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Laser Acupuncture for Carpal Tunnel Syndromeby Margaret A. Naeser, Ph.D., Lic.Ac., Dipl.Ac.IntroductionThis information is provided in response to a request from the public for information on availability of an alternative therapy to treat the painful symptoms of Carpal Tunnel Syndrome (CTS) or Repetitive Strain Injury (RSI). It is not intended to replace medical advice. This alternative therapy applies painless, non-invasive red-beam laser light and microamps transcutaneous electrical nerve stimulation (TENS) to acupuncture points on the involved hand. The results from that study were published in the July, 2002 issue of the journal, Archives of Physical Medicine and Rehabilitation (Vol. 83, pages 978-988). That abstract is provided here: AbstractObjective: To investigate whether real or sham, low-level laser therapy (LLLT) plus microamps TENS applied to acupuncture points significantly reduces pain in carpal tunnel syndrome (CTS). Design: Randomized, double-blind, placebo control, crossover trial. Patients and staff administering outcome measures, blinded. Setting: Outpatient, V.A. hospital, university-affiliated. Patients: Eleven mild-moderate CTS cases (nerve conduction study, clinical exam) who failed standard medical or surgical treatment for 3-30 months. Intervention: Patients received real and sham treatment series (each for 3-4 weeks), order randomized. Real treatments used red-beam laser (continuous wave, 15 mW, 632.8 nm) on shallow acupuncture points on affected hand; infrared laser (pulsed, 9.4W, 904 nm) on deeper points on UE and cervical paraspinal areas; and microamps TENS on affected wrist. Devices were painless, non-invasive and produced no sensation whether real or sham. Hand treated behind hanging black curtain without patient knowing if devices were turned on (real) or off (sham). Main Outcome Measures: Melzack pain score, sensory and motor latencies, Phalen and Tinel signs. Results: Significant decreases in Melzack pain score, median nerve sensory latency, Phalen sign and Tinel sign, Post-real treatment series but not Post-sham. Patients able to perform prior work (computer typist, handyman) and stable for 1-3 years. Conclusions: This new, conservative treatment was effective to treat CTS pain in this study, larger studies are recommended. Source: Naeser MA, Hahn K-A K, Lieberman BE, Branco KF. Carpal Tunnel Syndrome Pain Treated with Low-Level Laser and Microamps TENS, A Controlled Study. Archives of Physical Medicine and Rehabilitation, 2002;83:978-988 Persons with mild-moderate CTS who wish to be treated with this alternative treatment method may contact the American Association of Acupuncture and Oriental Medicine, for referral to a licensed acupuncturist who has been trained in laser acupuncture (1-916-443-4770). Information on this treatment method is provided in this web site and in the booklet, "Naeser Laser Home Treatment Program for the Hand©" (Laser Acupuncture and Microamps TENS). The booklet is published by the nonprofit professional organization, American Association of Acupuncture and Oriental Medicine and may be ordered through the AAAOM (1-916-443-4770). The proceeds from sales of the booklet are donated to the American Association of Acupuncture and Oriental Medicine and to laser acupuncture research. The treatment was designed in a manner, which would permit patients with CTS or RSI to provide supplemental treatments for themselves, at home. It is suggested, however, that these home treatments only be performed under the supervision of a licensed acupuncturist trained in laser acupuncture. In addition, it is recommended that this method be used as early as possible into the course of the CTS or RSI disorder, preferably within the 6 to 12 months of symptom onset. A treatment course of three treatments per week (every other day) for 5 weeks (15 treatments) is recommended. The success rate (as defined by at least a 50% reduction in pain following the full series of treatments) ranges from 88% in the controlled study (Naeser, Hahn, Lieberman, Branco, in press) to 92% in an open-protocol, acupuncture office study (Branco & Naeser, 1999). Branco K, Naeser MA. Carpal tunnel syndrome: Clinical Outcome After Low-Level Laser Acupuncture, Microamps Transcutaneous Electrical Nerve Stimulation, and Other Alternative Therapies - An Open Protocol Study. J Alternative and Complementary Med 1999; 5(1):5-26. To view photographs showing a demonstration of this program to treat pain in carpal tunnel syndrome, click here. Suggested links:Laser Acupuncture FAQ's
http://www.NAALT.org/
http://www.laser.nu/
http://www.laserponcture.net/ About Carpal Tunnel Syndrome
Carpal Tunnel Syndrome Laser Acupuncture Research
"The Naeser Laser Home Treatment Program"
The Cost of Carpal Tunnel Syndrome
Source MaterialThe "Naeser Laser Home Treatment Program for the Hand ©" utilizes a red-beam laser pointer (laser pen), and a microamps TENS device (painless transcutaneous electric nerve stimulation) to stimulate acupuncture points on the wrist and fingers (no needles). The small, red-beam laser pen is a 5 mW, laser pen, with a fixed "on/off" switch. The red-beam laser light coming from the laser pen is similar to the red-beam laser light coming from the check-out scanner at grocery stores - i.e., no significant risk when used properly (i.e. not staring directly into the laser beam). The small, lightweight, microamps TENS device is the MicroStim 100 TENS. It is highly portable and fits into a shirt pocket. (More information is provided on these devices, later.) It is thought that these devices may have an anti-inflammatory effect on the painful area where they are applied to the skin. This type of home treatment appears to be more appropriate for CTS patients who have mild-to-moderate levels of wrist/hand pain, where there has been no atrophy of the thumb muscles. In more severe cases where there is abnormality on EMG (and atrophy of the thumb muscles), surgery may be more appropriate; and such decisions should be made in consultation with a physician. Our experience with nerve conduction studies in CTS patients indicates that patients who have a motor latency for the median nerve across the wrist which is less than 7.0 msec, are likely to have good outcome for pain relief following a series of treatments with laser acupuncture and microamps TENS. (In our study, a normal motor latency was considered to be less than 4.3 msec.) The sensory latency may even be absent, but the patient is still likely to have good outcome for pain relief, as long as the motor latency is less than 7 msec (Branco & Naeser, 1999; Naeser, Hahn, Lieberman, Branco, in press). Patients who continue to smoke cigarettes will not have as good an outcome. Although we did include one patient with diabetes mellitus, we have not conducted a systematic study of patients with diabetes, and cannot comment on likelihood of outcome. About Carpal Tunnel SyndromeDefinition of Carpal Tunnel Syndrome (CTS)Carpal Tunnel Syndrome (CTS) is an entrapment neuropathy of the median nerve at the wrist (Rosenbaum & Ochoa, 1993). In other words, the nerve that travels from one's arm to parts of the hand gets entrapped within the carpal tunnel. The carpal tunnel consists of some tissues (the transverse carpal ligament and 9 flexor tendons) that surround the median nerve as it passes through the wrist and palm area. If this median nerve gets compressed due, in part, to a repetitive stress, such as typing, then carpal tunnel syndrome is one disorder that may result. Thus, CTS occurs when there is chronic pressure on the median nerve in the wrist area. Patients with CTS go to the doctor with pain in the wrist that radiates into the hand, and sometimes into the forearm; numbness and tingling in the thumb, index, and middle fingers; and sometimes weakness in the hand. CTS occurs more commonly in workers whose tasks involve repetitive hand movements including computer keyboard operators. Repetitive strain injury (RSI) is different from CTS. In CTS, there is abnormality on nerve conduction studies of the median nerve across the wrist. In our research study, we defined mild CTS as abnormality on the sensory latency of the median nerve, where the sensory peak latency was equal to or longer than 3.6 msec. We defined moderate CTS as abnormality on the sensory latency and the motor latency of the median nerve, where the motor latency was longer than 4.3 msec (Naeser, Hahn, Lieberman, Branco, in press). In patients with RSI, there is no abnormality on nerve conduction studies of the median nerve. RSI patients have pain which is associated with soft tissue injury (muscles or tendons), but no abnormality of the median nerve at the wrist. A proposed definition of work-related CTS from the National Institute of Occupational Safety and Health (NIOSH) is provided in Table 1 (Matte et al., 1989). Patients who participated in this research project met these NIOSH criteria for diagnosis of CTS. In 1988, the incidence of CTS was estimated to be 515 per 100,000 population (Occupational Disease Surveillance, 1989). Thus, it was estimated there were 1.3 million cases. In 1995, the U.S. National Center for Health Statistics estimated there were over 1.89 million cases of CTS in the U.S. Other debilitating forms of RSI are even more prevalent. Current Treatment for Carpal Tunnel SyndromeIn work-related CTS, a trial of abstinence from activities which incite the symptoms is tried, as well as analysis of work habits and tools (Feldman et al., 1987). The goal is to decrease exposure to provocative actions through patient education, as well as through appropriate ergonomic changes in the worksite area. The wrist may be splinted in a neutral position, especially at night and during activities that aggravate the symptoms. Direct injection of steroids into the carpal tunnel may provide only temporary relief. After 2 to 4 months, between 65 and 90% of patients can be expected to have recurrence of symptoms (Slater, Jr. & Bynum, 1993). In one study, at 18 months after steroid injection, only 22% of patients were still free of symptoms (Gelberman, Aronson, Weisman, 1980). In another study, only 11% of cases treated with steroid injection had permanent relief and these were the mildest cases in the series (Goodman & Foster, 1962). Operative release of the transverse carpal ligament is performed in approximately 40% of CTS cases, followed by a 2-3 month period of rehabilitation. Carpal Tunnel Syndrome Laser Acupuncture ResearchThe Purpose of this Research ProjectThe purpose of this research project was to investigate whether red-beam low-energy laser and microamps TENS (painless transcutaneous electric nerve stimulation) could be used to stimulate acupuncture points on the hand, to treat the painful symptoms of CTS, under controlled research conditions. This research project used a painless, non-invasive technique, which can also be applied by the patient him/herself at home, under supervision of a licensed acupuncturist trained in laser acupuncture. Method used in this Research ProjectIn the controlled research at the hospital, the patient's hand was treated behind a black curtain, and the patient did not know whether the laser beam and TENS devices were "on or off," because each device produced no feeling. The research at the hospital was a randomized, double-blind, placebo-controlled, cross-over design. There, patients received 3 treatments per week (every other day), with 12 real and 12 sham treatments (each for 4 weeks), order randomized. Pre- and post-testing were performed with objective and subjective tests. These tests included nerve conduction studies; Melzack pain questionnaires; and hand strength and dexterity testing which were performed by hospital staff blind as to the treatment condition (real or sham). In the controlled research at the hospital, various lasers were used, but limited space here does not permit discussion of all lasers. Some of these larger lasers include a 15 mW red-beam, helium neon (632.8 nm) laser (Dynatronics Model 1620, Salt Lake City, UT) used on shallow acupuncture points on the affected hand; and a pulsed, 9.4W infrared-beam, gallium arsenide (904 nm) laser (Respond Systems, Branford, CT) used on deeper points on the upper extremity and cervical paraspinal areas. Three other patients were treated in an open protocol with the Naeser Laser Home Treatment Program for the hand using the 5 mW laser pen, and MicroStim 100 TENS device at home. All resumed prior type of work (computer keyboard typing and transcription work) without pain after 4 weeks. The laser used in the Home Treatment program is described later, under "The Naeser Laser Home Treatment Program for the Hand ©."
Status of Funding for this Research ProjectThis research was funded by the American Association of Acupuncture and Oriental Medicine (AAAOM), Sacramento, CA (1-916-443-4770) through sales of the published booklet, "Naeser Laser Home Treatment Program for the Hand©" An Alternative Treatment for Carpal Tunnel Syndrome and Repetitive Strain Injury. Naeser MA, Hahn CK, Lieberman BE. 1996. All equipment (lasers and microamps TENS devices) were donated by the companies which produced them.
The laser acupuncture and microamps TENS treatments were provided by licensed acupuncturists who had research acupuncture clinical privileges at the Boston VA Medical Center. Case Examples of some Patients with CTS who were Treated with Laser Acupuncture and Microamps TENS Utilizing this Research ProtocolPATIENT #1. G.M., a 40 year old man who had wrist pain in the right hand, for 3 months prior to Laser Acupuncture and Microamps TENS treatments under controlled research conditions at the hospital. Treated with research protocol in January and February '94, and March '95. Melzack pain score was 24 before treatment; 26, after sham treatment, and 0, after real treatment. Works now as a Computer Information Systems Administrator, at a major university in the Boston area. Able to resume all computer keyboard work for 8 - 10 hours a day, without pain. PATIENT #2 L.P., a 46 year old man who had wrist pain in the right hand for 12 years, following surgical release of the carpal tunnel on the right hand; and new wrist pain in the left hand for 2 years. He did not want to have surgery again. He received Laser Acupuncture and Microamps TENS treatments under controlled research conditions at the hospital. Both hands were treated with this research protocol in October, November, and December '94. Melzack pain score in the right hand was 16 before treatment; 0, after real treatment. This was the hand with post-surgical pain for 12 years. Pain score in the left hand was 23 before treatment, and 0, four weeks later, after real treatment; and still 0, four weeks later, after sham treatment. Able to resume handyman work all day (laying cement steps, electrical wiring, painting, etc.), without pain. PATIENT #3. E.R. E.R., a 59 year old woman who had wrist pain in the right hand for 2 years, prior to Laser Acupuncture and Microamps TENS treatments under controlled research conditions at the hospital. She has diabetes. Steroid injections or surgery are to be avoided, if possible, with diabetic patients, due to possible problems with wound healing. Treated with this research protocol in November and December '94, and January '95. Melzack pain score was 23 before treatment; 9, after real treatment, and 0, four weeks later, after sham treatment. This pain score of 0 after the sham treatment could represent a final placebo effect, or a "delayed effect" from the real laser treatments. We do not know. Prior to treatment, she stated that she was "Crippled for the day, if wrote for one hour." After treatments completed, "Able to type all day." Note: After 2 months following completion of research treatments, however, some pain returned (Melzack pain score of 16). The patient then treated herself at home with the 5 mW red-beam laser pen and microamps TENS device, and after two weeks of home treatment, the pain returned to zero. However, one year later, the pain again returned, and it was not successfully treated. This patient had had a stroke two years prior to entry into the research project. It has been our anecdotal experience, that patients who have carpal tunnel syndrome (peripheral nervous system damage) who also have a stroke (central nervous system damage) tend not to have long-term pain relief following this protocol (Branco & Naeser, 1999).
"The Naeser Laser Home Treatment Program""The Naeser Laser Home Treatment Program for the Hand ©"A general description of this treatment program is provided here. A more detailed description of this treatment program is available in a booklet available from the American Association of Acupuncture and Oriental Medicine (AAAOM). The AAAOM can also help a patient to locate a licensed acupuncturist, who can help train the patient in the home treatment program. Information on how to order this booklet, "Naeser Laser Home Treatment Program for the Hand ©," and how to locate a licensed acupuncturist, is provided at the end of this report. Two devices are used in the home treatment program:
Consumer warningsFor the Laser Pen:
For the Microamps TENS Device:
Before beginning the treatment, the patient washes his/her hands, and wipes all areas on the hand to be treated, with alcohol. It is important that there is no perspiration or hand lotion present on the skin, because these would block the laser beam and microamps TENS stimulation of the acupuncture points. A substance with yellow color such as iodine, would also block the stimulation effects of the laser light. Step 1.The tip of the laser pen is physically placed onto the skin at the median nerve area on the wrist crease at the base of the palm (acupuncture point, Pericardium 7) for 21 minutes (6.3 joules or 32.1 joules per cm2). See Figure #1. The laser pen is held in a 90 degree position, so that the laser beam is entering the acupuncture point at a perpendicular angle for maximum penetration. The "continuous wave" laser beam is used, not the "pulsating" laser beam. The actual depth of tissue penetration with a red-beam laser is believed to be only 0.8 mm (direct energy), and 11-15 mm (indirect energy) (Seitz & Kleinkort, 1986). Thus, the red-beam laser is ideally suited for stimulation of shallow acupuncture points located on the hand. Step 2.The primary electrode for the MicroStim 100 TENS device is taped onto the same area which was treated in Step 1 - e.g., the palm side of the wrist crease at the median nerve (acupuncture point, Pericardium 7). The primary electrode used with the MicroStim 100 TENS device is the metallic, circular-shaped electrode with four tiny LED red lights which are embedded into it; it is about the size of a fifty-cent coin. This primary electrode should be pre-moistened with some clear conducting gel before it is taped into place. Or, a clear, double-sided, self-sticking electrode patch may be used over the primary electrode. See Figures #2, #3, and #4. The grounding pad electrode is then pre-moistened with a few drops of water, and taped onto the back of the wrist area (acupuncture point, Triple Warmer 4). The MicroStim 100 TENS device is turned on, and adjusted so that the patient does not feel any "tingling" sensation at all. For example, the intensity knob is turned up until a "tingling" sensation is felt at either electrode site, then the intensity is turned down, until there is no "tingling" sensation at all. This will be the ideal setting for treatment with microamps TENS for that patient, on that day. The ideal setting is usually around 200 to 500 microamps (around 2 to 4 or so, on the knob). A high-frequency pulse rate of 292 Hz (F4) is used for two minutes, then the pulse rate is turned down to a low-frequency pulse rate of 0.3 Hz (F1), which is used for 18 minutes. A more detailed explanation of exactly how to use the MicroStim 100 TENS for this treatment protocol is provided in the booklet from the American Association of Acupuncture and Oriental Medicine. Step 3.While the TENS device is in place at the wrist, the red-beam laser is applied to other acupuncture points on the affected hand, 3 minutes per acupuncture point (1 joule or 4.6 joules per cm2). See Figures #5 and #6. The acupuncture points are as follows: Lung 11, Large Intestine 1, Pericardium 9, Triple Warmer 1, Heart 9, Small Intestine 1, Distal BaXie points in the webs between the fingers, Large Intestine 4, Pericardium 8, Heart 8, Lung 9 or 10, and Heart 7. Some patients prefer to work with two laser pens at the same time, so that two acupuncture points may be treated at the same time, thus reducing the duration of one treatment session. Each treatment lasts about 45 minutes. Each device produces no feeling whatsoever, no heat, no cold, no pain. Additional acupuncture points may be treated on the forearm or up to the shoulder area (according to the distribution of possible radiating pain) and the posterior neck, paraspinal region (cervical vertebrae C5 to T1). However, these deeper acupuncture points need to be treated with infrared laser or acupuncture needles. It is extremely important to be trained by a licensed acupuncturist in the location of all acupuncture points. For example, an acupuncture paper published in 1990 observed complete pain relief in 24 of 36 cases with CTS (82%) success rate, following a series of needle acupuncture treatments (Chen, 1990). Frequently Asked Questions1. Is it OK to continue to take non-steroidal anti-inflammatory medications (ibuprofen) while doing the Laser Acupuncture and Microamps TENS treatments?
2. Do I have to treat a minimum of every other day?
How do Laser Acupuncture and Microamps TENS work?The effects of low-energy laser biostimulation on the cellular level have been reviewed by Basford (1989). The mechanism of exactly how this treatment program with red-beam laser and microamps TENS stimulation works is unknown. However, some possibilities include:
How to Purchase this Equipment for Home TreatmentThe 5 mW ITO laser lecture pen may be purchased from Lhasa Medical, Inc., 539 Accord Station, Accord, MA 02018-0539; 1-800-722-8775. It sells for $125.00 There are other laser lecture pens sold in the U.S. Some of these pens are also approximately 5 mW in power output. These other laser pens are often less expensive, but more difficult to use. Two additional vendors are: Damark, 7101 Winnetka Ave., N., P.O. Box 9437, Minneapolis, MN 55440-9437, 1-800-729-9000; and Edmund Scientific, 101 E. Gloucester Pike, Barrington, NJ 08007, (609) 547-3488. The MicroStim 100 TENS device may be purchased from MicroStim, Inc., 7881 NW 90th Ave., Tamarac, FL 33321; 1-800-326-9119, or (954) 720-4383. It sells for $400.00. There are many other types of red-beam laser pens, and microamps TENS devices available for purchase today, however the information which is provided here, is based only on treatment experience with these specific devices. No endorsement is made for these devices, however, and no medical claims are made for them. The FDA considers low-level laser biostimulation to be "investigational." Therefore, no medical claims are made for the "Naeser Laser Home Treatment Program for the Hand ©." It is up the patient to decide whether he/she wants to try this Home Treatment program under the supervision of a licensed acupuncturist who is trained in the use of laser acupuncture. This information is offered as one possible alternative therapy for the treatment of painful symptoms associated with CTS. How to Obtain More Information on the "Naeser Laser Home Treatment Program for the Hand ©" and obtain a referral for a licensed acupuncturist trained in this technique.To obtain a booklet explaining more detailed information on how to use the "Naeser Laser Home Treatment Program for the Hand ©," contact the American Association of Acupuncture and Oriental Medicine (AAAOM), which publishes the booklet. Their telephone number is 1-916-443-4770. The booklet sells for $24.95, including shipping. To obtain a referral for a licensed acupuncturist who has been trained in this technique, please contact the American Association of Acupuncture and Oriental Medicine (AAAOM) at 1-916-443-4770. To see photographs showing a demonstration of this program to treat pain in carpal tunnel syndrome, click here. The Cost of Carpal Tunnel Syndrome and Potential Cost Savings with use of this Treatment ProgramThe primary advantage of the "Naeser Laser Treatment Program," is a much lower cost to treat the painful symptoms of CTS, than current treatments. The current estimate to treat one case of CTS without surgical intervention in the U.S. is around $5,246 (Clairmont, 1997). The cost to provide treatment for one case of CTS with the LLLT and microamps TENS stimulation of acupuncture points is around $1,000 ($65 per office visit x 15 visits=$975). Thus, there is a potential savings of at least $4,000 per mild-moderate CTS case. Supplemental home treatments are also possible with a total equipment cost of around $525, as described in this web site and in the booklet, "Naeser Laser Home Treatment Program for the Hand ©." (The cost of a 5 mW red-beam laser pen is around $125 and the cost of the microamps TENS device used here, $400.) See Table 2. Table 1. Proposed Definition of Work-Related Carpal Tunnel Syndrome National Institute of Occupational Safety and Health (NIOSH) (Matte et al., 1989)Criteria A, B, and C must be met:
Table 2. Potential Cost Savings with Laser Acupuncture and Microamps TENS Treatments for Carpal Tunnel SyndromeLaser Acupuncture Treatments in the Office:
Supplemental Home Treatments:
Given that the current cost to treat one patient with CTS (without surgery) is estimated to be $5,246 (Clairmont, 1997), and the cost for laser acupuncture and microamps TENS treatments in the acupuncturist's office is around $1,000, there is a potential cost-savings of at least $4,000 per patient treated with laser acupuncture and microamps TENS. The number of patients with CTS in the U.S. today is unknown. It is estimated, however, that more than 460,000 surgical procedures are performed each year, for release of the transverse carpal ligament, with a direct medical cost of over $1.9 billion (Vennix et al., 1998). If even half of these 460,000 patients are successfully treated with laser acupuncture and microamps TENS within the first year of symptom onset, there is a potential cost-savings of $920,000,000, or almost $1 billion per year (230,000 patients x $4,000 cost-savings per patient = $920,000,000). Thus, this alternative treatment program has the potential for significant cost-savings, when it is administered early on in the development of carpal tunnel syndrome (preferably within the first 6 to 12 months of symptom onset). A treatment course of 15 treatments, three times per week, is recommended. References
About Margaret A. Naeser, Ph.D., Lic.Ac., Dipl.Ac.
How to Purchase this Equipment for Home TreatmentHow to obtain the booklet that explains this therapy in detail |
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