Activator 2011


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Activator 2011

  1. 1. Laser Therapy for CTS Douglas Johnson, ATC, EES, CLS Senior Vice President, Multi Radiance 800-373-0955
  2. 2. 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 800-373-0955
  3. 3. 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 originateThe carpal tunnel is approximately as wide as the thumb and its the medial epicondyle ofboundary lies at the distal wrist skin crease and extends distallyinto the palm for approximately 2 cm. the elbow joint and attach to the MP, PIP, PIP bones 800-373-0955
  4. 4. 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 800-373-0955
  5. 5. 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 800-373-0955
  6. 6. 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 800-373-0955
  7. 7. 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 patients complaints are related to daily activities or to an underlying disorder• rule out other painful conditions that mimic carpal tunnel syndrome 800-373-0955
  8. 8. 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 800-373-0955
  9. 9. Special Testing• Tinel test: taps on or presses on the median nerve in the patients 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. 800-373-0955
  10. 10. • 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 800-373-0955
  11. 11. Non Surgical Standard of Care 800-373-0955
  12. 12. Surgery versus non-surgical therapy for carpaltunnel syndrome: a randomised parallel-group trialThe Lancet, Volume 374, Issue 9695, Pages 1074 - 1081, 26September 2009Jeffrey G Jarvik MD, Bryan A Comstock MS, Michel KliotMD, Prof Judith A Turner PhD, Leighton Chan MD, Patrick JHeagerty PhD, William Hollingworth PhD, Carolyn L KerriganMD, Richard A Deyo MDMETHODS: RTC, 116 patients, primary outcome was handfunction measured by the Carpal Tunnel SyndromeAssessment Questionnaire (CTSAQ) at 12 monthsFINDINGS: 44 (77%) patients assigned to surgery underwentsurgery. At 12 months, 101 (87%) completed follow-up andwere analyzed (49 of 57 assigned to surgery and 52 of 59assigned to non-surgical treatment). Analyses showed asignificant 12-month adjusted advantage for surgery infunction (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 surgicaltreatment led to better outcome than did non-surgicaltreatment. However, the clinical relevance of this differencewas modest. Overall, our study confirms that surgery is usefulfor patients with carpal tunnel syndrome without denervation. 800-373-0955
  13. 13. Comparative efficacy of conservative medical and chiropractic treatments for carpal tunnel syndrome: a randomized clinical trailJ 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 withchiropractic care in the treatment of carpal tunnel syndrome.DESIGN: Two-group, RTC, single blind, 9 week of treatmentand a 1-month follow-up interview, 96 eligible subjectsconfirmed by clinical exam and nerve conduction studies.Interventions included ibuprofen (800 mg 3 times a day for 1week, 800 mg twice a day for 1 wk and 800 mg as needed to amaximum daily dose of 2400 mg for 7 week) and nocturnal wristsupports for medical treatment. Chiropractic treatment includedmanipulation of the soft tissues and bony joints of the upperextremities and spine (three treatments/week for 2 week, twotreatments/week for 3 week and one treatment/week for 4week), ultrasound over the carpal tunnel and nocturnal wristsupports.RESULTS: There was significant improvement in perceivedcomfort and function, nerve conduction and finger sensationoverall, but no significant differences between groups in theefficacy of either treatment.CONCLUSIONS: Carpal tunnel syndrome associated withmedian nerve demyelination but not axonal degeneration maybe treated with commonly used components of conservativemedical or chiropractic care. 800-373-0955
  14. 14. Improving the StandardLaser 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 800-373-0955
  15. 15. The Effectiveness of Conservative Treatments of Carpal Carpal Tunnel Syndrome Treated with a Diode Laser: ATunnel Syndrome: Splinting, Ultrasound, and Low-Level Controlled Treatment of the Transverse Carpal LigamentLaser Therapies Wen-Dien Chang, Jih-Huah Wu, Joe-Air Jiang, Chun-YuUmit 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 laser100 hands of 50 women patients with bilateral CTS Thirty-six patients with mild to moderate degree of CTSPatients were randomly allocated to three groups thatreceived 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 upObjective: No significant differences were found in grip strengths orCombinations 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 inHowever, LLL therapy plus splinting was more these variables at 2-wk follow-upadvantageous than US therapy plus splinting Conclusion:Conclusion: LLLT was effective in alleviating pain and symptoms, andLaser therapy and splinting lessens symptomseverity, provides pain alleviation, and increases patient in improving functional ability and finger and hand strengthsatisfaction for mild and moderate CTS patients with no side effects.. 800-373-0955
  16. 16. 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 andidiopathic 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) andsplinting plus low-level laser therapy (SLLLT) in mild or moderate OBJECTIVES:. The present study evaluates the effects of LPLidiopathic (CTS) irradiation through NCS and clinical signs and symptoms.METHODS: RTC, symptoms over 3 months. The SLLLT groupreceived ten sessions of laser therapy and splinting while S group was METHODS: 80 patients, diagnosis based on both clinical examinationgiven only splints. The patients were evaluated at the baseline and and EMG, randomly assigned into group A (underwent laserafter 3 months of the treatment. Follow-up parameters were nerve therapy, 9-11 joules/cm2, 5x week, 3 weeks over the carpal tunnelconduction study (NCS), Boston Questionnaire (BQ), grip area) group B (control). Pain, hand grip strength, median proximalstrength, and clinical response criteria. Forty-five patients with CTScompleted the study. Twenty-four patients were in S and 21 patients sensory and motor latencies, transcarpal median sensory nervewere in SLLLT group. conduction (SNCV) were recorded.. Pain was evaluated by Visual Analog Scale (VAS; day-night). Hand grip was measured by JamarRESULTS: In the third-month control, SLLLT group had significant dynometer.improvements on both clinical and NCS parameters (median motornerve distal latency, median sensory nerve conduction velocities, BQ RESULTS: There was a significant improvement in clinical symptomssymptom severity scale, and BQ functional capacity scale) while Sgroup had only symptomatic healing (BQ symptom severity scale). and hand grip in group A (p < 0.001). Proximal median sensoryThe grip strength of splinting group was decreased significantly. latency, distal median motor latency and median sensory latenciesAccording to clinical response criteria, in SLLLT group, five (23.8%) were significantly decreased (p < 0.001). Transcarpal median SNCVpatients had full and 12 (57.1%) had partial recovery; four (19%) increased significantly after laser irradiation (p < 0.001). There werepatients 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 symptomschange or worsened. (p < 0.001).CONCLUSIONS: CONCLUSIONS: Laser therapy is effective in treating CTSApplied laser therapy provided better outcomes on NCS but not in paresthesia and numbness and improves the subjects power of handclinical parameters in patients with CTS. grip and electrophysiological parameters. 800-373-0955
  17. 17. • 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. 800-373-0955
  18. 18. Priority Principle1st = Swelling/edema2nd = Inflammation3rd = Spasms4th = Pain5th = Tissue Repair6th = ROM7th = Functional Strength 800-373-0955
  19. 19. Thoracic Outlet Syndrome(#1 Swelling/Edema)No Primary Treatment area Emitter † MR4 TQ Activ Exposure time1, 2, 3 Lymphatic drainage sites (Woodpecker Technique) SE25, LS50* , 1000-3000 2 Minutes each LS50-6D and 1000-3000 Hertz 3000 Hertz Hertz location LaserStim4 Subclavian Artery All 50 Hz 5 minutes 3 4 2 1 800-373-0955
  20. 20. No Primary Treatment Emitter MR4 TQ Activ Exposure area time1† 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 800-373-0955
  21. 21. No Treatment area Emitter MR4 TQ Activ Exposure time1 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 800-373-0955
  22. 22. Photoinhibition (#4 Pain)• Relieve pain through adjustment techniques (Activator) combined with laser therapy• Utilize other adjunctive modalitiesNo Primary Treatment area Emitter † MR4 TQ Activ Exposure time1 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 800-373-0955
  23. 23. No Primary Treatment Emitter MR4 TQ Exposure area time1† 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 NerveNo. Secondary Treatment Emitter MR4 TQ Exposure area time2 C6 cervical spine and ANY 1000 Hertz 1000 Hertz 2 minutes nerve root3 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 800-373-0955
  24. 24. No Primary Emitter † MR4 TQ Activ Exposure Treatment area time1 Affected spinal level SE25, LS50* , 500-1000 1000 1000 LS50-6D 5 minutes2 Above and below Hertz Hertz Hertz and affected level LaserStim • Optimal emitter † Choose only ONE 800-373-0955
  25. 25. 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 800-373-0955
  26. 26. 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!!) 800-373-0955
  27. 27. • 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 800-373-0955
  28. 28. 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 800-373-0955
  29. 29. CloseEarly diagnosis andtreatment are important toavoid permanent damage tothe median nerve 800-373-0955