Activator 2011

www.MultiRadiance.com 800-373-0955

Douglas Johnson, ATC, EES, CLSSenior Vice President, Multi Radiance Medical

Laser Therapy for CTS

http://www.multiradiance.com/


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 medial epicondyle of the elbow joint and attach to the MP, PIP, PIP bones

The carpal tunnel is approximately as wide as the thumb and its boundary lies at the distal wrist skin crease and extends distally into the palm for approximately 2 cm.



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 nerve distal to the transverse carpal ligament

Compression of the median nerve as it runs deep to the transverse carpal ligament (TCL) causes atrophy of the thenar eminence



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.


http://upload.wikimedia.org/wikipedia/en/4/43/Carpal_Tunnel_Syndrome,_Operation.jpg


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 Tunnel Syndrome: Splinting, Ultrasound, and Low-Level Laser Therapies

Umit Dincer, M.D., Engin Cakar, M.D., Mehmet Zeki Kiralp, M.D., Hilmi Kilac, P.T., Hasan Dursun, M.D.

Study:

100 hands of 50 women patients with bilateral CTS

Patients were randomly allocated to three groups that received the following treatment protocols: splinting only, splinting plus US, and splinting plus LLL therapy.

Boston Questionnaire, patient satisfaction inquiry, visual analogue scale for pain, and electroneuromyography.

Objective:

Combinations of US or LLL therapy with splinting were more effective than splinting alone in treating CTS

However, LLL therapy plus splinting was more advantageous than US therapy plus splinting

Conclusion:

Laser therapy and splinting lessens symptom severity, provides pain alleviation, and increases patient satisfaction.

Carpal Tunnel Syndrome Treated with a Diode Laser: A Controlled Treatment of the Transverse Carpal LigamentWen-Dien Chang, Jih-Huah Wu, Joe-Air Jiang, Chun-Yu Yeh, Chien-Tsung Tsai.

Study:Placebo-controlled study on 830-nm diode laserThirty-six patients with mild to moderate degree of CTS were randomly divided into two groups.

Objective:VAS scores were significantly lower in the laser group than the placebo group after treatment and at 2 wk follow upNo significant differences were found in grip strengths or for symptoms and functional assessments.However, there were statistically significant differences in these variables at 2-wk follow-up

Conclusion:LLLT was effective in alleviating pain and symptoms, and in improving functional ability and finger and hand strength for mild and moderate CTS patients with no side effects.




Clin Rheumatol. 2009 Jun 21.

Comparison of splinting and splinting plus low-level laser therapy in idiopathic carpal tunnel syndrome.

Yagci I, Elmas O, Akcan E, Ustun I, Gunduz OH, Guven Z.

OBJECTIVES: compare the short-term efficacy of splinting (S) and splinting plus low-level laser therapy (SLLLT) in mild or moderate idiopathic (CTS)

METHODS: RTC, symptoms over 3 months. The SLLLT group received ten sessions of laser therapy and splinting while S group was given only splints. The patients were evaluated at the baseline and after 3 months of the treatment. Follow-up parameters were nerve conduction study (NCS), Boston Questionnaire (BQ), grip strength, and clinical response criteria. Forty-five patients with CTS completed the study. Twenty-four patients were in S and 21 patients were in SLLLT group.

RESULTS: In the third-month control, SLLLT group had significant improvements on both clinical and NCS parameters (median motor nerve distal latency, median sensory nerve conduction velocities, BQ symptom severity scale, and BQ functional capacity scale) while S group had only symptomatic healing (BQ symptom severity scale). The grip strength of splinting group was decreased significantly. According to clinical response criteria, in SLLLT group, five (23.8%) patients had full and 12 (57.1%) had partial recovery; four (19%) 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 change or worsened.

CONCLUSIONS:

Applied laser therapy provided better outcomes on NCS but not in clinical parameters in patients with CTS.

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

The effects of low level laser in clinical outcome and neurophysiological results of carpal tunnel syndrome.Shooshtari SM, Badiee V, Taghizadeh SH, Nematollahi AH, Amanollahi AH, Grami MT.

OBJECTIVES:. The present study evaluates the effects of LPL irradiation through NCS and clinical signs and symptoms.

METHODS: 80 patients, diagnosis based on both clinical examination and EMG, randomly assigned into group A (underwent laser therapy, 9-11 joules/cm2, 5x week, 3 weeks over the carpal tunnel area) group B (control). Pain, hand grip strength, median proximal sensory and motor latencies, transcarpal median sensory nerve conduction (SNCV) were recorded.. Pain was evaluated by Visual Analog Scale (VAS; day-night). Hand grip was measured by Jamar dynometer. RESULTS: There was a significant improvement in clinical symptoms and hand grip in group A (p < 0.001). Proximal median sensory latency, distal median motor latency and median sensory latencies were significantly decreased (p < 0.001). Transcarpal median SNCV increased significantly after laser irradiation (p < 0.001). There were no significant changes in group B except changes in clinical symptoms (p < 0.001).

CONCLUSIONS: Laser therapy is effective in treating CTS paresthesia and numbness and improves the subjects' power of hand grip and electrophysiological parameters.




Dincer et al, Photomed Laser Surg. 2009

• 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)

32 1

4

No Primary Treatment area Emitter † MR4 TQ Activ Exposure time

1, 2, 3 Lymphatic drainage sites (Woodpecker Technique) SE25, LS50* ,

LS50-6D and LaserStim

1000-3000 Hertz

3000 Hertz1000-3000 Hertz

2 Minutes each location

4 Subclavian Artery All 50 Hz 5 minutes



Carpal Tunnel Syndrome(#2 Inflammation)

No Primary Treatment area

Emitter MR4 TQ Activ Exposure time

1† Median Nerve SE25 50 or 5-250 Hertz

50 Hertz 50 or 5-250 Hertz

2 minutes each location

Centered over the Median Nerve

LS50 and LS50-6D

5 minutes

Using TARGET identify areas along the distribution of the Median Nerve

LaserStim Use DOSE

† Choose only ONE



Muscle Spasm: Pontinen’s Principle (#3 Muscle Spasm)

No Treatment area Emitter MR4 TQ Activ Exposure time

1 To palpable muscle spasm

SE25, LS50 and LS50-6D

1000 Hertz 2 minutes each location

At identified TARGET locations in the musculature

LaserStim 1000 Hertz Use DOSE



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 roots

SE25, LS50* , LS50-6D and LaserStim

1000 or 3000 Hertz

1000 or 3000 Hertz

1000 or 5000 Hertz

2-5 minutes each location



Carpal Tunnel Syndrome(#5 Tissue Repair)

No Primary Treatment area Emitter MR4 TQ Exposure time

1† Median Nerve SE25 500-1000 Hertz

1000 Hertz 2 minutes each location

Centered over the Median Nerve

LS50 and LS50-6D

500-1000 Hertz

1000 Hertz 5 minutes

Using TARGET identify areas along the distribution of the Median Nerve

LaserStim 500-1000 Hertz

1000 Hertz Use DOSE

No. Secondary Treatment area

Emitter MR4 TQ Exposure time

2 C6 cervical spine and nerve root

ANY 1000 Hertz 1000 Hertz 2 minutes

3 Photohemotherapy to the Subclavian Artery

ANY (LS Series is Optimal)

50 Hertz 50 Hertz 5 minutes

4† At palpable muscle spasms or trigger points of the flexor muscle group

SE25, LS50, orLS50-6D

1000 Hertz 5 minutes

At identified TARGET areas in flexor muscle group

LaserStim 1000 Hertz Use DOSE

† Choose only ONE



No Primary Treatment area

Emitter † MR4 TQ Activ Exposure time

1 Affected spinal level

SE25, LS50* , LS50-6D and LaserStim

500-1000 Hertz

1000 Hertz

1000 Hertz

5 minutes2 Above and below

affected level

Cervical Spine Involvement(#5 Tissue Repair)

• 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!!)



Differentiated Movements

• 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


Documents

Activator 2011