres-sure without a corresponding increase in extraneuralpressure. This indicates that traction on the ulnarnerve is a major cause of increased intraneural pres-sure in association with flexion of the elbow.’’ ‘‘Asneural traction appears to be a source of increasedintraneural pressure under normal conditions, it ap-pears reasonable that a goal of treatment of entrap-ment neuropathy is the elimination of all sources of

nerve impingement, including those causing exces-sive neural traction.’’6

Wright et al.8 used ten cadaveric arms to measureexcursion of the ulnar nerve with various upper-ex-tremity positions. He found that, ‘‘Elbow flexion (of908) is responsible for an average strain (increase intension) of 29%, well above the 15% strain reportedto be deleterious to the nerve by Ogata and Naito.’’Ogata and Naito had applied various degrees ofstretch to the sciatic nerves of rabbits. The averagestretching of more than 15.7% caused complete arrestof blood flow in the stretched nerve. The averagestretching force at this point was 74 g. Completestandstill of intraneural circulation was observed un-der compression of 50e70 mm Hg.12 Byl et al.11 alsoexamined strain on the median and ulnar nervesand found that, ‘‘A statistically significant increasein ulnar nerve strain occurred with elbow flexion.’’

Other investigators focused on the consequences ofsustained pressure or strain on nerves as it relates toedema, ischemia, and ability to recover. Rempel et al.reviewed literature in which the physiological, path-ophysiological, biochemical, and histological effectsof biomechanical loading on the peripheral nerveswere evaluated in humans and animals. Their reviewof the literature concluded: ‘‘On the basis of theanimal studies, it appears that if elevated extraneuralpressures are maintained for an adequate durationthe initial injury, remodeling, and repair mecha-nisms, which are constantly ongoing, may be over-whelmed, leading to persistent extraneural orintraneural edema and eventually to synovial orintraneural fibrosis and loss of nerve function.’’13

Clark et al. studied the sciatic nerves of rats and theeffect of tension upon nerve blood flow. They foundthat, ‘‘Nerve blood flow decreased approximately50% with substantial recovery in 30 minutes after 8%elongation, whereas 15% elongation produced ap-proximately an 80% reduction in blood flow withminimal recovery.’’14 Wall et al. exposed the tibialnerves of 24 rabbits, and the nerves were stretchedby 0%, 6%, and 12%. At 6% strain, the amplitude ofthe action potential had decreased by 70% at onehour and returned to normal during the recovery pe-riod. At 12% strain, conduction was completelyblocked by one hour and showed minimal recovery.15

Hong et al. compared 12 ulnar nerves in tenpatients, assigning them randomly into two groups.Group A was treated with splinting only. Thosepatients were advised to use a splint limiting elbowflexion to 30e358 the whole night during sleep and onany other occasion that warranted flexion of theelbow during which the ulnar nerve might be com-pressed at the elbow. Group B was treated with localsteroidal injections in addition to splinting. Theywere assessed one and six months after treatment.This study concludes that, ‘‘Splint application aloneis adequate to improve the symptoms and ulnar


nerve conduction across the elbow. The addition of asteroid injection did not provide further benefit in thetreatment of cubital tunnel syndrome.’’4

There are many custom fabricated, commercial,and ‘‘homemade’’ splints, of many variations avail-able for the treatment of CBTS. Clinically, we postu-late that some cubital tunnel splints may be superiorto others in achieving the desired restriction of elbowflexion, especially in the sustained positions thatusually occur during sleep.

Review of research literature reveals that optimalpositioning of the elbow during sleep is still not wellunderstood. There are many discrepancies betweenauthors’ recommendations. There was a range ofelbow flexion from between 308 to 358, according toHong et al.,4 and 458 was recommended byBozentka,1 Gelberman et al.,6 and Sailer.3 Blackmorenoted ‘‘Most patients do not tolerate full elbow exten-sion splinting, so a position of 308 to 608 is sug-gested.’’2 Gelberman et al.6 also reported that withelbow positioning in full extension, the mean intra-neural and extraneural pressures within the cubitaltunnel were higher than they were with the elbowat 30e708 of flexion. According to our data, none ofthe splints held the elbow within the 30e458 or30e708 ranges cited above. The Pil-O-Splint ElbowSupport with stay, Hely & Weber splint, and theFolded Towel, all restricted elbow flexion to lessthan a 908 range criteria both with and without weightapplied. The same splints were the only ones toachieve a less than 100e1108 ROM restriction criteria.

The fetal position is a common sleeping position.When full elbow flexion is combined with shoulderabduction, strain on the ulnar nerve increases signif-icantly. Despite evidence that shoulder abduction mayexacerbate ulnar neuropathy,8,10,11 especially whencombined with elbow flexion, nocturnal splinting istypically limited to the elbow. The logistics of control-ling shoulder abduction during sleep are challenging.It must suffice to educate the patient and hope that heor she will attempt to voluntarily change or modifysleep positions. Wrist extension, pronation, and radialdeviation also affect the ulnar nerve.8,11 Most authorsdo not address wrist positioning for ulnar neuropathy.The positioning of the shoulder and/or wrist andfingers, and their effect on ulnar nerve pressure ortraction may be the subject of future studies.

It is important to note that there are many variablesthat should be considered in splint design and selec-tion in addition to ROM parameters. Some of theseinclude comfort, dermatological issues (due to skincontact with different materials), elevated cubitaltunnel pressure secondary to pressure exerted bythe splint itself, skin temperature generated by splintmaterial, practicality (including ease of splint appli-cation and splint maintenance), cosmesis, durability,functionality, and many other factors, which mayaffect patient compliance.7


Study Limitations

An important limitation of this study is that thesubjects were cadavers instead of living humansubjects. It is unknown to what extent the differencein resting tension of cadaver versus living tissues, aswell as the effects of repeated ROM, may haveaffected the outcome of this study. Another limitationwas the small number of cadaver arms used. Thenumber and size of cadavers was limited by avail-ability. As noted above, the small cadaver had a 158

elbow flexion contracture. The authors opted toinclude the small arm as the elbow contracture wasdetermined to be irrelevant to the outcome of thestudy because our primary concern was the amountof elbow flexion each splint would restrict, and thatparameter was unaffected.

The use of cadavers eliminates any evaluation ofsplint comfort, compliance, pressure, and tempera-ture generation. As previously mentioned, variousneck, shoulder, elbow, and hand postures areassumed and maintained during sleep that mayinfluence the ulnar nerve. This study focused onlyon the elbow. Only a limited number of splints wereevaluated in this pilot study. Future areas suggestedfor research would be studies involving living hu-man subjects, assessment of different postures, in-cluding variations of shoulder, elbow, wrist, and digitpositioning in combination and individually.Customized and prefabricated cubital tunnel splintsshould also be studied.

CONCLUSION

In comparing the ROM constraints of five differenttypes of nighttime splints used in the conservativetreatment of CBTS, the AliMed splint allowed themost elbow flexion with an average 1108 without theweight and 1208 with weight. The Hely & Webersplint allowed the least flexion (averaging 538 with-out weight and 688 with weight). All of the testedsplints allowed full extension except the Hely &Weber, which restricted full extension averaging 178

without weight and 158 with the 1-pound weight. ThePil-O-Splint with stay, Hely & Weber splint, and theFolded Towel were all effective in preventing elbowflexion beyond the 100e1108 criteria cited as beingmost significant for increasing cubital tunnel pres-sure. There is limited scientific evidence regardingoptimal splinting protocols for CBTS; therefore,additional research in this area is recommended.

REFERENCES

1. Bozentka DJ. Cubital tunnel syndrome pathophysiology. ClinOrthop. 1998;351:90–4.

2. Blackmore SM. Therapist’s management of ulnar nerve neuro-pathy at the elbow. In: Mackin EJ, Callahan AD, Skirven TM,

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Schneider LH, Osterman AL (eds). Rehabilitation of the Handand Upper Extremity. 5th ed. St. Louis, MO: Mosby, 2002, pp679–89.

3. Sailer SM. The role of splinting and rehabilitation in the treat-ment of carpal and cubital tunnel syndromes. Hand Clin. 1996;12:223–41, 13.

4. Hong CZ, Huon-Ang L, Kanakamedala RV, Chang YM, YatesL. Splinting and local steroid injection for the treatment of ul-nar neuropathy at the elbow: clinical and electrophysiologicalevaluation. Arch Phys Med Rehabil. 1996;77:573–7.

5. Pechan J, Julis I. The pressure measurement in the ulnar nerve.A contribution to the pathophysiology of the cubital tunnelsyndrome. J Biomech. 1975;8:75–9.

6. Gelberman RH, Yamaguchi K, Hollstien SB, et al. Changes ininterstitial pressure and cross-sectional area of the cubital tun-nel and of the ulnar nerve with flexion of the elbow. An exper-imental study in human cadavera. J Bone Joint Surg Am. 1998;80:492–501.

7. Apfel E, Johnson M, Abrams R. Comparison of range-of-mo-tion constraints provided by prefabricated splints used in thetreatment of carpal tunnel syndrome: a pilot study. J HandTher. 2002;15:226–33.

8. Wright TW, Glowczewskie F, Cowin D, Wheeler DL. Ulnarnerve excursion and strain at the elbow and wrist associatedwith upper extremity motion. J Hand Surg 2001;26A:655e662.

9. Casanova Jean S (ed). Clinical Assessment Recommendations.2nd ed. Chicago, IL: ASHT, 1992, pp 62–3.

10. Macnicol MF. Extraneural pressures affecting the ulnar nerveat the elbow. Hand. 1982;14:5–11.

11. Byl C, Puttlitz C, Byl N, Lotz J, Topp K. Strain in the medianand ulnar nerves during upper-extremity positioning. J HandSurg [Am]. 2002;27A:1032–40.

12. Ogata K, Naito M. Blood flow of peripheral nerve effects of dis-section, stretching and compression. J Hand Surg [Br]. 1986;11B:10–4.

13. Rempel D, Dahlin L, Lundborg G. Pathophysiology of nervecompression syndromes: Response of peripheral nerves toloading. J Bone Joint Surg Am. 1999;81:1600–10.

14. Clark WL, Trumble TE, Swiontkowski MF, Tencer AF. Nervetension and blood flow in a rat model of immediate and de-layed repairs. J Hand Surg [Am]. 1992;17A:677–87.

15. Wall EJ, Massie JB, Kwan MK, Rydevik BL, Myers RR, GarfinSR. Experimental stretch neuropathy: changes in nerve con-duction under tension. J Bone Joint Surg Br. 1992;74B:126–9.


JHT Read for CreditQuiz: Article #040

Record your answers on the Return Answer Formfound on the tear-out coupon at the back of thisissue. There is only one best answer for eachquestion.

#1. The purpose of the study was to assessa. the cubital tunnel pressures while wearing five

different elbow splints.b. the effectiveness in treating CBTS with five dif-

ferent elbow splints.c. the ROM constraints of five different elbow

splints.d. the role of five different ROM settings on CBTS.

#2. CBTS isa. the second most common peripheral compres-

sion neuropathy in the upper extremity.b. the second most common peripheral compres-

sion neuropathy affecting the ulnar nerve.c. the most common compression neuropathy in

the upper extremity.d. as common as carpal tunnel syndrome

#3. The null hypothesis wasa. that the custom made splint would be the most

effective in restricting elbow flexion.


b. that the Hely & Weber splint would bethe most effective in restricting elbowflexion.

c. that the AliMed splint would be the least effec-tive in restricting elbow flexion.

d. that the five splints would restrict elbow ROMequally.

#4. The only custom splint evaluated wasa. a posterior plaster shell flexed at about 308.b. a thermoplastic bivalve flexed at about 458.c. a large towel circumferentially applied and

taped about the elbow.d. an anterior block splint with a 408 flexion

stay.#5. The_____________splint allowed the least elbow

flexion.a. AliMedb. Hely & Weberc. Folded Toweld. Pil-O-Splint

When submitting to the HTCC for recertification,please batch your JHT RFC certificates in groupsof three or more to get full credit.

comparison of range-of-motion constraints provided by

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