Activator 2011

Laser Therapy for CTS
Douglas Johnson, ATC, EES, CLS
Senior Vice President, Multi Radiance Medical

www.MultiRadiance.com 800-373-0955

Carpal Tunnel Syndrome
• Symptoms usually start gradually
• frequent burning, tingling, or itching numbness in the
palm of the hand and the fingers, especially the
thumb and the index and middle fingers
• fingers feel useless and swollen, even though little or
no swelling is apparent
• symptoms often first appear in one or both hands
during the night, since many people sleep with flexed
wrists
• As symptoms worsen, people might feel tingling
during the day
• Decreased grip strength may make it difficult to form
a fist, grasp small objects, or perform other manual
tasks
• Some people are unable to tell between hot and cold
by touch

http://www.ninds.nih.gov/disorders/carpal_tunnel/detail_carpal_tunnel.htm


Anatomy
• Carpal tunnel contains:
– nine flexor tendons
– median nerve
– carpal bones
• Nerve and the tendons
provide
function, feeling, and
movement to some of the
fingers
• Flexor muscles originate
The carpal tunnel is approximately as wide as the thumb and its the medial epicondyle of
boundary lies at the distal wrist skin crease and extends distally
into the palm for approximately 2 cm. the elbow joint and attach
to the MP, PIP, PIP bones


Median Nerve Compression

• The median nerve can be compressed by:
– a decrease in the size of the canal,
– an increase in the size of the contents (such
as the swelling of lubrication tissue around the
flexor tendons),
– flexing the wrist to 90 degrees


Symptoms

• Compression of the median
nerve as it runs deep to the
transverse carpal ligament
(TCL) causes:
– atrophy of the thenar
eminence,
– weakness of the flexor
pollicis brevis, opponens
pollicis, abductor pollicis
brevis,
– sensory loss in the
distribution of the median Compression of the median nerve as it runs deep to the transverse
nerve distal to the carpal ligament (TCL) causes atrophy of the thenar eminence
transverse carpal ligament


Carpal tunnel syndrome associated
with other diseases
• Non-traumatic causes generally happen over a period of time, and are not triggered by one certain
event. Many of these factors are manifestations of physiologic aging
– rheumatoid arthritis and other diseases that cause inflammation of the flexor tendons
– pregnancy and hypothyroidism, fluid is retained in tissues, which swells the tenosynovium
– Hormonal changes during pregnancy
– Previous injuries including fractures of the wrist
– Medical disorders that lead to fluid retention or are associated with inflammation such as:
inflammatory arthritis, Colles' fracture, hypothyroidism, diabetes mellitus, acromegaly, and
use of corticosteroids and estrogens.

• A variety of patient factors can lead to CTS including
– heredity
– size of the carpal tunnel
– associated local and systematic diseases
– certain habits contribute to its etiology

• Carpal tunnel syndrome is also associated with repetitive activities of the hand and
wrist, particularly with a combination of forceful and repetitive activities


Physical Examination
• The wrist is examined for
– tenderness
– swelling
– warmth
– discoloration
• Each finger should be tested for:
– Sensation
– strength and signs of atrophy

• determine if the patient's complaints are related to daily
activities or to an underlying disorder
• rule out other painful conditions that mimic carpal tunnel
syndrome


Diagnostic Testing

• Often it may be
necessary, especially in cases of
workers’ compensation, to confirm
the diagnosis via diagnostic tests
– Routine laboratory tests and X-rays
can reveal diabetes, arthritis, and
fractures
– nerve conduction study
– Ultrasound imaging can show
impaired movement of the median
nerve
– Magnetic resonance imaging (MRI)
can show the anatomy of the wrist


Special Testing
• Tinel test: taps on or presses on the
median nerve in the patient's wrist. The
test is positive when tingling in the fingers
or a resultant shock-like sensation occurs.
• The Phalen: have the patient hold his or
her forearms upright by pointing the
fingers down and pressing the backs of
the hands together. The presence of
carpal tunnel syndrome is suggested if
one or more symptoms, such as tingling or
increasing numbness, is felt in the fingers
within 1 minute.
• Ask the patients to try to make a
movement that brings on symptoms.


• Rule out Vascular
Involvement (TOS)
• Always check for C6
involvement
• Consider exploring the
patients job or hobbies for
exacerbating activities
• Compressive wrist braces
yield better results than
simple immobilization


Non Surgical Standard of Care


Surgery versus non-surgical therapy for carpal
tunnel syndrome: a randomised parallel-group trial
The Lancet, Volume 374, Issue 9695, Pages 1074 - 1081, 26
September 2009

Jeffrey G Jarvik MD, Bryan A Comstock MS, Michel Kliot
MD, Prof Judith A Turner PhD, Leighton Chan MD, Patrick J
Heagerty PhD, William Hollingworth PhD, Carolyn L Kerrigan
MD, Richard A Deyo MD
METHODS: RTC, 116 patients, primary outcome was hand
function measured by the Carpal Tunnel Syndrome
Assessment Questionnaire (CTSAQ) at 12 months

FINDINGS: 44 (77%) patients assigned to surgery underwent
surgery. At 12 months, 101 (87%) completed follow-up and
were analyzed (49 of 57 assigned to surgery and 52 of 59
assigned to non-surgical treatment). Analyses showed a
significant 12-month adjusted advantage for surgery in
function (CTSAQ function score: Δ −0·40, 95% CI 0·11—
0·70, p=0·0081) and symptoms (CTSAQ symptom score:
0·34, 0·02—0·65, p=0·0357).

RESULTS: Symptoms in both groups improved, but surgical
treatment led to better outcome than did non-surgical
treatment. However, the clinical relevance of this difference
was modest. Overall, our study confirms that surgery is useful
for patients with carpal tunnel syndrome without denervation.


Comparative efficacy of conservative medical and
chiropractic treatments for carpal tunnel syndrome: a
randomized clinical trail
J Manipulative Physiol Ther. 1998 Jun;21(5):317-26.
Davis PT, Hulbert JR, Kassak KM, Meyer JJ.

OBJECTIVE:
To compare the efficacy of conservative medical care with
chiropractic care in the treatment of carpal tunnel syndrome.

DESIGN: Two-group, RTC, single blind, 9 week of treatment
and a 1-month follow-up interview, 96 eligible subjects
confirmed by clinical exam and nerve conduction studies.
Interventions included ibuprofen (800 mg 3 times a day for 1
week, 800 mg twice a day for 1 wk and 800 mg as needed to a
maximum daily dose of 2400 mg for 7 week) and nocturnal wrist
supports for medical treatment. Chiropractic treatment included
manipulation of the soft tissues and bony joints of the upper
extremities and spine (three treatments/week for 2 week, two
treatments/week for 3 week and one treatment/week for 4
week), ultrasound over the carpal tunnel and nocturnal wrist
supports.

RESULTS: There was significant improvement in perceived
comfort and function, nerve conduction and finger sensation
overall, but no significant differences between groups in the
efficacy of either treatment.

CONCLUSIONS: Carpal tunnel syndrome associated with
median nerve demyelination but not axonal degeneration may
be treated with commonly used components of conservative
medical or chiropractic care.


Improving the Standard
Laser therapy is:
• Non-surgical
• No medications
• Safe and effective
• FDA Cleared
• Treatments
generally take less
than 10 minutes
• No need to stop or
modify
work/activities
• Long lasting results
• No side effects or
adverse reactions

The Effectiveness of Conservative Treatments of Carpal Carpal Tunnel Syndrome Treated with a Diode Laser: A
Tunnel Syndrome: Splinting, Ultrasound, and Low-Level Controlled Treatment of the Transverse Carpal Ligament
Laser Therapies Wen-Dien Chang, Jih-Huah Wu, Joe-Air Jiang, Chun-Yu
Umit Dincer, M.D., Engin Cakar, M.D., Mehmet Zeki Yeh, Chien-Tsung Tsai.
Kiralp, M.D., Hilmi Kilac, P.T., Hasan Dursun, M.D.
Study:
Study:
Placebo-controlled study on 830-nm diode laser
100 hands of 50 women patients with bilateral CTS
Thirty-six patients with mild to moderate degree of CTS
Patients were randomly allocated to three groups that
received the following treatment protocols: splinting were randomly divided into two groups.
only, splinting plus US, and splinting plus LLL therapy.
Boston Questionnaire, patient satisfaction inquiry, visual Objective:
analogue scale for pain, and electroneuromyography. VAS scores were significantly lower in the laser group than
the placebo group after treatment and at 2 wk follow up
Objective: No significant differences were found in grip strengths or
Combinations of US or LLL therapy with splinting were for symptoms and functional assessments.
more effective than splinting alone in treating CTS However, there were statistically significant differences in
However, LLL therapy plus splinting was more these variables at 2-wk follow-up
advantageous than US therapy plus splinting
Conclusion:
Conclusion:
LLLT was effective in alleviating pain and symptoms, and
Laser therapy and splinting lessens symptom
severity, provides pain alleviation, and increases patient in improving functional ability and finger and hand strength
satisfaction for mild and moderate CTS patients with no side effects.
.


Clin Rheumatol. 2009 Jun 21. Electromyogr Clin Neurophysiol. 2008 Jun-Jul;48(5):229-31.

Comparison of splinting and splinting plus low-level laser therapy in The effects of low level laser in clinical outcome and
idiopathic carpal tunnel syndrome. neurophysiological results of carpal tunnel syndrome.
Yagci I, Elmas O, Akcan E, Ustun I, Gunduz OH, Guven Z. Shooshtari SM, Badiee V, Taghizadeh SH, Nematollahi
AH, Amanollahi AH, Grami MT.
OBJECTIVES: compare the short-term efficacy of splinting (S) and
splinting plus low-level laser therapy (SLLLT) in mild or moderate OBJECTIVES:. The present study evaluates the effects of LPL
idiopathic (CTS)
irradiation through NCS and clinical signs and symptoms.
METHODS: RTC, symptoms over 3 months. The SLLLT group
received ten sessions of laser therapy and splinting while S group was METHODS: 80 patients, diagnosis based on both clinical examination
given only splints. The patients were evaluated at the baseline and and EMG, randomly assigned into group A (underwent laser
after 3 months of the treatment. Follow-up parameters were nerve therapy, 9-11 joules/cm2, 5x week, 3 weeks over the carpal tunnel
conduction study (NCS), Boston Questionnaire (BQ), grip area) group B (control). Pain, hand grip strength, median proximal
strength, and clinical response criteria. Forty-five patients with CTS
completed the study. Twenty-four patients were in S and 21 patients sensory and motor latencies, transcarpal median sensory nerve
were in SLLLT group. conduction (SNCV) were recorded.. Pain was evaluated by Visual
Analog Scale (VAS; day-night). Hand grip was measured by Jamar
RESULTS: In the third-month control, SLLLT group had significant dynometer.
improvements on both clinical and NCS parameters (median motor
nerve distal latency, median sensory nerve conduction velocities, BQ RESULTS: There was a significant improvement in clinical symptoms
symptom severity scale, and BQ functional capacity scale) while S
group had only symptomatic healing (BQ symptom severity scale). and hand grip in group A (p < 0.001). Proximal median sensory
The grip strength of splinting group was decreased significantly. latency, distal median motor latency and median sensory latencies
According to clinical response criteria, in SLLLT group, five (23.8%) were significantly decreased (p < 0.001). Transcarpal median SNCV
patients had full and 12 (57.1%) had partial recovery; four (19%) increased significantly after laser irradiation (p < 0.001). There were
patients had no change or worsened. In S group, one patient (4.2%)
had full and 17 (70.8%) partial recovery; six (25%) patients had no no significant changes in group B except changes in clinical symptoms
change or worsened. (p < 0.001).

CONCLUSIONS: CONCLUSIONS: Laser therapy is effective in treating CTS
Applied laser therapy provided better outcomes on NCS but not in paresthesia and numbness and improves the subjects' power of hand
clinical parameters in patients with CTS. grip and electrophysiological parameters.


• The Effectiveness of Conservative Treatments of Carpal Tunnel Syndrome:
Splinting, Ultrasound, and Low-Level Laser Therapies.
• Abstract Objective: investigate the effectiveness of splinting, ultrasound (US), and
low-level laser (LLL) in the management of CTS.
• Materials and Methods: 100 hands of 50 women patients with bilateral CTS at 3
months post treatment, three groups, splinting only, splinting + US, and splinting +
LLLT. Patients were assessed with the Boston Questionnaire, patient satisfaction
inquiry, visual analogue scale for pain, and electroneuromyography.
• Results and Conclusion: combinations of US or LLLT with splinting were more
effective than splinting alone in treating CTS. However, LLLT + splinting was more
advantageous than US + splinting, especially for the outcomes of lessening of
symptom severity, pain alleviation, and increased patient satisfaction.


Priority Principle
1st = Swelling/edema
2nd = Inflammation
3rd = Spasms
4th = Pain
5th = Tissue Repair
6th = ROM
7th = Functional Strength

Thoracic Outlet Syndrome
(#1 Swelling/Edema)
No Primary Treatment area Emitter † MR4 TQ Activ Exposure time
1, 2, 3 Lymphatic drainage sites
(Woodpecker Technique) SE25, LS50* ,
1000-3000 2 Minutes each
LS50-6D and 1000-3000 Hertz 3000 Hertz
Hertz location
LaserStim

4 Subclavian Artery All 50 Hz 5 minutes

3 4
2 1


No Primary Treatment Emitter MR4 TQ Activ Exposure
area time
1† Median Nerve SE25 50 or 5- 50 Hertz 50 or 5-250 2 minutes
250 Hertz Hertz each
location
Centered over the LS50 and 5 minutes
Median Nerve LS50-6D
Using TARGET identify LaserStim Use DOSE
areas along the
distribution of the
Median Nerve

† Choose only ONE


No Treatment area Emitter MR4 TQ Activ Exposure
time
1 To palpable muscle SE25, LS50 1000 Hertz 2 minutes
spasm and LS50-6D each
location
At identified LaserStim 1000 Hertz Use DOSE
TARGET locations
in the musculature


Photoinhibition (#4 Pain)
• Relieve pain through
adjustment techniques
(Activator) combined
with laser therapy
• Utilize other adjunctive
modalities
No Primary Treatment area Emitter † MR4 TQ Activ Exposure time
1 Painful site, dermatomes, nerve SE25, LS50* , 1000 or 3000 1000 or 3000 1000 or 5000 2-5 minutes each
roots LS50-6D and Hertz Hertz Hertz location
LaserStim


No Primary Treatment Emitter MR4 TQ Exposure
area time
1† Median Nerve SE25 500-1000 1000 Hertz 2 minutes
Hertz each
location
Centered over the Median LS50 and 500-1000 1000 Hertz 5 minutes
Nerve LS50-6D Hertz
Using TARGET identify LaserStim 500-1000 1000 Hertz Use DOSE
areas along the Hertz
distribution of the Median
Nerve

No. Secondary Treatment Emitter MR4 TQ Exposure
area time
2 C6 cervical spine and ANY 1000 Hertz 1000 Hertz 2 minutes
nerve root
3 Photohemotherapy to the ANY (LS 50 Hertz 50 Hertz 5 minutes
Subclavian Artery Series is
Optimal)
4† At palpable muscle SE25, 1000 Hertz 5 minutes
spasms or trigger points of LS50, or
the flexor muscle group LS50-6D

At identified TARGET LaserStim 1000 Hertz Use DOSE
areas in flexor muscle
group

† Choose only ONE


No Primary Emitter † MR4 TQ Activ Exposure
Treatment area time
1 Affected spinal
level

SE25,
LS50* ,
500-1000 1000 1000
LS50-6D 5 minutes
2 Above and below Hertz Hertz Hertz
and
affected level
LaserStim

• Optimal emitter
† Choose only ONE


Laser Treatment Frequency
• ―Local‖ treatments may
be given up to 3-4 times
per week, using
TARGET and DOSE
• ―Systemic‖ treatments
should be kept to no
more than 30 minutes
per day

Electrical Stimulation


Treatment Goals
(#6 ROM and #7 Strength)
• Avoid or modify activities that
aggravate pain
• Maintain joint movement and muscle
strength through rehabilitation
• Decrease stress on the joints by
using assistive devices: taping,
bracing (Multi Radiance Medical
lasers can be applied through the
through the tape!!)


• Postural correction
• C and L Spines rotate in
same direction while T
Spine rotates in ―opposite‖
directions.
• Laser therapy prior to
mobilization/manipulation
may ease the patient’s pain
and improve joint mobility


Double Crush Syndrome
• Associated secondary trauma or root
cause of the symptoms. Current Definition
does not address specific tissue injuries.

• Carpal Tunnel Symptoms not syndrome


Close

Early diagnosis and
treatment are important to
avoid permanent damage to
the median nerve


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