A STUDY TO COMPARE THE

EFFECTIVENESS OF ULTRASOUND AND LOW LEVEL LASER

THERAPY IN THE TREATMENT OF CARPAL TUNNEL SYNDROME
USING VISUAL ANALOGUE SCALE FOR PAIN ASSESSMENT AND
ACTION RESEARCH ARM TEST FOR HAND FUNCTION

By

MR. LINU P.KURIKESU

Dissertation submitted to the

Rajiv Gandhi University of Health Sciences, Karnataka, Bangalore

In partial fulfillment
of the requirements for the degree of

MASTER OF PHYSIOTHERAPY

in

Neurological and psychosomatic Disorders

Under the Guidance of

PROF. SUSAN VARGHESE .MPT

Dept. of Physiotherapy
KARNATAKA COLLEGE OF PHYSIOTHERAPY
MANGALORE
2004-2006

I
 RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES,
KARNATAKA, BANGALORE.

DECLARATION BY THE CANDIDATE

I hereby declare that this dissertation / thesis entitled “A STUDY TO COMPARE

THE EFFECTIVENESS OF ULTRASOUND AND LOW LEVEL LASER

THERAPY IN THE TREATMENT OF CARPAL TUNNEL SYNDROME

USING VISUAL ANALOGUE SCALE FOR PAIN ASSESSMENT AND

ACTION RESEARCH ARM TEST FOR HAND FUNCTION ” is a bonafide

and genuine research work carried out by me under the guidance of

PROF. SUSAN VARGHESE. MPT Professor, Karnataka College of

Physiotherapy.

Date: 15/12/2005 Signature of the Candidate

Place: Mangalore
MR. LINU P. KURIKESU

II
 RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES,
KARNATAKA, BANGALORE.

CERTIFICATE BY THE GUIDE

This is to certify that this dissertation / thesis entitled “A STUDY TO COMPARE

THE EFFECTIVENESS OF ULTRASOUND AND LOW LEVEL LASER

THERAPY IN THE TREATMENT OF CARPAL TUNNEL SYNDROME

USING VISUAL ANALOGUE SCALE FOR PAIN ASSESSMENT AND

ACTION RESEARCH ARM TEST FOR HAND FUNCTION” is a bonafide

research work done by MR. LINU P. KURIKESU in partial fulfillment of the

requirement for the degree of MASTER OF PHYSIOTHERAPY.

Date: 15/12/2005 Signature of the Guide

Place: Mangalore PROF. SUSAN VARGHESE. MPT

Professor, Dept. of physiotherapy

III
 RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES,
KARNATAKA, BANGALORE.

ENDORSEMENT BY THE HOD/PRINCIPAL/HEAD OF

THE INSTITUTION

This is to certify that this dissertation / thesis entitled “A STUDY TO COMPARE

THE EFFECTIVENESS OF ULTRASOUND AND LOW LEVEL LASER

THERAPY IN THE TREATMENT OF CARPAL TUNNEL SYNDROME

USING VISUAL ANALOGUE SCALE FOR PAIN ASSESSMENT AND

ACTION RESEARCH ARM TEST FOR HAND FUNCTION ” is a bonafide

research work done by MR. LINU P. KURIKESU under the guidance of

PROF. SUSAN VARGHESE. MPT Principal, Karnataka College of

Physiotherapy.

Date: 15/12/2005 Seal and Signature of the Principal

Place: Mangalore
PROF. SUSAN VARGHESE. MPT

IV
 COPYRIGHT

Declaration by the candidate

I hereby declare that the Rajiv Gandhi University of Health Sciences, Karnataka

shall have the rights to preserve, use and disseminate this dissertation/thesis in print

or electronic format for Academic/Research purpose.

Date: 15/12/2005 Signature of the Candidate

Place: Mangalore
MR. LINU P. KURIKESU

© Rajiv Gandhi University of Health Sciences, Karnataka

V
 ACKNOWLEDGEMENT

First and foremost I would like to thank God almighty, for his divine grace

and blessing throughout my studies.

A thesis in all its sense certainly can be accomplished only by the guidance

and assistance of many people. I take this opportunity to express my gratitude to all

those who have helped me for completing this thesis successfully.

It is my pleasure and privilege to acknowledge Prof. Susan Varghese,

Principal, Karnataka College of physiotherapy, Mangalore for her valuable

guidance and interest shown in this dissertation and without whom this work would

not have taken its shape.

I owe a great debt of gratitude to P.G Co-ordinator

Mr. Manoj Oommen Thomas Karnataka college of physiotherapy for his sincere

guidance from the beginning.

I am immensely grateful to, Mr. Sreejesh P, Asst. Prof. Karnataka college

of physiotherapy for his sincere assistance from the beginning

I am deeply indebted to Dr. Amarnath Sorake for all the facilities extended

to me for this study.

I wish to thank Dr. Shankar DM (Neuro) for his valuable support and

guidance given on my subject required for the study.

I would like to thank Mr. Nidhi Cherian Koshy and all my teachers for

their valuable guidance throughout this course.

I wish to express my sincere thanks to Varghese John P,

Harish S. Krishna, Roshan Ninan Rajan, Jince Augustine, Jipsy George and

Mr.Ramesh for their valuable help and support during this study.

VI
 I express my thanks to all the staffs and Librarians of Karnataka college of

physiotherapy, MAHE, and all the contributors, whose name have not mentioned,

but though they all deserve my gratitude.

I extend my sincere thanks to Mrs. Reshma kolar for her valuable support to

complete the statistical work for this study.

Last but not the least I would like to thank my Family and relatives for their

love and support.

Date:15/12/2005 Signature of the Candidate

Place: Mangalore. Linu P. Kurikesu

VII
 LIST OF ABBREVIATIONS USED

ARAT - Action Research Arm Test

ATP - Adenosine Tri phosphate

Cm - Centimeter

CTS - Carpal tunnel syndrome.

LLLT - Low level Laser Therapy

LS\L - Laser

MHz - Mega hertz

mmHg - Millimeters of Mercury

MW - Milliwatts

nm - Nanometer

US\U - Ultrasound

VAS - Visual Analogue Scale

W/CM2 - Watts per centimeter square

VIII
 ABSTRACT

BACKGROUND AND OBJECTIVES: Ultrasound and low level laser therapy

are frequently used by physical therapists in carpal tunnel syndrome. The objective

of this study was to compare the effectiveness of ultrasound and low level laser

therapy in the treatment of carpal tunnel syndrome. Greater emphasis had been

given to find out the best modality to reduce pain and improve hand function among

ultrasound and laser treatments. Action Research Arm Test and Visual Analogue

Scale were used as the outcome measures.

SETTING: Post Graduate Research Lab, Karnataka College of Physiotherapy.

MATERIALS AND METHODS: 30 patients aged 30-50 years with carpal tunnel

syndrome were selected from different hospital and clinics in Mangalore. And were

divided in to two experimental groups, that is group A ultrasound and group B laser.

Ultrasound was given to group A at 1 MHz, 1.0 W/cm,2 1:4 pulse,15 minutes per

session, once a day, 5 days in a week for 15 days. Laser treatment was given to

group B at 9 joules, 830nm, 15 minutes per session, once a day, ,5 days in a week

and was continued for 15 days. The Reduction of pain and improvement in hand

function were assessed by using Visual Analogue Scale (VAS) and Action Research

Arm Test (ARAT) before the first day of treatment and at the end of each week

treatment. At the end of the third week, the data’s were analyzed to find out the

effective modality among two modalities.

RESULTS:The one way Anova showed P<0.05 among the two treatment

modalities.

Which stated that there were high significant differences between the two treatment

modalities. When we compare the mean difference in ultrasound and laser from

IX
base to 3rd week, the mean difference found in ultrasound is 9.2 and in laser it is

6.14, mean difference is greater in ultrasound. Therefore ultrasound is considered to

be more effective than laser.

[[

INTERPRETATION & CONCLUSION: The results indicate that Ultrasound

treatment is more effective than Laser therapy for reducing pain and improvement

of hand function in Carpal Tunnel Syndrome

KEY WORDS: Carpal tunnel syndrome; Ultrasound therapy; Laser therapy;

Visual Analogue Scale (VAS); Action Research Arm Test (ARAT) .

X
 TABLE OF CONTENTS

1. Introduction Page No. 01

2. Objectives Page No. 06

3. Review of Literature Page No. 07

4. Methodology Page No. 13

5. Results Page No. 23

6. Discussion Page No. 36

7. Conclusion Page No. 40

8. Summary Page No. 41

9. Bibliography Page No. 42

10. Annexures Page No. 48

LIST OF TABLES

SI.
Tables Page No.
No
1. Table 5.1: Mean and standard deviation-standard error of 23

ultrasound and laser in Carpal Tunnel Syndrome

2. Table 5.2: Two way (ANOVA)analysis of variance between 24

two treatment modalities

XI
 3. Table 5.3: Multiple range test for comparing weekly 25

improvement of patients with ultrasound and Laser treatment

4. Table 5.4: Independent sample test 27
5. Table 5.5: Friedman test for the comparison of pain from base 28

to 3rd week in Laser

6. Table 5.6: Friedman test for the comparison of pain from base 29

to 3rd week in Ultrasound

7. Table 5.7: Base to week wise pain comparison 29
8. Table 5.8: Comparison of pain in ultrasound and Laser using 30

Mann Whitney Test

LIST OF FIGURES

Sl. No Figures Pages

1. Figure 4.1.1 Materials used 14
2. Figure 4.1.2: Materials used 14
3. Figure 4.2: Ultrasound Treatment 18
4. Figure 4.3: Laser Treatment 18
5. Figure 4.4: ARAT –Ultrasound 32
6. Figure 4.5: ARAT- Laser 32
7. Figure 4.6:Ultrasound - Laser Comparison 33
8. Figure 4.7: Variation in hand function

from base to 3rd week in Ultrasound and

Laser 33
9 Figure 4.8: Pain Ultrasound 34
10. Figure 4.9: Pain Laser 34

XII
11. Figure 4.10: Pain- Ultrasound Laser 35

comparison

XIII
1
 INTRODUCTION

The human hand has been characterized as a symbol of power, as an

extension of intellect and as a seat of the will. The symbiotic relationship of the

mind and hand is exemplified by the sociologists who claim that the brain is

responsible for the design of civilization but the hand is responsible for its

formation. The entire upper limb is subservient to the hand. Any loss of function in

the upper limb, regardless of the segment ultimately translates in to diminished

function of its most distal joints1. carpal tunnel syndrome (CTS) is a common

diagnosis with an estimated life time risk of 10% and an annual incidence of 0.1 %

among adults.2,3.

Carpal tunnel syndrome is the most common peripheral entrapment

4,5
neuropathy with an annual incidence of 50-150 cases in /100,0006 and is more

common in people of age 30-50 years and during pregnancy 7. It is an important

cause of workspace morbidity .

More recent estimates of the prevalence of CTS in the general population are

0.6% in men and 5.8% in women. And an overall prevalence of 2.1%8. CTS occurs

more frequently among females than males, and can be associated with a number of

etiologies typically involving repetitive motion and gripping with the hand when the

wrist is in a severly flexed or extended posture.

Carpal tunnel syndrome affects the women predominantly and if untreated it

usually pursues a variable course with exacerbations and remissions for years.

Paroxysms occur most commonly in the night and are often of such frequency and

severity that the sufferer can get little sleep for weeks on end. By day, symptoms

1
may be induced by use of the hands, and many patients have to give up much of

their daily domestic occupations. Thus this syndrome can be a source of great

distress and disability to those affected by it. The carpal tunnel syndrome consists

of paroxysmal paresthesia, pain and subjective numbness in one or both hands,

often accompanied by some objective impairment of sensation in the digits

supplied by the median nerve, and muscular weakness and wasting in the thenar

eminence9.

Carpal tunnel is a fibro- osseous canal bounded dorsally and laterally by the

carpal bones and ventrally by the transverse carpal ligament. Through this contained

space the nine flexor tendons and the median nerve run10. Therefore any space

occupying lesion can compress the median nerve and produce the typical symptoms

of carpal tunnel syndrome such as pain, paresthesia11or numbness and tingling in the

distribution of the median nerve in the hand. The median nerve supplies sensation to
12,13
the most important portion of the hand, the lateral half of the palm, the lateral

half of the ring finger and the volar aspect of the entire middle finger, index finger

and thumb. Symptoms of more severe cases include hypesthesia 14, clumsiness, loss

of dexterity and weakness of grip16. In the most severe cases patients experience

marked sensory loss and significant functional impairment with thenar atrophy.

Ultrasound is a well established treatment for soft tissue lesions seen in

physiotherapy departments and is used mainly to treat the acute phase of

inflammation16. It is a mechanical disturbance in which the molecules of media that

transmit it such as biologic tissues are made to oscillate or vibrate at a frequency at

17.
the upper limit of human hearing Ultrasonic therapy is of considerable value in

accelerating wound healing provided that ultrasound is used correctly. Ultrasound is

2
particularly effective if the treatment is commenced shortly after injury, during the

inflammatory phase of repair. Ultrasound can produce a wide range of effects on

cells and tissues. Some of these effects are potentially beneficial, while others are

harmful 16.

Laser is an acronym for light amplification by stimulated emission of

Radiations. It refers to the production of a beam of radiation which differs from

ordinary light. Lasers are of a single specific wavelength and hence of a defined

frequency. These waves produce efficiently some sort of monochromatic radiation.

When laser radiation interact with matter, the effects are the same as any other

equivalent electromagnetic radiation such as reflection, refraction, absorption and

hence scattering.

Low level lasers refer to the use of red beam or near infrared lasers with a

wave Length between 600-1000 nm and watts from 5-500 mill watts.

The introduction of energy transfers and resultant enhancement of metabolic

activity is most pronounced in biologically challenged components. Low level laser

therapy is thus selectively targeting compromised cells, in reality these cells exhibit

a lowered reaction threshold to the effects of laser light and are more easily

triggered to energy transfer responses. The results is that LLLT has a significant

effect on damaged cells and tissues while normative biological constituents are

appreciably less affected 18 .

A Visual Analogue Scale (VAS) is a measurement instrument that tries to

measure a characteristic or attitude that is believed to range across a continuum of

values and cannot easily be directly measured. For example, the amount of pain.

From the patient feels ranges across a continuum from none to an extreme amount

3
of pain. From the patient’s perspective this spectrum appears continuous denoting

their pain and it does not take discrete jumps, as a categorization of none, mild,

moderate and severe would suggest. It was to capture this idea of an underlying

continuum that the VAS was devised. Operationally a VAS is usually a horizontal

line, 100 mm in length, anchored by word descriptors at each end, The patients were

asked to indicate their pain magnitude by marking on the line at the appropriate

point which represents their current state of pain. The VAS score is determined by

measuring in millimeters from the left hand end of the line to the point that the

patient marks. There are many other ways in which VAS have been presented,

including vertical lines and lines with extra descriptors. As such an assessment is

clearly highly subjective, these scales are of most value when looking at change

within individuals, It could be argued that a VAS is trying to produce interval/ratio

data out of subjective values that are at best ordinal 19.

The Action Research Arm test is developed by Lyle20. The ARAT was

constructed for assessing recovery of upper extremity function (focal disability)

following cortical injury. The ARAT is designed for evaluation of both sides of the

patient in order to obtain a more total description of the upper extremity function.

The ARAT contains four subscales. Grasp Grip, Pinch and Gross movement

comprising 19 items in total. Each subscale fulfilled the statistical criteria for

Guttman scales and so is constructed of items arranged in hierarchical order of

difficulty. Items within each subscales are ordered in such a way that if a patient

accomplishes the most difficult item, this predicts success with all less difficult

subscale items. Thus patient is credited with succeeding with all items of the

subtests for that limb. On the other hand, failure with the easiest item predicts

failure with the all items of greater difficulty on that subscale. Thus the ARAT has

4
been specially constructed to save testing time. It takes no more than 10 minutes to

examine a patient on the ARAT 21.

The purpose of this study was to determine the effective modality among

ultrasound and low level laser therapy in patients with mild to moderate carpal

tunnel syndrome patients for reducing pain and improving hand function. A total

of 15 minutes Ultrasound treatment were performed once a day, five days a week

for 15 days at a frequency of 1MHz and an intensity of 1.0 W/cm2 , with pulsed

mode duty cycle of 1:4 with aqua sonic gel as the couplant. Laser was administered

for 15 minutes per session over the carpal tunnel at 9 joules, 830nm, once a day, 5

days in a week for 15 days.

5
6
 OBJECTIVES OF THE STUDY

1. To compare the effectiveness of ultrasound and low level laser therapy in the

treatment of carpal tunnel syndrome using Visual Analogue Scale for pain

assessment and Action Research Arm Test for hand function.

2. To find out the effectiveness of ultrasound in the treatment of carpal tunnel

syndrome using Visual Analogue Scale for pain assessment and Action

Research Arm Test for hand function.

3. To find out the effectiveness of low level laser therapy in the treatment of

carpal tunnel syndrome using Visual Analogue Scale for pain assessment

and Action Research Arm Test for hand function.

HYPOTHESIS

Alternate hypothesis:-

There may be significant difference between the effectiveness of ultrasound and low

level laser therapy in the treatment of carpal tunnel syndrome using Visual

Analogue Scale for pain assessment and Action Research Arm Test for hand

function.

Null Hypothesis :-

There may not be a significant difference between the effectiveness of ultrasound

and low level laser therapy in the treatment of carpal tunnel syndrome using Visual

Analogue Scale for pain assessment and Action Research Arm Test for hand

function.

6
1
 REVIEW OF LITERATURE

Jableck said that in recent publication the incidence of bilateral symptoms in carpal

tunnel syndrome has been reported to be between 60% and 87%.22 Padua and co-

workers expressed that the incidence of bilateral symptoms in CTS is reported to be

between 60% and 87%.23 Silverstein and co- workers expressed that carpal tunnel

syndrome is a major problem in occupational health, particularly in occupations

requiring highly repetitive and/or forceful hand motions24. Gizell said that CTS can

occur in one or both hands and can occur at any age. He also stated that work

related CTS is more common in people with the ages of 20-50 and non –work

related CTS is most common in people over age 50. Regardless of age It is more

prevalent in women than in men25. Stevens J.C reported that the prevalence of carpal

tunnel syndrome range from 55 to 125 cases per 100,000 people2.

Masear said that up to 15 percent of workers in the highest risk industries are

affected annually.26 Dekrom MC and fellow workers said that recent estimates of the

prevalence of CTS in the general population are 0.6% in men and 5.8% in women

and an overall prevalence of 2.1%.8 Green D.P said that carpal tunnel syndrome

results from the entrapment of the median nerve within the carpal tunnel
27.
Bendler stated that CTS can occur in one or both hands28.

Brook L Martin told that CTS is a mono neuropathy occurring due to

compression of median nerve in carpal tunnel 29. Phalen reported that carpal tunnel

syndrome is the entrapment mono neuropathy seen most frequently in clinical

practice caused by compression of the median nerve at the wrist.12 Sen D said that

carpal tunnel syndrome can be resulted from renal dialysis.30 Phalen reported that

thickening or fibrosis of the flexor tendons synovia within the carpal tunnel is the

most frequent cause for CTS 31. Gelberman Said that occupations that cause greatest

7
risk to persons are those that require highly repetitive motions that involve extremes

of wrist flexion and extension they said that elevation of carpal canal pressure

occurs with wrist flexion and extension in normal subjects but they also have

increased pressure with the wrist in neutral 32.

Wertsch stated that in CTS, patients show one or more symptoms of hand

weakness and numbness. He said that symptoms are worse at night and often wake
10
the patient Jose J. Monsivais reported that there is symptoms of weakness of the

affected extremity, paresthesia in the distribution of the median nerve and pain in

the wrist or distal forearm. Decreased sensibility of the median nerve and thenar

atrophy are signs of advanced median nerve compression.15 Eversmann stated that

decreased sensibility of the median nerve and thenar atrophy are sings of advanced

median nerve compresson.33 Spinner said that in CTS a typical presentation may

include shoulder pain, numbness restricted to a single finger, or increased sensitivity

34
to cold in the fingers . Martin J. O’ malley et al said, they believe that re-

exploration will not result in a satisfactory outcome. They said that there are clearly

exists a group of patients with unrelieved symptoms who have experienced no relief

after surgical treatment. They reported that thirteen patients (15 hands) reported no

relief of symptoms after the initial operation. One patient complained of worsening

of symptoms.14

Dawson et al stated that the benefit of non- surgical treatment seems to be

limited.35 Gerritsen opinioned that the efficacy of most conservative treatment

options for carpal tunnel syndrome is still little known.36 Brook L Martin et al did a

study on mild to moderate carpal tunnel syndrome to compare the effectiveness of

conservative and surgical treatment for reducing the symptoms and they concluded

that the conservative treatment was effective.29 Ebenbichler said that among the

8
different options for conservative treatment, low level laser therapy and ultrasound

therapy is having the potential to induce biophysical effects within

the nerve tissue 37.

Stolke and seiferat said that experiments on the stimulation of nerve

regeneration and on nerve conduction by low level laser therapy support the consent

that these treatments might facilitate recovery from nerve compression38 Weintraub

treated 30 hands with an infrared 830 nm 30mW over painful spots along the

median nerve at the wrist and reported photobiological responses

in 80% of nerves.39 Clockie stated that there is a large amount of endorphins are

produced by the application of LLLT.40 Byrnes said that low level laser therapy is

found to be effective in reducing pain and inflammation. The localized and systemic

endogenous peptide b-endrophins after low level laser therapy has been clinically

reported in multiple studies with subsequent pain reduction. He added that several

studies have documented the ability of LLLT to induce axonal sprouting and some

neuronal regeneration in damaged nerve tissues where pain sensation is being

magnified due to nerve structure damage call regeneration and sporting may assist
41.
in pain decrease. Walker said that the application of LLLT results in increased

serotonin production 42

Tsuchiya et al said that by blocking the depolarization of fiber afferent

nerve the pain blocking effect of low level laser therapy can be pronounced,

particularly in low velocity neural Pathways such as non –myeliated afferent axons

from nociceptors. Laser irradiation suppresses the excitation of these fibres in the
43.
afferent sensory pathway Ailioaie said that the LLLT can produce anti-

inflammatory effects on tissue 44 Kubota J stated that low level laser therapy induces

angiogenesis. Both blood capillaries and lymphatic capillaries and lymphatic have

9
been clinically documented to undergo significant increase and regeneration in the

presence of laser irradiation. The resulting improvement in circulation and perfusion

enhances all repair and healing processes45. Rochkind stated that low level laser

therapy helps to induce axonal sprouting and nerve regeneration in damaged

tissues46. Lievens P and Vander Veen PH said that beneficial acceleration of

leukocytic activity results in enhanced removal of non-viable cellular and tissue

components, allowing a more rapid repair and regeneration process. It influences

the capillaries and blood vessels thus enhances repair and healing 47. Richard Martin

stated that laser therapy has been shown to accelerate temperature normalization,

demonstrating its beneficial influence on the inflammatory process. The unique pain

reduction abilities of LLLT have been extensively researched and documented in

numerous clinical studies and medical papers. He said that there is a wealth of

knowledge currently available to demonstrate the effectiveness of laser therapy in

this regard because the pain amelioration capabilities of LLLT are accomplished

via the combination of local and systemic actions. There is a preponderance of

medical evidence that justifies a conclusion that effective pain reduction can be

achieved via low level laser therapy (LLLT). Since Bradykinins elicit pain by

stimulating nociceptive afferents in the skin and viscera, mitigation of elevated

levels through LLLT can result in pain reduction. LLLT promotes normalization in

Ca++ Na+ and K+ , concentrations resulting in beneficial pain reduction results from

these ion concentration shifts 18. Kyung –Aek Hahn did a study in 11 patients with

mild to moderate CTS who had failed to standard medical or surgical treatment, to

evaluate the effectiveness of low level laser therapy. The result showed that all 11

patients resumed their previous work activities with less or no pain.48

10
 Basford said that the nerve compression can be recovered by giving

ultrasound therapy 49. Ebinbichler et al did a study on CTS to assess the efficacy of

ultrasound treatment for mild to moderate carpal tunnel cases and the results

suggested that there are short to medium term effects due to ultrasound treatment in

patient with mild to moderate idiopathic carpal tunnel syndrome. They have given

ultrasound 1 MHz, 1.0 W/cm,2 pulsed mode 1:4, 15 minutes per session applied to

the area over the carpal tunnel and the treatments were performed daily ( 5 sessions

per week)37. Enwemeka experimentally studied the effect of 1MHz therapeutic

ultrasound on the healing strength of tendons and reported a significant increase in

both the tensile strength and the energy absorption capacity of tendon, concluding

that the therapeutic ultrasound quickened the healing process.50 Ebinbichler et al

suggested that optimal treatment schedules of ultrasound treatment alone or in

combination with other non –surgical treatments await elucidation.They said no

satisfactory conservative treatment is available at present. Score of subjective

symptom ratings assessed by Visual Analogue Scale. He opinioned that hand grip

and finger pinch strength had improved significantly with active treatment at the

end of the treatments.37 Bierman et al said that therapeutic ultrasound is reputed to

reduce edema, relieve pain, accelerate tissue repair and modify scar formation.51

Vaile JH, Mathers DM, Ramos – Remusc, Russell AS did studies in CTS

and they administered Visual Analogue Scale (VAS) incorporating measures of

overall well being and pain assessment. They found that VAS is significantly better

at determining improvement.52 Huskisson stated that the most common VAS

consists of a 10cm horizontal line with the two end points labeled ‘no pain’ and

‘worst pain ever’(or similar verbal descriptors). The patient is required to place a

mark on the 10 cm line at a point which corresponds to the level of pain intensity he

11
or she presently feels. The distance in centimeters from the low end of the VAS to

the patients mark is used as a neumerical index of the severity of pain. 53 Price et al

opinioned that the major advantage of the VAS as a measure of sensory pain

intensity is it’s ratio scale properties. In contrast to many other pain measurement

tools, equality of ratio is implied, making it appropriate to speak meaningfully about

percentage differences between VAS measurements obtained either at multiple

points in time or from independent samples of subjects.54

Carroll DA did a quantitative study on upper extremity function using

Action Research Arm test (ARAT), a validated functional hand and arm test. She

was taken the assessment at the start of the treatment, midway through the treatment

period, at the end of the treatment period. The results of the study showed

significantly greater improvements in total scores in the ARAT 55. Hsieh et al tested

the inter- rater reliability, validity of the Action Research Arm Test and he got value

at 0.98 using 50 patients.56 Vander lee JH, De Groot V, Beckeraman H et al did

studies in the intra and inter rater reliability of the Action Research Arm test, a

practical test of upper extremity function in patients with stroke and they concluded

that ARAT has high reliability, high validity and high practical applicability. 57

Kozin SH, Porters et al did a study on intrinsic muscles to prove that the grip and

pinch strength are effected by median nerve lesion 58.ARAT was first described by

Lyle20. It is a performance test that consists of 4 subtests comprising 19 movements

to be performed by the patient. One of the pre requisites for usefulness of the ARA

test is that it’s measurement error is smaller than the estimated minimal clinically

important difference. ARA maximum test score is 57. Wagenaar et al set time limits

for each item. The time limit is 2.4 seconds. Above which the score is 2

instead of 3.60

12
13
 METHODOLOGY

SOURCE OF DATA

Patients were selected from different Hospitals and Clinics in Mangalore, Consent

forms were collected from the participants, the procedures have been explained to

them.

METHOD OF COLLECTION OF DATA

The patients between age group of 30-50 years with mild to moderate symptoms

were selected by simple random sampling. Subjects who satisfied the inclusion

criteria were selected as participants for this study. The sample composed of 30

participants.

INCLUSION CRITERIA

1. Patients diagnosed as carpal tunnel syndrome.

2. Patients between age group of 30-50 years.

3. Participants who are accepted for the study after evaluation by the

assessment proforma.

EXCLUSION CRITERIA

1. Contraindicated for ultrasound and laser therapy sessions.

2. Patients with any other orthopedic and neurological abnormalities.

13
Fig 4.1.1 materials used

Fig 4.1.2: Materials used

14
MATERIALS USED

1. Ultrasound Machine; Electrocare Systems (Fig 4.1.1)

2. Low level laser therapy machine; Energy Biorem, Model BRT\1 (Fig 4.1.2)

3. Evaluation tool (VAS scale for pain assessment ranging from 0 to 10

points(Fig 4.3)

4. Action Research Arm Test (ARAT) to measure hand function ranging from

0 to 57 points.(Fig 4.4)

Action Research Arm Test tools are

a) 10 cm cube (Fig 4.4a)

b) 7.5 cm cube (Fig 4.4b)

c) 5 cm cube (Fig 4.4c)

d) 2.5 cm cube (Fig 4.4d)

e) 6 mm Ball bearing (Fig 4.4e)

f) 1.5 cm Marble (Fig 4.4f)

g) 3.5 cm diameter washer with bolt. (Fig 4.4g)

h) 7.5 cm cricket ball (Fig 4.4h)

i) 2.25 cm Tube (Fig 4.4i)

j) 1x16 cm Tube (Fig 4.4j)

k) 10x2.5x1 cm stone (Fig 4.4k)

l) 2 glasses (Fig 4.4l)

5. Goggles (Fig 4.5)

6. Aqua sonic Gel (Fig 4.6)

7. Cotton (Fig 4.7)

8. 2 boxes( Fig 4.8)

9. Pillow(Fig 4.9)

15
METHOD OF PROCEDURE

After thorough assessment with the help of an evaluation Proforma and an inclusion

and exclusion criteria, 30 participants were selected for the study and are divided in

to two experimental groups, Group A ultrasound and Group B laser. Before starting

the treatment their intensity of pain over the hand was assessed by using Visual

Analogue Scale (VAS).

The VAS consists of a 10 cm line labeled at the anchor points with ‘no pain’

at left end and ‘worst pain ever’ is written at the right end of the line. Patients were

asked to indicate their pain magnitude by marking the line at the appropriate point,

and the measurement were taken from the left end of the line using a scale.

The hand function was measured by the Action Research Arm Test (ARAT)

The ARAT material consists of a wooden box, which is placed on the table in front

of the patient, containing blocks and objects of different sizes in 3 subtests (grasp,

Grip and pinch) the ability to grasp, move and release objects differing in size,

weight and shape were tested. The patient has to pick the objects up and moved

vertically (subtests of grasp and pinch) or horizontally (subtest of grip) to a

standardized location. Two items in the subtest of grip also consists of a certain

degree of vertical movement and pronation ( pouring water from I glass in to

another or supination (turning a washer) among the 6 items in the subtest of pinch,

the patient were asked to pick up marbles of 2 different sizes with 2 fingers only

(thumb and index finger, thumb and middle finger, thumb and ring finger,

respectively) and move them to a holder on top of the box. The fourth subtest

consists of placement of hand behind the head). The quality of the movements per

item is rated on a 4 point scale 0=no movement possible 1=movement partially

16
performed, 2= movement performed, but abnormally , 3=movement performed

normally. To allow for easier distinction, time of the subjects. To enable the

movement to the timed, the patient was asked to start and finish each movement

task with his/her hand flat on the table. If performance is slower than the time limit

or if the patient loses contact with the back of the chair during performance, the

score is 2 instead of 3. Ultrasound treatment was administered for 15 minutes per

session to the area over the carpal tunnel at a frequency of 1 MHz and an intensity

of 1.0 W/cm2 with pulsed mode duty cycle of 1:4 using an electrocare system with

aquasonic gel as the couplant.. A total of 15 minute ultrasound treatments were

performed once a day, five days a week for 15 days.

Low –level laser therapy was administered by applying a low intensity (9 j)

infrared laser diode energy Biorem mod. BRT/1 830 nm over the course of the

median nerve at the wrist. A total of 15 minute laser therapies were performed once

a day, 5 days a week for 15 days.

17
Fig 4.2 Ultrasound treatment

Fig 4.3 Laser treatment

18
DATA ANALYSIS

The following tests are performed in this study for data analysis.

ARITHMETIC MEAN

X=Σ X
N
Where, X = Arithmetic mean
Σ X = Sum of all variable
N = Total number of variable

STANDARD DEVIATION (S. D)

S.D = Σ (X - X)2
N
Where, X = The individual score
X = The mean score
N = The total number of scores

STANDARD ERROR (S.E)

S.E = S.D
N
Where, S.D = Standard deviation
N = The total number of scores

19
ONE - WAY ANALYSIS OF VARIANCE (ANOVA)

F - Ratio = Ms Weeks
Ms Error

Ms Week = SS Weeks
d. f Week

SS Weeks = Σ TC2 - (Σ X)2

n N

Ss Error = Total SS - (SS Weeks)

Σ X = Each individual score
Σ TC2 = Sum of squared total for each weeks
n = Number of sets of matched SS.
N = Total number of scores

MULTIPLE (SCHEFFE'S TEST) RANGE TEST

a) F = (X1 - X2)2
Ms error + Ms error
n1 n2

Where X1 = Mean score of condition 1

X2 = Mean score of condition 2
Ms error = Mean square value for the random error valuation

(From the one way anova calculation)

n1 = Number of subjects in treatment 1.
n2 = Number of subjects in treatment 2.

b) F1 = (C-1) F0
Where, C = Number of treatments
F0 = The figure of the inter section point of the appropriate of
values in the table.

INDEPENDENT SAMPLE TEST

20
t= X1 - X2

Σ (X1i – X1)2 + Σ (X2i - X2)2 X 1+1

n1 + n2 - 2 n1 n2
With d. F = (n1 + n2 - 2)
X1 = Mean of first group
X2 = Mean of second group
n1 = Number of observations in first group
n2 = Number of observations in second group
WILCOXON MATCHED - PAIRS TEST (SIGNED RANK TEST)

Z = T - UT
σ T

UT = n (n+1)
4

σ T n(n+1) (2n+1) / 24

n = (number of given matched pairs) - (Number of dropped out pairs)

MANN-WHITNEY TEST

U = n1n2 + nx (nx+1) - Tx
2
Where n1 = The number of subjects in condition 1
n2 = The number of subject in condition 2
TX = The larger rank total
nx = The number of Ss in the condition with the larger rank total

(i.e. condition 2=13).

FRIEDMAN TEST

21
Xr2 = 12
( Σ TC2 ) -3N (C+1)
(NC(C+1)

Where N = Number of Ss in the group (or in he case of matched

designs, the number of sets of subjects
C = Number of conditions
TC = Total of ranks for each condition
Σ TC = The sum of the squared ranks for each condition
2

22
23
 RESULTS

TABLE 5.1: Mean and standard deviation (S.D) of the baseline and during week 1,
week 2 and week 3 with ultrasound and laser treatments.

TABLE 5.1

MEAN AND STANDARD DEVIATION-STANDARD ERROR OF

ULTRASOUND AND LASER IN CARPAL TUNNEL SYNDROME

Treatment Mean SD SE
U 45.13 1.92 0.49
Base
L 43.46 2.26 0.58
U 48.00 2.17 0.56
Week 1
L 45.40 2.41 0.62
U 51.60 2.13 0.55
Week 2
L 48.80 2.27 0.58
U 54.33 1.87 0.48
Week 3
L 49.60 3.73 0.96

Table 5.1 : Shows that Mean and standard deviation (S.D) of the baseline (Pre

treatment) and during the 3 weeks of treatment with ultrasound and Laser.

The mean and significant difference in the ultrasound was 45.13+1.92 and in

the Laser was 43.46+ 2.26 during the pre week treatment period. This shows that

the baseline activity in the two treatment groups are almost same with slight

deviations which shows that there is no significant difference.

23
 The mean and significant difference in the 1st week for ultrasound was 48.00

+2.17 and for laser it was 45.40+2.41 .This shows that there is a slight significant

difference between two treatment groups.

The mean and significant difference in the 2nd week for ultrasound was 51.60

+2.13and for laser it was 48.80+2.27 .This shows that there is a significant

difference between two treatment groups.

The mean and significant difference in the 3rd week for ultrasound was

54.33+1.87 and for laser 49.60+3.73. This shows that there is a high significant

difference between two treatment groups during base to week 3.

TABLE 5.2 : One way analysis of variance (Anova) between two treatments.

TABLE-5.2
ANOVA

Sum of Mean
Treatment F P Result
squares square
Ultra SS between 732.067 244.022 59.242 .000 P<0.05 H.S
sound SSE 230.667 4.119
Total 962.733

Laser SS between 354.000 118.00 15.472 .001 P<0.05 H.S

SSE 426.933 7.624
Total 780.933

Table 5.2: Shows the one way analysis of variance performed to compare the

effectiveness of two treatment modalities among 3 weeks. When comparing

between weeks, the F calculated value is 59.242 and P value 0.000, P<0.05 which

shows that there is a high significant difference from base to third week in

ultrasound.

24
 In the laser group, the F calculated value is 15.472 and P value 0.001. So

P<0.05 this shows that there is a high significant difference from base to third week

in laser.

TABLE 5.3 : Multiple range test ( Scheffe’s test) for comparing ultrasound

and laser treatments among weeks.

TABLE 5.3
MULTIPLE COMPARISONS
95%
Treatment Weeks Mean P Confidence Interval Result
Difference Lower Upper
Bound Bound
Base-Week 1 -2.8667 .004 -5.0028 -.7306 P< 0.05 H.S
Base –Week2 -6.4667 .000 -8.6028 -4.3306 P<0.05 V.H.S
Ultrasound Base- Week3 -9.2000 .000 -11.3361 -7.0639 P<0.05V.H.S
Week1-Week2 -3.6000 .000 -5.7361 -1.4639 P<0.05V.H.S
Week1-Week3 -6.3333 .000 -8.4694 -4.1972 P<0.05V.H.S
Week2-Week3 -2.7333 .006 -4.8694 -.5972 P<0.05H.S
Base-Week 1 -1.7333 .406 -4.6394 1.1728 P>0.05 N.S
Base –Week2 -5.1333 .000 -8.0394 -2.2272 P<0.05 V.H.S
Laser Base- Week3 -5.9333 .000 -8.8394 -3.0272 P<0.05V.H.S
Week1-Week2 -3.4000 .015 -6.3061 -.4939 P<0.05 Sig
Week1-Week3 -4.2000 .002 -7.1061 -1.2939 P<0.05 H.S
Week2-Week3 -.8000 .889 -3.7061 2.1061 P>0.05 N.S

Table 5.3 is a multiple (Scheffe’s test ) range test for comparison of treatments of

ultrasound and laser from base to week 3. When analyzing the mean difference from

base to week1, It was -2.8667, In the 95% confidence interval since this comes in

between the lower bound of -5.0028 and upper bound of -0.7306 the P<0.05 which

shows that there is a high significant difference in the treatment of ultrasound

during base to week 1.

25
 When analyzing the mean difference from base to week 2, it was -6.4667. In

the 95% confidence interval since this comes in between the lower bound of -8.6028

and upper bound of -4.3306 , the P<0.05 which shows that there is a very high

significant difference in the treatment of ultrasound during base to week 2.

When analyzing the mean difference from base to week 3, it was -9.2000. In

the 95% confidence interval since this comes in between the lower bound of

-11.3361 and upper bound of -7.0639. The P<0.05 which shows a very high

significant difference in the ultrasound during base week 3.

When analyzing the mean difference from week 1 to week 2 it was -3.6000.

in the 95% confidence interval since this comes in between the lower bound of

-5.7361 and upper bound of -1.4639, the P<0.05 which shows a very high

significant difference in the ultrasound during week 1 to week 2

When analyzing the mean difference from week 1 to Week 3, it was

-6.3333. In the 95% confidence interval since this comes in between the lower

bound of -8.4694 and upper bound of -4.1972. P<0.05 shows very high significant

difference in ultrasound group from week 1 to week 3.

When analyzing the mean difference from week 2 to week 3, it was -2.7333.

In the 95% confidence interval since this comes between the lower bound of

-4.8694 and upper bound of -0.5972 P<0.05 This shows that there is a high

significant difference in treatment from base to week 1 in Laser group.

When analyzing the mean difference from base to week 1 in Laser, it was

-1.7333. In the 95% confidence interval since this comes between the lower bound

26
of -4.6394 and upper bound of 1.1728, P>0.05 . This result shows that there is no

significant difference in laser treatment from base to week1.

When analyzing the mean difference from base to week 2, it was -5.1333. In

the 95% confidence interval since this comes between the lower bound of -8.0394

and upper bound of -2.2272 P<0.05 This result shows there is a very high

significant difference in laser treatment from base to week 2.

When analyzing the mean difference from base to week 3, It was -5.9333. In

the 95% confidence interval since this comes between the lower bound of -8.8394

and upper bound of -3.0272 P<0.05, So there is a very high significant difference

from base to week.3.

When analyzing the mean difference from week 1 to week 2, it

was -3.4000. In the 95% confidence interval since this comes between the lower

of -6.3061 and upper bound of -0.4939, P < 0.05 this shows that there is a

significant difference in treatment from week 1 to week 2.

When analyzing the mean difference from week 1 to Week 3, it was -4.2000.

In due 95% confidence interval since this comes between the lower bound of

-7.1061 and upper bound of -1.2939 P<0.05 This shows that there is a high

significant difference from week 1 to week 3 in laser.

When analyzing the mean difference from week 2 to Week 3, it was -0.8000.

In the 95% confidence interval since this comes between the lower bound of

-3.7061 and upper bound of 2.1061, P>0.05. This shows that there is no significant

difference in the values from week 2 to Week 3 in laser group.

TABLE – 5.4
INDEPENDENT SAMPLE TEST

27
 Mean t p Result
Difference
Base 1.666 2.174 0.038 P<0.05 Sig
Week1 2.600 3.101 0.004 P<0.05 H.S
Week2 2.800 3.479 0.002 P<0.05 V.H.S
Week3 4.733 4.383 0.000 P<0.05 V.H.S

Table 5.4 shows the week wise comparison between Ultrasound and
Laser.

When we compare the baseline of Ultrasound and Laser, the mean

difference is 1.666. Which shows that mean is greater in ultrasound and t=2.174and

P= 0.038 which shows that there is significant difference between Ultrasound and

Laser.

When we compare the week 1 of Ultrasound and Laser, the mean difference

is 2.600, t=3.101 and P=0.004 . This shows that P<0.05. So there is a high

significance in week 1

When we compare the week 2 of Ultrasound and Laser, the mean difference is 2.800,

t=3.479 and P=0.002, P<0.05. This shows that there is a very high significant difference in

the week 2 between the treatments.

When we compare the week 3 of Ultrasound and Laser, the mean difference

is 4.733, t= 4.383and P=0.000 P<0.05. This shows that there is a very high

significant difference in the week 3 between the treatments.

TABLE-5.5
FRIED MAN TEST FOR THE COMPARISON OF PAIN FROM BASE TO
3rd WEEK IN LASER

N 15

Chisquare 23.896

P Value 0.000

28
 Result P<0.05 V.H.S

Friedman test is used to test the significant change in pain of Laser.

Chisquare value is 23.896 and P value is 0.000 and P<0.05. This shows that

there is a very high significant difference in Laser.

TABLE-5.6

FRIED MAN TEST FOR THE COMPARISON OF PAIN FROM

BASE TO 3rd WEEK IN ULTRASOUND

N 15

Chisquare 40.986

P Value 0.000

Result P<0.05 V.H.S

Fried man test is used to test the significant change in pain of Ultrasound. Chisquare value

is 40.986, P value is 0.000, P<0.05. This shows that there is a very high significant difference

in Ultrasound.

TABLE-5.7
BASE TO WEEKWISE PAIN COMPARISON

Treatment Weeks Mean Z P Result

Difference
Ultrasound Base- Week1 0.53 -2.739 0.006 P<0.05 H.S
Base- Week 2 1.35 -3.411 0.001 P<0.05 H.S
Base-Week 3 2.49 -3.411 0.001 P<0.05 H.S
Base- Week1 0.67 -2.731 0.006 P<0.05 H.S
Laser Base- Week 2 1.01 -2.732 0.006 P<0.05 H.S
Base-Week 3 1.46 -2.936 0.003 P<0.05 H.S

29
 Table5.7 Wilcoxon test for base to weekwise pain comparison in Ultrasound and laser

In Ultrasound, base to week 1, mean difference is 0.53. It shows that pain is

greater in base. Z value is -2.739, P=0.06, P<0.05 This data shows a significant difference

between base to week 1.

When comparing the pain from base to week 2 in Ultrasound, the mean difference is

1.35, Z value is -3.411 and P=0.001, P<0.05 This data shows that there is a high significant

difference in pain between base and week 2 in Ultrasound group.

When comparing the pain from base to week 3in Ultrasound, the mean difference is

2.49, Z value is -3.411 and P=0.001. P<0.05 This data shows that there is a high significant

difference in pain between base and week 3 in Ultrasound group.

In Laser, base to week 1 mean difference is 0.67.It shows that pain is greater in base. Z

value is -2.731, P=0.006. P<0.05 This data shows that there is a significant difference between

base to week 1.

When comparing the pain from base to week 2 in Laser, the mean difference is 1.01, Z

value is –2.732 and P=0.006. P<0.05 This data shows that there is a high significant

difference in pain between base to week 2 in Laser group.

When comparing the pain from base to week 3in Laser, the mean difference is 1.46, Z

value is –2.936 and P=0.003. P<0.05 This data shows that there is a high significant difference

in pain between base to week 3 in Laser group.

TABLE – 5.8
COMPARISON OF PAIN IN ULTRASOUND AND LASER USING
MANN WHITNEY TEST

30
 Mann Whitney Test is used for the week wise comparison of pain between Ultrasound

and Laser .

When we compare base of Ultrasound and Laser, Pain mean rank in Ultrasound is 17.70

and Laser is 13.30. At the initial period of treatment, pain was more in Ultrasound. U=79.50

and P=0.174, This data shows that there is no significant difference between Ultrasound and

Laser in reducing pain.

When we compare week 1 of Ultrasound and Laser, Pain mean in Ultrasound is 13.50

and 17.50 in Laser. U=82.50 and P=0.217, P<0.05 This data shows that there is no significant

difference between Ultrasound and Laser in reducing pain.

When we compare week 2 of Ultrasound and Laser, Pain mean in Ultrasound is 11.97

and 19.03 in Laser. U=59.50 and P=0.026, P<0.05 This data shows that there is a very

significant difference between Ultrasound and Laser in week 2 for reducing pain.

When we compare week 3 of Ultrasound and Laser, Pain mean in Ultrasound

is 11.67 and 19.33 in Laser. U=55.00 and P=0.016, P<0.05 This data shows that there is a very

significant difference between Ultrasound and Laser in week 3 for reducing pain.

Mean Base Week 1 Week 2 Week3

Rank U.S 17.70 13.50 11.97 11.67
L.S 13.30 17.50 19.03 19.33
Mann 79.50 82.50 59.50 55.00
Whitney
P .174 .217 .026 .016
Results P>0.05 N.S P>0.05 N.S P<0.05 V.S P<0.05 V.S

31
Figure 4.4: Action Research Arm Test – Ultrasound

60
Figure 4.5: Action Research Arm Test – Laser

50

40
UE

32
 51
Fig 4.6: Overall Comparsion of hand function between Ultrasound and Laser

50
49
48
UE

33

47
Fig 4.7: Variation in hand function from base to 3rd week in
Ultrasound and Laser

60

50
Fig 4.8 Weekly variation of pain in Ultrasound

40
LUE

34
 Fig 4.9 Weekly variation of Pain in Laser

Fig 4.10 Pain- Ultrasound –Laser - Comparison

Fig 4.10 Pain- Ultrasound-Laser Comparison

35
36
37
 DISCUSSION

Carpal tunnel syndrome has been associated with a variety of occupations including

computer employees, Thabalinists, aircraft and bearing manufacturing,24sewing,

grocery checking and many others. Epidemiologic studies relating carpal tunnel

syndrome to specific occupations have been limited by lack of uniform, valid

criteria for case ascertainment. The diagnostic gold standard, nerve conduction

testing is not suitable for many large surveillance efforts. Further more, simple

clinical tests are of limited diagnostic value.

Wrist flexion or extension not only is associated with increased intra carpal

tunnel pressure32 but may also result in micro circulatory ischaemia, which in turn

may be responsible for an increment in distal latency. Most patients with

presumptive CTS have an aggravation of symptoms after strenuous use of their

hands, or after sleeping with the wrist flexed. An increase in pressure in the carpal

tunnel is usually caused by non – specific flexor tenosynovitis. Chronic focal

compression of a nerve trunk can cause focal demyelination by mechanical stress

deforming the myelin lamellae. Ischaemia also plays a pathogenic role in the carpal

tunnel syndrome. It could account for intermittent paraesthesia that occurs at night

or with wrist flexion. Symptoms are usually markedly worse on the dominant side.

This study examined the results of ultrasound treatment and laser treatment

in patients who had carpal tunnel syndrome. There were significantly greater

changes in all parameters for the ultrasound treatment group compared to the low

level laser therapy group. Different effects were also found between pinch, grip,

grasp and gross movements which may be due to the different muscles involved.

36
For example the main muscle to produce the force in a pinch between the thumb

and little finger is Opponens pollicis,which is innervated only by the median nerve.

In grip strength, different types of muscles with different innervations are

responsible for the generated force58. So this measurement could be varied

according to the patients ability to use other muscles innervated by the ulnar nerve

to overcome the grip weakness caused by median nerve involvement. This

uncontrolled variable may interfere with the recorded values and may cause smaller

mean differences with grip strength compared to pinch strength.

The evaluation of hand function was done by using Action Research Arm

Test (ARAT). This is used for measuring upper limb function because of its

presumed high reliability, validity and practical applicability. Although the items on

the ARA test are scored on an ordinal 4 point scale, performance on this test is

usually expressed as a sum score, which is generally treated as on interval scale

ranging from 0 to 57.56,59,60

Many if not most, methods of treating pain as a single dimension varies in

magnitude, much like varying sound level by turning the volume knob on a radio.

Pain magnitude has been assessed by both sophisticated measures of pain threshold

and by classical indirect and direct psychophysical scaling methods VAS have been

used successfully for assessment of the sensory intensity and unpleasantness of

experimental pain sensations, and for the evaluation of the mechanisms and efficacy

of both pharmacological and non pharmacological interventions54.The VAS consists

of a 10 cm line labelled at the anchor points with ‘no pain’ and ‘worst pain ever’

indicate their pain magnitude by marking the line at the appropriate point. The ease

of administration and scoring has contributed to the popularity of this method.

37
 Conservative treatment approaches seems to offer clear advantages

over surgical treatment in patients with mild or moderate carpal tunnel syndrome.

Recent studies have shown short term effects of steroid injections into the carpal

tunnel, with modest or complete pain relief up to 92% of the patients, although long

term recurrence rates seem variable. The value of this treatment has been limited by

potential adverse effects to nerves and tendons with repeated injections. Wearing

wrist splints at night seems suitable only when symptoms are mainly nocturnal.

Studies reported that re-exploration will not result in a satisfactory

outcome. It is already noticed that there are groups of patients with unrelieved

symptoms after surgical interventions. It is also reported that a number of patients

have no relief of symptoms after the initial operation. And few studies are found to

have worsening of symptoms14.

Few studies have reported some beneficial effects of other conservative

treatments such as ultrasound therapy37and laser therapy39,49. They have claimed that

these physical agents may facilitate the recovery from carpal tunnel syndrome,

The findings of the present study confirm that ultrasound treatment is more

effective than laser treatment in patients with carpal tunnel syndrome. The rate of

improvement from ultrasound treatment was similar to that reported in other

studies37 and may indicate its similar effectiveness to steroid injection but without

their complications or limits.

Previous studies on the effects of laser therapy have been performed with a

wide range of therapeutic parameters such as wave length, exposure intensity and

38
different methods of local or acupuncture application. In a study by Basford et al the

radiation of infrared laser over 10 points of the median nerve path caused reduced

motor and sensory distal latency49.

Such different reports on the effects of laser therapy may be due to the

different therapeutic parameters which have been applied in these studies and it

seems that there is no general agreement on the therapeutic parameters of laser

therapy for treatment of carpal tunnel syndrome. In this study, the comparison

between the findings from low level laser therapy and those from ultrasound therapy

illustrates the superior effects of ultrasound on recovery.

Ultrasound could elicit anti-inflammatory and tissue stimulating effects, as

already shown in clinical trials16 and experimentally. In this way, ultrasound has the

potential to accelerate normal resolution of inflammation 17. The results of these

studies confirm that ultrasound therapy may accelerate the healing process in

damaged tissues. These mechanisms may explain the findings, that showed

ultrasound therapy relieved pain, increased hand functioning towards normal values

better than laser therapy in patients with mild to moderate carpal tunnel syndrome.

Inspite of the limited time period and number of subjects , this study proves

that Ultrasound therapy accelerates the healing process in damaged tissues in

patients with mild to moderate carpal tunnel syndrome.

39
40
 CONCLUSION

This clinical study showed that ultrasound treatment is more effective than

low level laser treatment in patients with mild to moderate carpal tunnel syndrome.

Therefore, it is concluded that ultrasound therapy can be given as an

effective treatment modality to reduce pain and improve hand functioning in

patients with carpal tunnel syndrome.

SUGGESTIONS

Further research is required to investigate the long term efficacy of ultrasound

versus laser and whether the combination of these two treatments is superior to

either treatment alone. Studies can be done by including more subjects and

increasing the treatment time to find out the long term effects of these interventions.

40
41
 SUMMARY

This study was conducted on 30 subjects between age group of 30-50

years within Mangalore.

They were divided in to two experimental groups. One group received

ultrasound treatment and other group received low level laser treatment. The
reduction of hand pain and improvement in hand function were assessed by Action
Research Arm Test (ARAT) and Visual Analogue Scale (VAS).

The analysis of the data led to the inference that :

1. Significant differences were seen in the mean changes of all

measurements between the two experimental groups.
2. Measurement of hand functions showed significant improvements in
both groups, but the mean changes were significantly higher in
ultrasound treatment group.
3. Patients ratings of pain at the end of each week treatment significantly
favoured ultrasound over laser treatment.

41
42
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49
 ANNEXURE- I

SELECTION CRITERIA OF SUBJECTS FOR THE STUDY

NAME :

AGE :

SEX :

OCCUPATION :

DOMINANT SIDE :

ADDRESS :

CHIEF COMPLAINTS :

PRESENT HISTORY :

PAST HISTORY :

HISTORY OF ANY OTHER

ASSOCIATED PROBLEMS :

PAIN :

TYPE OF PAIN :

INTENSITY OF PAIN IN VAS :

AGGREVATING FACTORS :

RELIEVING FACTORS :

ON GENERAL OBSERVATION :

49
BUILT OF THE PATIENT :

LOCAL OBSERVATION :

ON PALAPATION :

ON EXAMINATION

SENSORY EVALUATION :

SPECIFIC TESTS

EXAMINATION OF :

NEIGHBOUR JOINTS :

Accepted for the study

Rejected for the study

50
 ANNEXURE -II

CONSENT FORM

TOPIC

A study to compare the effectiveness of ultrasound and low level laser therapy in

the treatment of carpal tunnel syndrome using Visual Analogue Scale for pain

assessment and Action Research Arm Test for hand function

INVESTIGATOR: LINU P. KURIKESU

PURPOSE OF THE STUDY: To compare the effectiveness of ultrasound and low

level laser therapy in the treatment of carpal tunnel syndrome using Visual

Analogue Scale

For pain assessment and Action Research Arm Test for hand function

PROCEDURES/METHODS TO BE USED

PAIN ASSESSMENT

Subjects will be given a Visual Analogue Scale (VAS) The VAS consists of a 10

cm line labeled at the anchor points with ‘no pain’ at left end and ‘worst pain ever’

is written at the right end of the line. Patients were asked to indicate their pain

magnitude by marking the line at the appropriate point,

HAND FUNCTION

Hand function is evaluated by using Action Research Arm Test (ARAT). Patient

will be in the sitting position with back supported on a chair, the materials will be

placed on the table with a standard distance. When the evaluator count 3, Patient

has to pick objects in each category and within the time limit he has to move the

objects to particular positions. The quality of the movements per item is rated on a 4

point scale.

51
 0 No movement possible
1 Movement partially performed
2 Movement performed, but abnormally
3 Movement performed normally

If performance is slower than the time limit or if the patient loses contact with the

back of the chair during performance, the score is 2 instead of 3.

ULTRASOUND THERAPY

Ultrasound treatment is given over the flexor retinaculam with a dose of 1 MHz

1.0 W/cm.2 ;1:4 pulse for 15 minutes per session, once a day, 5 days in a week for

15 days. Aquasonic gel is used as a couplant.

LASER THERPY

Laser treatment is given at the area over carpal tunnel with 9 joules, 830nm

for 15 minutes per session,once a day, 5 days in a week for 15 days..

RISK INHERENT IN THE PROCEDURE

As this study is concerned, there are no potential risks. I have taken care to

minimize all the known potential risks and reasonable steps were taken to safe

guard the unknown risks.

BENEFITS

No financial expense for the patient

Better cure from the disease

CONFIDENTIALITY

Your name and identity will be kept confidential. You will be assigned number for

identification, which will be used for research proceedings.

PARTICIPATION

52
Your participation in this research is voluntary. Your signature acknowledges that

you have read and understood the information stated in your language and willingly

signed this consent from. If you feel any discomfort, you can withdraw from the

study at any moment. Your sign also acknowledges that you have received on the

date signed, a copy of this document.

INVESTIGATOR SIGN PARITICIPATS SIGN

INVESTIGATORS NAME PARICIPANTS NAME

DATE :

53
 ANNEXURE- III
TOOL FOR DATA COLLECTION

SUBJECT NAME AGE SEX DURATION SIDE BEFORE AT THE AT THE AT THE
NUMBER TRETMENT END OF 1ST END OF 2ND END OF 3RD
WEEK WEEK WEEK
VAS ARAT VAS ARAT VAS ARAT VAS ARAT

54
55