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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
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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: MangaloreMR. LINU P. KURIKESU
II
Page 3
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
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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: MangalorePROF. SUSAN VARGHESE. MPT
IV
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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
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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.
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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
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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
.
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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
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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) .
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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
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LIST OF TABLES
SI.
NoTables Page No.
1. Table 5.1: Mean and standard deviation-standard error of
ultrasound and laser in Carpal Tunnel Syndrome
23
2. Table 5.2: Two way (ANOVA)analysis of variance between
two treatment modalities
24
3. Table 5.3: Multiple range test for comparing weekly
improvement of patients with ultrasound and Laser treatment
25
4. Table 5.4: Independent sample test 27
5. Table 5.5: Friedman test for the comparison of pain from base
to 3rd week in Laser
28
6. Table 5.6: Friedman test for the comparison of pain from base
to 3rd week in Ultrasound
29
7. Table 5.7: Base to week wise pain comparison 29
8. Table 5.8: Comparison of pain in ultrasound and Laser using
Mann Whitney Test
30
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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
11. Figure 4.10: Pain- Ultrasound Laser
comparison
35
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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
neuropathy 4,5 with an annual incidence of 50-150 cases in /100,0006 and is more
common in people of age 30-50 years and during pregnancy7. 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
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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
the most important portion of the hand, 12,13 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 hypesthesia14, 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
the upper limit of human hearing 17. Ultrasonic therapy is of considerable value in
accelerating wound healing provided that ultrasound is used correctly. Ultrasound is
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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
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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
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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.
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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.
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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
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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
the patient 10 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
to cold in the fingers 34. 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
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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
in pain decrease. 41. 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
afferent sensory pathway 43. 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
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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
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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
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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
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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.
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Fig 4.1.1 materials used
Fig 4.1.2: Materials used
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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)
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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
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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.
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Fig 4.2 Ultrasound treatment
Fig 4.3 Laser treatment
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DATA ANALYSIS
The following tests are performed in this study for data analysis.
ARITHMETIC MEAN
X = X N
Where, X = Arithmetic mean
X = Sum of all variable
N = Total number of variable
STANDARD DEVIATION (S. D)
S.D = (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
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ONE - WAY ANALYSIS OF VARIANCE (ANOVA)
F - Ratio = Ms Weeks Ms Error
Ms Week = SS Weeks d. f Week
SS Weeks = TC2 - (X)2
n N
Ss Error = Total SS - (SS Weeks)
X = Each individual score
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
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t = X1 - X2
(X1i – X1)2 + (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 T
UT = n (n+1) 4
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
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Xr2 = 12 ( 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 conditionTC2 = The sum of the squared ranks for each condition
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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
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.
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.
23
Treatment Mean SD SE
BaseU 45.13 1.92 0.49L 43.46 2.26 0.58
Week 1U 48.00 2.17 0.56L 45.40 2.41 0.62
Week 2U 51.60 2.13 0.55L 48.80 2.27 0.58
Week 3U 54.33 1.87 0.48L 49.60 3.73 0.96
Page 43
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-5.2ANOVA
TreatmentSum of squares
Mean square
F P Result
Ultrasound
SS betweenSSETotal
732.067230.667962.733
244.0224.119
59.242 .000 P<0.05 H.S
Laser SS betweenSSETotal
354.000426.933780.933
118.007.624
15.472 .001 P<0.05 H.S
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.
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.
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TABLE 5.3 : Multiple range test ( Scheffe’s test) for comparing ultrasound
and laser treatments among weeks.
TABLE 5.3MULTIPLE COMPARISONS
Treatment Weeks Mean Difference
P95%
Confidence Interval ResultLower Bound
Upper Bound
Ultrasound
Base-Week 1 -2.8667 .004 -5.0028 -.7306 P< 0.05 H.SBase –Week2 -6.4667 .000 -8.6028 -4.3306 P<0.05 V.H.SBase- 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.SWeek1-Week3 -6.3333 .000 -8.4694 -4.1972 P<0.05V.H.SWeek2-Week3 -2.7333 .006 -4.8694 -.5972 P<0.05H.S
Laser
Base-Week 1 -1.7333 .406 -4.6394 1.1728 P>0.05 N.SBase –Week2 -5.1333 .000 -8.0394 -2.2272 P<0.05 V.H.SBase- Week3 -5.9333 .000 -8.8394 -3.0272 P<0.05V.H.S
Week1-Week2 -3.4000 .015 -6.3061 -.4939 P<0.05 SigWeek1-Week3 -4.2000 .002 -7.1061 -1.2939 P<0.05 H.SWeek2-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.
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.
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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
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.
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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 – 5.4INDEPENDENT SAMPLE TEST
Mean Difference
t p Result
Base 1.666 2.174 0.038 P<0.05 SigWeek1 2.600 3.101 0.004 P<0.05 H.SWeek2 2.800 3.479 0.002 P<0.05 V.H.SWeek3 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
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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-5.5FRIED MAN TEST FOR THE COMPARISON OF PAIN FROM BASE TO
3rd WEEK IN LASER
N 15
Chisquare 23.896
P Value 0.000
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.
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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-5.7BASE TO WEEKWISE PAIN COMPARISON
Treatment Weeks Mean Difference
Z P Result
Ultrasound Base- Week1 0.53 -2.739 0.006 P<0.05 H.SBase- Week 2 1.35 -3.411 0.001 P<0.05 H.SBase-Week 3 2.49 -3.411 0.001 P<0.05 H.S
LaserBase- Week1 0.67 -2.731 0.006 P<0.05 H.SBase- Week 2 1.01 -2.732 0.006 P<0.05 H.SBase-Week 3 1.46 -2.936 0.003 P<0.05 H.S
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.
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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 – 5.8COMPARISON OF PAIN IN ULTRASOUND AND LASER USING
MANN WHITNEY TEST
Mean Rank
Base Week 1 Week 2 Week3U.S 17.70 13.50 11.97 11.67L.S 13.30 17.50 19.03 19.33
Mann Whitney
79.50 82.50 59.50 55.00
P .174 .217 .026 .016Results P>0.05 N.S P>0.05 N.S P<0.05 V.S P<0.05 V.S
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
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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.
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Figure 4.4: Action Research Arm Test – Ultrasound
ARAT- ULTRA SOUND
45.13 48 51.6 54.3
0
10
20
30
40
50
60
PRE WEEK1 WEEK2 WEEK3
DURATION
ME
AN
VA
LU
E
Figure 4.5: Action Research Arm Test – Laser
ARAT- LASER
43.645.4
48.8 49.6
404142434445464748495051
PRE WEEK1 WEEK2 WEEK3
DURATION
MA
EN
VA
LU
E
Series1
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Fig 4.6: Overall Comparsion of hand function between Ultrasound and Laser
ULTRA SOUND-LASER COMPARISON
45.1348
51.654.33
43.6 45.448.8 49.6
0
10
20
30
40
50
60
PRE WEEK1 WEEK2 WEEK3
DURATION
ME
AN
VA
LU
ES
ULTRA
LASER
Fig 4.7: Variation in hand function from base to 3rd week in Ultrasound and Laser
45.1348
51.654.3
43.6 45.448.8 49.6
0
10
20
30
40
50
60
BASE WEEK1 WEEK2 WEEK3
ME
AN
VA
LU
E
ULTRA
LASER
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Fig 4.8 Weekly variation of pain in Ultrasound
Fig 4.9 Weekly variation of Pain in Laser
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Fig 4.10 Pain- Ultrasound –Laser - Comparison
Fig 4.10 Pain- Ultrasound-Laser Comparison
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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.
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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.
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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
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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 inflammation17. 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.
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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.
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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.
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BIBLIOGRAPHY
1. Cynthia C. Norkin, Pamela K. Levangie; Joint structure and function. A
comprehensive Analysis; 3rd ed. J.P. Brothers medical publishers (P) Ltd.;
2001
2. Stevens JC, Beard CM, O’ Fallon WM, Kurland WT, Carpal tunnel
syndrome in Rochester, Minnesota, 1961 to 1980 Mayo Clin Proc. 1988;
38:134-8.
3. Quality standards subcommittee of the American Academy of Neurology
1993; 43:2406-2409.
4. Hunt J. Ramsay, The thenar and hypothenar types of neural atrophy of the
hand. American journal of Medical science, 141,224-241,1911.
5. Hunt J. Ramsay, The neural atrophy of the muscles of the hand without
sensory disturbances Review of Neurology and psychiatry 12, 137-148,
1914.
6. Cheadle A, Franklin G, wolfhagen C, Savarino J, Liupy, Salley C, et al:
Factors influencing the duration of work –related disability: a population –
based study of Washington state worker’s compensation. AM J Public
Health 1994,84:190-196.
7. Kanaan N, Sowaya RA: Carpal tunnel syndrome: Modern diagnostic and
management techniques; BR J Gen Pract 2001, Apr; 51(465): 311-4.
8. Dekrom MC, kinipschild PG, Kester AD, Thijs CT, Boekkooi PF, spaans F.
carpal tunnel syndrome J clinic Epidemiol 1992; 45:373-376.
9. R.S. Crow, Treatment of carpal tunnel syndrome. British Medical Journal
1960;1:1611-1615.
42
Page 66
10. Wertsch JJ, Melvin J: Median nerve anatomy and entrapment syndromes:
review. Arch Phys Med Rehabil 63:623-627, 1982.
11. James 1. Kendrick and George S. Phalen. Compression Neuropathy of the
median nerve in the carpal tunnel. JAMA june 1 1957, 524-530.
12. Phalen GS. The carpal tunnel syndrome: 17 years experience in diagnosis
and treatment of 654 hands. Journal of Bone and Joint Surgery 48A:211-
228;1966.
13. Blue Cross Blue shield of Georgia, Low Level laser therapy as a treatment
for carpal tunnel syndrome, Orthop Med 2004,1-3.
14. Martin J.O’ Malley, Marguerite Evanoff and Lewish Millender. Factors that
determine re exploration treatment of carpal tunnel syndrome. J Hand Surg
1992;17A:638-41.
15. Jose J. Monsivais and Shawna Scully. Rotary subluxation of the scaphoid
resulting in persistent carpal tunnel syndrome J Hand Surg. 1992; 17A:642-
4.
16. M. EL Hag, K. Coghlan P, Christmas, W. Harvey, and M. Harris. The anti –
inflammatory effects of Dexamethasone and therapeutic ultrasound in oral
surgery. British Journal of Oral and Maxillofacial Surgery 1985; 23, 17-23.
17. Dyson M. Mechanisms involved in therapeutic ultrasound: Physiotherapy
73, 116-120; 1987.
18. Richard Martin. Laser accelerated inflammation, pain reduction and healing-
practical pain management Nov-Dec 2003.
19. Von Korff M, Deyo RA, Cherkin D, Barlow SF, Back pain in primary case
out comes at one year. Spine 1993;18:855-862.
43
Page 67
20. Lyle RC. A performance test for assessment of upper limb function in
physical rehabilitation treatment and research. Int J. Rehabil Res.
1981;4:483-92.
21. Ching Lin Hsieh, L-ping Hsueh, Fu-Mei Chiang, Po –Hsin. Inter –rater
reliability and validity of the Action Research Arm Test in stroke patients.
Age and Ageing, March 1998.
22. Jableki CK, Andary MT, Wilkins DE, Literature review of the usefulness of
nerve conduction studies and electro myography for the evaluation of
patients with carpal tunnel syndrome. AAEM Quality Assurance
Committee. Muscle Nerve 1993; 16:1392-414.
23. Padua L, Padua R, Nazzarom, Incidence of bilateral symptoms in carpal
tunnel syndrome. J Hand Surg. [Br] 1998;23:603-6.
24. Silverstein BA, fine LJ, Armstrong TJ; Occupational factors and carpal
tunnel syndrome. AMJ indust med 1987; 11:343-358.
25. Gizell R. Larson M.D. of the Neuroscience group of Northeast Wisconsin
(copyright 1992, American Academy of Neurology).
26. Masear VR, Hayes JM, Hyde AG : An industrial cause of carpal tunnel
syndrome. J Hand Surg [AM] 1986; 11:222-227.
27. Green DP. Diagnostic and therapeutic value of carpal tunnel injection. J
Hand Surg [AM] 1984;9A:850-4
28. Bendler EM, Greenspun B, YU J, Erdman WJ 2nd. The Bilaterality of carpal
tunnel syndrome. Arch Phys Med Rehabil 58(8):362-364;1977.
29. Brook L Martin, Linda M Levenson, William Holling Worth, Michel Kliot,
Patric J, Heagerty, JudithA, Turner. Randomized clinical trial of surgery
44
Page 68
versus conservative therapy for carpal tunnel syndrome BMC
Musculoskeletal Disorders 2005, 6:2 doi: 10.1186/1471-2474-6-2.
30. Sen D, Chhaya S, Morris VH: Carpal tunnel syndrome. Hosp Med 2002; 63:
392-395.
31. Phalen GS: Reflections on 21 year’s experience with carpal tunnel syndrome
JAMA 212:1365-1367, 1970.
32. Gelber man RH, Hergenroeder PT, Hargens AR, lund borg GN, Akeson
WH. The carpal tunnel syndrome: a study of carpal canal pressures. J Bone
Joint Surg 1981; 63A: 380-3.
33. . Eversmann WW: Entrapment and compression neuropathies in Green DP
(ed) Operative Hand Surgery. New York, Churchill Livingstone,
1988:1423-78.
34. Spinner M: Injuries to major Braches of Peripheral Nerves of Forearm. Ed 2,
Philadelphia, sunders, 1978, PP 200,216.
35. Dawson DM (1993): Entrapment neuropathies of the upper extremities. New
England journal of medicine 329: 2013-2015
36. Gerritsen AA, Decrom MC, Struijs MA, Scholten RJ, Devet HC and Bouter
LM: (2002) Conservative treatment options for carpal tunnel syndrome; A
systematic review of randomized controlled trials journal of neurology
294:772,780.
37. Ebenbichler GR, Resch KL, Nicolakis P, Wieasinger GF, Ghanem AH and
Fialka V. ultrasound treatment for treating the carpal tunnel syndromes:
randomized sham controlled trial BMJ 316:731:735;1998.
38. Stolke D and Seifert V. Clinical use of a new method in microsurgical
transplantation of peripheral nerves Neurochirugia 32:177-179;1998.
45
Page 69
39. Weintraub Mi : Non invasive laser neurolysis in carpal tunnel syndrome.
Muscle and Nerve1998; 21:1232-1233.
40. Clockie C, Bentley KC and Head TW. The effect of the helium –neon laser
on postsurgical discomfort: A pilot study. Journal of the Candian Dental
Association 57:584-586;1991.
41. Byrnes KR, et al. cellular invasion following spinal cord lesion and low
power laser irradiation Lasers Surg Med 2002. S 14:11.
42. Walker J. Relief from chronic pain by low power laser irradiation.
Neuroscience Letters 43:339-344:1983.
43. Tsuchiya K. et al. Diode laser irradiation selectively diminishes slow
component of axonal volleys to dorsal roots from the saphenous nerve.
Neuroscience Letters 1993;161:65-68.
44. Ailioaie C and Lupusoru - Ailioaie LM : Beneficial effects of laser therapy
in the early stages of rheumatoid arthritis onset. Journal of Laser Therapy
1999; 11:79- 87.
45. Kubota J. Laser and Sports Medicine in plastic and reconstructive surgery.
Department of plastic and Reconstructive surgery, Kyorin University School
of Medicine, Tokyo, Japan. Abstract from 11 congress of the internat Assn
for Laser and Sports Medicine, Rosario, Argentina, March 10-12: 2000.
46. Rochkind S, Shahar A, and Nevoz. An innovative approach to induce
regeneration and the repair of spinal cord injury. Laser therapy 1997:9(4):
151.
47. Lievens P and Vander Veen PH. Wound healing process: Influence of LLLT
on the proliferation of fibroblasts and on the lymphatic regeneration.
Department of Rehabilitation research, Vrije University, Brussels, Belgium
46
Page 70
Abstract from the 7th international congress of European Medical Laser
Association, Dubrovnik, Croatia, June 2000.
48. Kyung Aek Hahn. Laser treatment promises relief in carpal tunnel
syndrome.
Archives of Physical Medicine and Rehabilitation. 2002; 83:978-988.
49. Basford JR, Hallman HO, Matsomoto JY, Moyersk, Buss JM and Baxter
GD (1993): Effects of 830 nm continuous wave laser diode irradiation on
median nerve function in normal subjects. Lasers in Surgery and Medicine
13:597-604.
50. Enwemeka C S (1987) the effects of therapeutic ultrasound on tendon
healing. A biomechanical study; Americal Journal of Physical Medicine and
Rehabilitation 69, 283-287.
51. Bierman, WC: Ultrasound in the treatment of scars. Archives of Physical
Medicine and Rehabilitation 1954 ;34,209-213.
52. Vaile JH, Mathers DM, Ramos – Remus C, J. Rheumatol 1999 May ; 26
(5): 1022-3.
53. Huskisson EC 1983 Visual Analogue Scales in: Melzack R(ed)Pain
measurement and assessment. Raven Press, New York, P 33-37.
54. Price DD, Mc Grath PA, Rafii A, Buckingham B 1983. The validation of
Visual Analogue Scales as ratio scale measures for chronic and experimental
pain. Pain 17:45-46.
55. Carroll D.A., A. Quantitative test of upper extremity function. J. Chroan Dis.
1965:18:479-491.
56. Hsieh CL, Hsueh IP, Chiang FM Lin PH. Inter rater reliability and validity
of the Action Research Arm Test in stroke patients. Age Ageing ,1998;
27:107-114.
47
Page 71
57. Van der Lee JH, De Groot V, Beckerman H, Wagenaar RC, Lank GJ, Bouter
LM. Int J. Rehabil Res. 1981; 4:483-492.
58. Kozin SH, Porter S, Clark P, Thoder JJ. J. Hand Surg [AM]. 1999 Jul;
24(4):870-1.
59. Lyle RC : A performance test for assessment of upperlimb function in
physical rehabilitation treatment and research. Int J Rehabil Res 1981:
4:483-492.
60. Wagennar RC, Meijer OG, Van Wieringer PCW, Kuik DJ, Hazenberg GJ,
Lindeboom J et al. The functional recovery of stroke:a comparison between
neuro-developmental treatment and the Brunstrom method. Scand J Rehabil
Med 1990:22;1-8.
48
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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 :
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BUILT OF THE PATIENT :
LOCAL OBSERVATION :
ON PALAPATION :
ON EXAMINATION
:
SENSORY EVALUATION :
SPECIFIC TESTS
:
EXAMINATION OF :
NEIGHBOUR JOINTS :
ANNEXURE -II
50
Accepted for the study
Rejected for the study
Page 75
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.
0 No movement possible
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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
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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 :
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ANNEXURE- III
TOOL FOR DATA COLLECTION
54
SUBJECTNUMBER
NAME AGE SEX DURATION SIDE BEFORE TRETMENT
AT THE END OF 1ST
WEEK
AT THE END OF 2ND
WEEK
AT THE END OF 3RD
WEEKVAS ARAT VAS ARAT VAS ARAT VAS ARAT