Luiz Antonio de Lima Resende
Professor, Department of Neurology, Psychology and Psychiatry, Botucatu School of Medicine, 18.618-000 Botucatu SP, Brazil; E-mail: ladlr@outlook.com
The Carpal Tunnel Syndrome (CTS) is the most common entrapment neuropathy. After surgery different types of complication may occur,1,2,3,4,5,6,7,8,9,10 then search for new clinical forms of treatment is necessary. The main clinical treatments are physical therapy, bracing, steroid injections and alternative therapies as yoga and acupuncture.11,12,13 In recent years, it has taken on increasing importance treatments with ultrasound and laser.14
The effects of laser on the peripheral nervous system are controversial. Laser application on the distal sensory branch of the radial nerve led to increased latency and decrease velocity.15 Application on the median nerve in 51 normal volunteers, led to a slight increased latency in sensory antidromic conducting study.16 Such data were not confirmed by others, whose normal volunteers showed no changes in conduction studies after application of Laser.17 Some authors described effectiveness of Laser in reversing carpal tunnel syndrome,18 but this was not confirmed by others.19 In one meta-analysis, only 2 papers with clinical and conduction studies improvement were found.20 One Brazilian study proposed a randomized controlled trial, which will be useful to assess the effectiveness of the conservative treatment and low-level laser therapy for patients with carpal tunnel syndrome.21 The aim of this study was to test the effectiveness of low intensity laser therapy in patients with CTS.
After approval by the Ethics Committee on Human Research of our Institution, patients with clinical and ENMG diagnosis of CTS never previously treated were included. Exclusion criteria were diabetes and other endocrine diseases, renal failure, alcoholism or occupational exposure to environmental toxic agents, patients with any other medical conditions that cause polyneuropathy, and antecedents of previous surgery, trauma, burns or fractures in the affected limb. Visual Analogic Scale (VAS), Carpal Flexion Amplitude (CFA) using a goniometer and Strength of the Abductor Pollicis Brevis (SAPB) muscle using a dynamometer (Daniels) were determined before and after treatment. Antidromic sensory conduction studies using ring electrodes, and motor conduction studies using standard surface disc electrodes were performed by conventional described techniques22 – Figure 1. Low intensity laser treatment using gallium-indium-phosphorus-aluminium Laser emitter was by 660 nm wave length, average power of 30 nw, continuous operation area of 0.06 cm2, fluency of irradiation of 10 J/cm2, exposure of 10 seconds per point, totalling 6 points of irradiation on the carpal tunnel, from the proximal to the distal sense. Laser was positioned at 90° to the skin, 2 sessions per week during 3 months were performed (24 sessions) – Figure 2. Statistical analysis from the data obtained before and after treatment was done by the paired “t” test. Correlation between clinical and conduction studies was performed by the Spearman correlation test and Pearson correlation test.
Figure 1: Motor conduction study. The distal motor latency of the median nerve is obtained by stimuli applied with distal cathode (blue, black arrow) and G1 and G2 electrodes positioned according to the belly-tendom technique (white arrows).
Figure 2: Application of the low-level laser on the median nerve across the carpal tunnel.
To this moment 30 hands from 18 patients were analysed (6 with unilateral CTS; 12 with bilateral CTS). From the clinical study, VAS, CFA and SAPB showed improvement after treatment (p<0.001, p<0.0028 and p<0.0001, respectively). VAS values are showed in the Graphic 1. From the conduction studies, distal motor latency and sensory conduction velocity improved after treatment (p<0.0003 and 0.0002, respectively). Distal motor latency values are showed in the Graphic 2. For the amplitude no significance was observed. In the Spearman correlation test, no statistic significance was observed. In the Pearson correlation test negative correlation between distal motor latency and SAPB was found (for larger values of latency minor values of strength). It was also observed positive correlation between distal motor latency and VAS (for larger values of latency larger values on the visual analogic scale of pain).
Graphic 1: Paired “t” test for the visual analogic scale (before and after treatment).
Graphic 2: Paired “t” test for the distal motor latency (before and after treatment).
The analysis of the 30 hands from 18 patients was possible in the last 2 years. For these 30 hands, visual analogic scale, carpal flexion amplitude, strength of the APB muscle, distal motor latency and sensory conduction velocity showed improvement. One study found no statistically significant clinical differences between the group of patients treated with laser and the placebo group, but improved sensory conduction in patients who received Laser was observed, similarly to our data.23 The Spearman correlation test between clinical data and conduction studies parameters showed no statistic significance. As the Spearman correlation test applies predominantly to ordinal scale variables, and, as in our study the only ordinal scale used was the VAS (visual analogue scale of pain, ranging from zero to ten), we opted for conducting also the Pearson correlation test. The results by this test were logical and predictable, for larger values of distal motor latency, minor values of the strength of the APB muscle and larger values of the VAS were found.
In the last years some encouraging results of Laser for the CTS were described, as subjective improvement;24,25 or improvement of the conduction studies and clinical data.26,27 In a recent prospective, randomized, placebo-controlled trial Evcik, et al. reported positive effects on hand and pinch grip strengths after low-level laser therapy.28 Beneficial effects of the combination of laser therapy with other methods as night orthopedic splint25 or magnetic stimulation29 were also reported.
In our opinion, low intensity laser therapy is emergent as a new, not expensive and easy to apply encouraging treatment for CTS.
The authors declare that they have no conflicts of interest.
We are grateful to the FAPESP, for the financial support (Process number 2013/10.082-4).
Consent statement
The authors have obtained written informed consent from the patient before submission of this manuscript for publication.
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