Physiotherapy Theory and Practice

An International Journal of Physical Therapy

ISSN: 0959-3985 (Print) 1532-5040 (Online) Journal homepage: http://www.tandfonline.com/loi/iptp20

The effectiveness of low-level laser therapy

on pain, self-reported hand function, and
grip strength compared to placebo or “sham”
treatment for adults with carpal tunnel syndrome:
A systematic review

Marlette Burger, Réna Kriel, Andrea Damon, Amy Abel, Anisha Bansda,
Marinique Wakens & Dawn Ernstzen

To cite this article: Marlette Burger, Réna Kriel, Andrea Damon, Amy Abel, Anisha Bansda,
Marinique Wakens & Dawn Ernstzen (2017): The effectiveness of low-level laser therapy on
pain, self-reported hand function, and grip strength compared to placebo or “sham” treatment for
adults with carpal tunnel syndrome: A systematic review, Physiotherapy Theory and Practice, DOI:
10.1080/09593985.2017.1282999

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Published online: 08 Mar 2017.

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PHYSIOTHERAPY THEORY AND PRACTICE
http://dx.doi.org/10.1080/09593985.2017.1282999

RESEARCH REPORT

The effectiveness of low-level laser therapy on pain, self-reported hand function,

and grip strength compared to placebo or “sham” treatment for adults with
carpal tunnel syndrome: A systematic review
Marlette Burgera, Réna Kriela, Andrea Damonb, Amy Abelc, Anisha Bansdad, Marinique Wakense,
and Dawn Ernstzena
a
Division of Physiotherapy, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa; bPhillo Beukes
Physiotherapy, Hunters Medical Services, Knysna, South Africa; cDepartment of Physiotherapy, Jacquie Kieck Physiotherapy, Port Alfred,
South Africa; dLinksfield Netcare Hospital and New Life Kensington Hospital, Johannesburg, South Africa; eDepartment of Physiotherapy, Prof
ZK Matthews Hospital, Barkly West, South Africa

ABSTRACT ARTICLE HISTORY

Background: Carpal tunnel syndrome (CTS) is one of the most common peripheral neuropathies Received 5 June 2015
in the upper extremity. Objective: The aim of this review was to systematically and critically Revised 20 January 2016
appraise the available literature for the effectiveness of Low-Level Laser Therapy (LLLT) on pain, Accepted 31 January 2016
self-reported hand function, and grip strength compared to placebo treatment in adults with CTS. KEYWORDS
Methodology: Seven databases were searched from 2000 to March 2015 namely: Cinahl, Low level laser therapy;
Cochrane Library, EBSCOhost, PEDro, PubMed, Science Direct, and Scopus. Key search terms were: carpal tunnel syndrome;
CTS, LLLT, and physiotherapy. Specific inclusion and exclusion criteria were applied. The metho- physiotherapy or physical
dological quality was appraised with the PEDro scale. Data were extracted and captured on an therapy; systematic review
Excel spreadsheet. Results: The nine included randomized control trials (RCTs) had an average
score of 8.2/11 according to the PEDro scale. The heterogeneity of the LLLT regimes used made
statistical pooling inappropriate for this review and results were described narratively.
Conclusion: No strong evidence exists concerning the effects of LLLT on CTS in adults. Studies
that used 780–860 nm Lasers and energy dosages of 9–11 J/cm2 or 10.8 J reported a more
favorable outcome for pain, symptom severity, and functional ability as well as grip strength at
the end of treatment and short-term follow up.

Introduction tunnel, by means of carpal tunnel release (Scholten et al,

2007). The indications for surgery include severe CTS and
Carpal Tunnel Syndrome (CTS) is the most common of
the failure to respond to conservative treatment (Scholten
all entrapment neuropathies and is caused by the com-
et al, 2007). Conservative treatment is generally consid-
pression of the median nerve in the carpal tunnel
ered a first option in treating mild to moderate cases of
(Tascioglu, Degirmenci, Ozkan, and Mehmetoglu,
CTS (Scholten et al, 2007). Conservative management for
2012). The elevated pressure on the median nerve
CTS includes wrist splinting, oral steroids, corticosteroid
leads to symptoms and signs of nerve dysfunction and
injections, ultrasound therapy, and low-level laser therapy
impaired nerve conduction (Werner and Andary,
(LLLT) (Gerritsen et al, 2002). Clinical and neurophysio-
2002). The typical symptoms of CTS include pain,
logic outcome measures used to determine the efficacy of
tingling, and numbness in the sensory distribution of
therapy include patient’s pain and symptom severity
the median nerve path (Abid Ali, Ja’afar, and Hasan,
scales, functional status scales, objective grip strength
2012) and muscle weakness or atrophy of the muscles
measurement by means of a dynamometer, sensory and
in the hand innervated by the median nerve (Moore,
motor nerve conduction measurements and ultrasono-
Dalley, and Agur, 2010). CTS is associated with repeti-
graphical assessments (Abid Ali, Ja’afar, and Hasan,
tive strain injuries, inflammatory, or metabolic diseases
2012; Tascioglu, Degirmenci, Ozkan, and Mehmetoglu,
and pregnancy (Evcik et al, 2007).
2012).
Management for CTS entails a wide range of options,
LLLT is a conservative management option for
both conservative and surgical. Evidence supports the
CTS, commonly used by physiotherapists (Herpich
effectiveness of surgical decompression of the carpal
et al, 2015), yet its effectiveness for CTS has not yet

CONTACT Marlette Burger mbu@sun.ac.za Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town 8000, South Africa

© 2017 Taylor & Francis

2 M. BURGER ET AL.
been confirmed. LLLT has been used to stimulate
wound healing by increasing collagen synthesis and
is effective in reducing edema formation and inflam-
matory in animal studies (Albertini et al, 2007;
Medrado, Pugliese, Reis, and Andrade, 2003).
LLLT’s physiological effect on altering the function
or stimulating the regeneration of peripheral nerves is
still unclear (Irvine, Chong, Amirjani, and Ming
Chan, 2004; Tascioglu, Degirmenci, Ozkan, and
Mehmetoglu, 2012). LLLT was found to be effective
in treating CTS by reducing pain, improving self-
reported hand functionality, and improved motor
and sensory nerve conduction in four randomized
control trials (RCTs) (Abid Ali, Ja’afar, and Hasan,
2012; Chang, Jiang, Yeh, and Tsai, 2008; Jiang et al,
2011; Shooshtari et al, 2008). However, these findings
were contradicted by Tascioglu, Degirmenci, Ozkan,
and Mehmetoglu (2012) and Irvine, Chong, Amirjani,
and Ming Chan (2004), who found that LLLT was not
more effective than placebo laser. Evcik et al. (2007)
reported that LLLT was effective for improving grip
strength. In order to optimize the quality of care for
patients with CTS, a critical review of the body of
evidence regarding the effectiveness of LLLT is
needed to support the development of evidence-
based treatment protocols and clinical guidelines.
The primary objective of this systematic review was
thus to review the available evidence on the effective-
ness of LLLT compared to placebo or “sham” treatment
in the management of adults with CTS with regard to
pain, hand function, and grip strength. The secondary
objective of this systematic review was to determine the
optimal treatment techniques and dosages (intensity
and duration) for LLLT in treating adults with CTS.
Methodology
Search strategy
A total of seven electronic databases, available through
the (Stellenbosch) University Library, were searched,
namely CINAHL, Cochrane Library, EBSCOhost,
PEDro, PubMed, Science Direct, and Scopus. The key
search terms used were: carpal tunnel syndrome, laser
AND/OR low level laser, physical therapy AND/OR
physiotherapy. Each database was searched indepen-
dently by two investigators. Based on the inclusion
and exclusion criteria below, five investigators indepen-
dently reviewed the titles, abstracts, and full text articles
retrieved in the initial search. The researchers com-
pared the eligible articles selected for inclusion and
disagreements for accepting full-text articles were dis-
cussed until consensus was achieved. The final
decisions regarding the inclusion of articles were
based on agreement among the seven investigators.
Study inclusion and exclusion criteria
Type of study
Only RCTs published in English from January 2000
until March 2015 were eligible for inclusion in this
review. According to the National Health and Medical
Research Council (NHMRC) Hierarchy of evidence
(Merlin, Weston, and Tooher, 2009), a well conducted
RCT, as level II evidence, is appropriate for the purpose
of answering an intervention question in a systematic
review. Levels III-2, 3, and IV are progressively less
reliable in answering an intervention effectiveness ques-
tion. The quality of the RCTs was used as an additional
criterion. Therefore, RCTs with a low methodological
score (below 4/11 on the PEDro scale) were excluded
from the final review.
Type of patients
Study patients could include adults (> 18 years), male
and/or females with a clinical diagnosis of CTS. RCTs
including patients with CTS caused by traumatic injury
were excluded. The types of interventions had to
include LLLT compared to placebo or “sham” therapy.
Studies that included additional interventions were
considered if both the experimental and control groups
received the interventions. Examples of such additional
interventions include: night splinting, patient educa-
tion, home and work advice on activities and risk
factors for CTS. RCTs including surgical carpal tunnel
release or corticosteroid injections or other electrother-
apy modalities (e.g. ultrasound) as part of their inter-
vention were excluded. The comparator to LLLT could
include placebo or “sham” treatment.
Type of outcomes
RCTs had to assess at least one the following four
clinical outcomes, namely pain, symptom severity,
hand function, and grip strength. The outcome mea-
sures that studies could utilize included, but were not
confined to: Visual Analog Scale (VAS) (Gallagher,
Liebman, and Bijur, 2001) or any other validated scale
for measurement of pain intensity, self-reported symp-
tom and function questionnaire/s, isometric pinch
strength and hand grip strength measured by a
dynamometer.
Methodological appraisal
The PEDro scale was used to determine the methodo-
logical quality and potential sources of bias of the
 PHYSIOTHERAPY THEORY AND PRACTICE 3

included studies. The PEDro scale is a valid measure of
the methodological quality of clinical trials and is
widely used in physiotherapy research (De Morton,
2009). The scale consists of eleven criteria of which
criteria 1–8 measure the internal validity, criteria 9–10
measure the statistical reporting score and criterion 11
measures the external validity. The eligible articles were
scored independently by two investigators. If a discre-
pancy in final scores existed, the rest of the research
group was consulted to reach consensus.
Data extraction and analysis method
The data were extracted and captured on a Microsoft
Excel spreadsheet by one investigator to ensure conti-
nuity. The information was cross-checked by the rest of
the team. All data were tabulated into the following
categories: citation, type of study, patients (including
number of patients and ages), type of intervention,
comparisons, outcome measures (including measure-
ment tool, validity, and reliability), dichotomous data
(intervention and comparison group), continuous data
(intervention and comparison group), clinical status,
and implication.
Due to the heterogeneity of the intervention used
(different types of lasers and dose regimens) in the
included studies, statistical pooling of data was not
appropriate for this review. Results were subsequently
summarized in the narrative form.
Results
Selection of articles
The results of the search strategy are presented in a
flow chart (Figure 1). A total of 487 initial titles were

Accepted titles or Duplicates among

Database / other sources Initial hits
abstracts databases
CINAHL 29 1
IDENTIFICATION

Cochrane library 38 5
Ebsco Host 17 5
PEDro 30 6
Pubmed 103 7 21
Science Direct 106 2
Scopus 164 4
Hand searches N/A 1
Total of records identified 487 31
SCREENING

Excluded titles and abstracts (Articles were excluded due

to irrelevant titles and animal studies) n = 456

Included titles and abstracts

n = 31

Excluded duplicate titles

ELIGIBILITY

n = 21

Full text eligible articles retrieved

n = 10

Excluded full text articles not meeting inclusion

criteria
n=1
Reason: comparison did not include sham LLLLT
INCLUDED

Studies included
n=9

Figure 1. Results of database searches.

4 M. BURGER ET AL.
found. Of these, 31 abstracts were reviewed and after
eliminating duplicates, nine full-text articles were sub-
sequently considered eligible for use in this systematic
review.
Evidence hierarchy and methodological appraisal
A total of nine articles were included: 1) Abid Ali,
Ja’afar, and Hasan, 2012; 2) Chang, Jiang, Yeh, and
Tsai, 2008; 3) Evcik et al, 2007; 4) Fusakul,
Aranyavalai, Saensri, and Thiengwittayaporn, 2014; 5)
Irvine, Chong, Amirjani, and Ming Chan (2004); 6)
Jiang et al, 2011; 7) Lazovic et al, 2014; 8) Shooshtari
et al, 2008; and 9) Tascioglu, Degirmenci, Ozkan, and
Mehmetoglu, 2012. All nine articles were classified as
Level II according to the NHMRC Hierarchy of
Evidence. The methodological quality of the nine
included articles, according to the PEDro scale, ranged
between 6/10 and 10/10, with an average score of 8.2/10
Table 1).
Description of studies
As indicated by Table 1, the included studies compared
LLLT with a placebo and/or with a control group.
Tascioglu, Degirmenci, Ozkan, and Mehmetoglu
(2012) and Jiang et al. (2011) both had two intervention
groups. Tascioglu, Degirmenci, Ozkan, and
Mehmetoglu (2012) administered a different energy
dosage in the A and B laser groups. Jiang et al. (2011)
subdivided the patients into either mild or moderate
CTS. The mean ages between intervention and control
groups were comparable and ranged between 43 and
52.6 years. The female to male ratio’s differed for all
articles; more females than males participated. Chang,
Jiang, Yeh, and Tsai (2008) and Jiang et al. (2011) did
not specify the patients’ gender. The total sample for
the LLLT and control groups captured in the nine
studies was 614.
Description of intervention
Table 2 summarizes the laser settings, dosages and
treatment intervals that were used for the different
trials. The number of treatment sessions ranged
between 10 to 20 sessions. Except for Irvine, Chong,
Amirjani, and Ming Chan (2004) and Fusakul,
Aranyavalai, Saensri, and Thiengwittayaporn (2014)
who had 3 weekly sessions for 5 weeks, all other studies
used once daily sessions five times per week for either 2
or 3 weeks. The duration of treatment ranged from 10
to 15 minutes per session. Irvine, Chong, Amirjani, and
Ming Chan (2012) used a much shorter treatment
duration of 15 seconds and Evcik et al. (2007) and
Shooshtari et al. (2008) did not specify their treatment
duration. Chang, Jiang, Yeh, and Tsai (2008) and Jiang
et al. (2011) used the exact same laser type and settings.
The other seven studies all used different settings as
indicated in Table 2. Abid Ali, Ja’afar, and Hasan
(2012) did not indicate the energy dosage (J/cm2) that
they have applied. The studies applied the LLLT over
the carpal tunnel area and/or followed the median
nerve path (Table 2).
All control groups in the articles reviewed, received
sham laser treatment over the matching areas as the
intervention groups. Evcik et al. (2007) also reported
that night splints were used for two weeks by the
intervention and placebo laser groups, while Fusakul,
Aranyavalai, Saensri, and Thiengwittayaporn (2014)
encouraged intervention and placebo laser groups to
use neutral wrist splints for 12 weeks during the night
as well as during the daytime.
Description of outcome measures
All studies measured and reported outcomes at base-
line. The studies had different re-assessment intervals
for the outcomes, ranging from 2 weeks to 12 weeks.
Evcik et al. (2007) and Fusakul, Aranyavalai, Saensri,
and Thiengwittayaporn (2014) retested at 12 weeks and
were the only studies to report on long-term outcome
(10 weeks and seven weeks respectively after the end of
the last treatment session). Evcik et al. (2007) only
retested grip strength at 4 weeks (2 weeks after the
end of the treatment period). Shoostari et al. (2008)
and Tascioglu, Degirmenci, Ozkan, and Mehmetoglu
(2012) re-assessed at the end of the treatment period
(at 3 weeks), but did not conduct a follow-up
assessment.
The outcome measures used in the nine articles of
this review are categorized into four main groups: 1)
Pain; 2) Symptom Severity Score; 3) Self-reported Hand
Function; and 4) Grip Strength. Pain, using the VAS,
was measured in all studies except Irvine, Chong,
Amirjani, and Ming Chan (2004). The Levine question-
naire was most commonly used to test symptom sever-
ity and functional status (Chang, Jiang, Yeh, and Tsai,
2008; Evcik et al, 2007; Irvine, Chong, Amirjani, and
Ming Chan, 2004; Tascioglu, Degirmenci, Ozkan, and
Mehmetoglu, 2012). Jiang et al. (2011) and Fusakul,
Aranyavalai, Saensri, and Thiengwittayaporn (2014)
used the Boston Questionnaire to assess symptom
severity and functional status. Abid Ali, Ja’afar, and
Hasan (2012) did not specify the questionnaire used
while Shooshtari et al. (2008) and Lazovic et al. (2014)
Table 1. Study sample description.
Shooshtari et al Tascioglu et al Fusakul et al Lazovic et al
Irvine et al (2004) Evcik et al (2007) Chang et al (2008) (2008) Jiang et al (2011) Abid Ali et al (2012) (2012) (2014) (2014)
Inclusion Criteria Numbness & CTS diagnosis by Diagnosed with CTS
Electro diagnostic Idiopathic CTS Idiopathic CTS CTS diagnoses CTS diagnosis by CTS diagnosis by
tingling in Median clinical First onset of CTS
evidence of diagnoses. diagnoses confirmed with clinical clinical
Nerve distribution. examination and more than a year prior
Median Nerve Nerve conduction sensory and examination and examination (pain,
Nocturnal electromyography to the start of the
compression studies. motor Median electro paraesthesia,
symptoms study with repeated
Paraesthesia and nerve diagnosis. numbness,
Weakness of thumb episodes numbness conduction tingling, + Tinel’s
abduction. Excessive hand studies sign)
Electrophysiological sweating or Electromyography
evidence of Median coldness + Tinel’s and Median Nerve
Nerve compression sign or Phalen test Conduction
Nocturnal studies
symptoms
Exclusion Criteria Evidence of axonal Trauma to wrist/ Previous wrist surgery Trauma to wrist/ Rheumatoid arthritis Did not specify CTS symptoms Metabolic Did not specify
loss. Arthritis arm Cervical Previous laser arm or neck Metabolic disorders longer than 6 disorders
Trauma to wrist/arm radiculopathy treatment for CTS Metabolic Previous wrist surgery months
Previous Carpal Thoracic Outlet Rheumatoid Arthritis disorders Other concurrent Previous wrist Pregnancy
tunnel release Syndrome Metabolic disorders Pregnancy treatments e.g. anti- surgery
Neurologic, Paralysis due to stroke Previous carpal inflammatory Carpal bone Previous distal
cognitive, tunnel release medication, physical fractures radial fracture.
inflammatory and Carpal bone therapy, acupuncture Proximal Wrist/hand
tumoral disorders fractures Median deformities
neuropathy Inflammation
of wrist
Cervical Rheumatoid
Radiculopathy Arthritis
Polyneuropathy Cervical
Radiculopathy
Brachial Polyneuropathy
plexopathy,
Thoracic Outlet Proximal
Syndrome Median
neuropathy
Rheumatoid Ulnar
Arthritis neuropathy
Metabolic Carpal tunnel
disorders release
Pregnancy
Acromegaly
Physical
Therapy prior
to study.
Participants LLLT n=7 n = 41, 72 wrists n = 20 n = 40 n(mild) = 27 n = 30 n(A) = 20 n = 56 wrists N = 40, 61 wrists
n(mod) = 18 n(B) = 20
Placebo n = 8 n = 40, 69 wrists n = 20 n = 40 n(mild) = 27 n = 30 n = 20 n = 56 wrists N = 39, 59 wrists
n(mod) = 15
Control n = 30
PHYSIOTHERAPY THEORY AND PRACTICE

(Continued )
5
 6
M. BURGER ET AL.

Table 1. (Continued).
Shooshtari et al Tascioglu et al Fusakul et al Lazovic et al
Irvine et al (2004) Evcik et al (2007) Chang et al (2008) (2008) Jiang et al (2011) Abid Ali et al (2012) (2012) (2014) (2014)
Age of LLLT 43 ± 4 47.7 ± 10.0 (28– 46.01 ± 11.65 48.12 ± 10.73 (30– (mild) 46.44 ± 10.12 45 ± 5.6 (A) 47.25 ± 50.7 ±1.39 50.5 ± 10.1
Participants 75) 70) 7.35
[mean ± SD (mod) 48.76 ± 14.57 (B) 45.80 ±
(age range)] 8.61
Placebo 50 ± 4 51.0 ± 11.8 (26– 49.07 ± 11.28 (mild) 51.10 ± 12.19 50.90 ± 9.11 50.79 ± 1.38 52.6 ± 11.6
76) (mod) 44.60 ± 9.60
Control 73/7 43.7 ± 3.7
Gender (F/M) LLLT 6/1 33/8 33/27 (A) 17/13 54/2 36/4
(B) 14/6
Placebo 6/2 37/3 15/5 54/2 34/5
PEDro Scores 10/10 8/10 8/10 6/10 8/10 7/10 8/10 9/10 10/10
Statistical significant No significant No significant Laser group showed Did not provide Laser group showed a Laser group showed No significant Laser group Laser group
main findings for Pain, difference in any of difference in any significant reduction in between group significant reduction in significant reduction in difference in showed a showed a
SSS, FSS, Grip Strength as the outcome of the outcome Pain, FSS, SSS, Hand statistical analysis Pain compared to Pain, FSS and SSS any of the significant significant
reported by the authors measures between measures Grip Strength and for the Laser and placebo group at end of compared to Placebo outcome reduction in the reduction in Pain
the Laser and the between the Pinch Grip Strength Placebo groups. treatment, but only the group at end of measures SSS compared to compared to
Placebo groups. Laser and the compared to Placebo mild group showed a treatment and at between the Placebo group at Placebo group at 8
Placebo groups. group at follow-up. significant reduction in follow up. Laser and the end of weeks follow up.
pain at follow up. Only Placebo treatment.
the mild CTS patients in groups.
the Laser group showed
significant reduction in
SSS compared to
Placebo group at end of
treatment.
Country of Origin Canada Turkey Taiwan Iran Taiwan Baghdad Turkey Thailand Serbia
SSS = Symptom Severity Scale; FSS = Functional Status Score; LLLT = Low-level laser therapy
Table 2. Treatment specifications.
Irvine et al Shooshtari Abid Ali et al Tascioglu et al (2012) Lazovic et al
(2004) Evcik et al (2007) Chang et al (2008) et al (2008) Jiang et al (2011) (2012) A B Fusakul et al (2014) (2014)
Energy dosage 6J/cm2 14J (7J/point) 9.7J/cm2 9–11J/cm2 9.7J/cm2 6J (3 J/ 3J (1.5 J/ 18J 10.8 J; 13.6 J/cm2
point) point)
Laser type Eriel TOP 250 GaAlAs PL-830 PL-830 Galium-Arsenide GaAlAs GaAlAs GaAlAs GaAlAs
GaAlAs
Wavelength (nm) 860 830 830 785 830 904 830 830 810 780
Power output (mW) 60 450 60(2x30) 400 60(2x30) 15 50 50 50 30
Laser probe diameter 1cm beam = beam =
1mm 1mm
Beam Single Single Double Single Double Single Single Single Single
Mode pulsed pulsed pulsed continuous continuous continuous continuous
Frequency (Hz) 1000 10 4672 & 10 5000
1168
Points 20 2 15 5 5 4
Sessions 15 10 10 15 10 10 15 15 15 20
Time per session (min) 15 sec 10 10 15 10 5 360sec 360sec
Accumulated dosage 140J 90J 45J 270J 216J
Frequency of 5 (3 times per 2 (5 times per 2 (5 times per week) 3 (5 times 2 (5 times per week) 2 (5 times per 3 (5 times 3 (5 times 5 (3 times per week)5 (5x/week for 2
intervention per week) week) per week) week) per week) per week) weeks; 3x/week
week for 3 weeks)
Treatment location/ A total of 20 Over the carpal Directly over the Over the Palm side of wrist Directly along Across the Across the Across the median Directly on the
area sites over and tunnel area at the transverse carpal carpal between pisiform and median nerve median median nerve path over the skin, at four
surrounding wrist - directly and ligament. Did not tunnel area navicular bones. Did path over the nerve path nerve path wrist. 10 cm away points
the carpal perpendicularly on follow the median at the not follow the median transverse carpal over the over the from the skin parallel perpendicularly
tunnel. the skin. nerve path. wrist. nerve path. ligament. wrist. wrist. to the distal crease of over the carpal
the wrist (5 cm below tunnel area.
and above the distal
crease) over the
median nerve.
*Grey blocks indicate missing information
PHYSIOTHERAPY THEORY AND PRACTICE
7
8 M. BURGER ET AL.

Table 3. Mean change from baseline and P-values for Pain.

Pain
12wks F/U Mean
Baseline EOT Mean change EOT within F/U Mean change change from 12wks F/U
mean on from baseline on same group from baseline on F/U P baseline on VAS within same
VAS (mm) VAS (mm) P Value VAS (mm) Value (mm) group P value
Shooshtari LLLT 78.0 −28.2 p < 0.001
et al Placebo 80.1 −3.9 p < 0.001
(2008)
Jiang et al Mild LLLT 50.7 −27.6
(2011) Placebo 51.6 -0.5
LLLT p < 0.001
versus
Placebo
Mode-rate LLLT 79.1 −31.7
Placebo 71.0 −20.1
LLLT p < 0.01
versus
Placebo
Abid Ali et LLLT 71.0 −45.5 p < 0.01 −50.4 p < 0.01
al (2012) Placebo 58.3 +5.3 p = 0.08 +18.7 p = 0.05
LLLT versus Placebo p < 0.001 p < 0.001
Tascioglu LLLT A 63.5 −23.0 p < 0.001
et al LLLT B 55.0 −17.0 p < 0.001
(2012) Placebo 54.0 −8.5 p < 0.01
Fusakul et LLLT 62.6 −20.1 p < 0.05 −28.1 p < 0.05
al (2014) Placebo 48.3 −16.8 p < 0.05 −23.5 p < 0.05
LLLT versus Placebo p = 0.243 p = 0.433
*Grey blocks indicate missing information; LLLT = Low-level laser therapy; VAS = Visual Analog Scale; EOT = End of Treatment; mm = millimeters; F/U =
Follow Up

did not measure self-reported symptom severity and
function status.
Hand grip strength was tested in five of the articles
(Chang, Jiang, Yeh, and Tsai, 2008; Evcik et al, 2007;
Fusakul, Aranyavalai, Saensri, and Thiengwittayaporn,
2014; Shooshtari et al, 2008; Tascioglu, Degirmenci,
Ozkan, and Mehmetoglu, 2012), while three articles
tested pinch grip strength (Chang et al, 2008; Evcik
et al, 2007; Fusakul, Aranyavalai, Saensri, and
Thiengwittayaporn, 2014). Chang, Jiang, Yeh, and
Tsai (2008) tested both digital prehension and lateral
prehension of pinch grip strength.
and placebo treatment for pain at the end of the treat-
ment period. Tascioglu, Degirmenci, Ozkan, and
Mehmetoglu (2012) and Shooshtari et al. (2008)
reported significant improvement in both the LLLT
and placebo groups at end of treatment. Jiang et al.
(2011) reported significant differences between LLLT
and placebo for both mild and moderate groups at
cessation of treatment in favor of the LLLT group.
Abid Ali, Ja’afar, and Hasan (2012) reported a signifi-
cant pain reduction in the LLLT group at cessation of
treatment which persisted at 2-week follow-up in com-
parison to the placebo group.

Effectiveness Immediate and intermediate effectiveness reported

The effectiveness of LLLT compared to sham laser
(control group) for treatment of adults with CTS is
categorized into four main groups, namely, Pain,
Symptom Severity Score, Functional status Score, and
Strength Measures. Please note that only the results of
the studies that reported before (baseline) and after
treatment values (e.g. mean, mean change and mea-
sures of variability – standard deviation (SD) for the
different variables were tabulated in Tables 3, 4, and 5.
Immediate and intermediate effectiveness reported
for pain
Fusakul, Aranyavalai, Saensri, and Thiengwittayaporn
(2014) reported no significant difference between LLLT
for symptom severity score, self-reported hand
function, and grip strength
Symptom Severity Score (SSS). Chang, Jiang, Yeh, and
Tsai (2008) reported no significant difference between
LLLT and placebo for SSS at end of treatment, but a
significant difference was reported at 2-week follow-up
(p = 0.006). Jiang et al. (2011) reported significant
difference between LLLT and placebo for only the
mild group at end of treatment (p < 0.001). Abid Ali,
Ja’afar, and Hasan (2012) reported a significant
improvement (p < 0.001) in LLLT treatment for the
SSS compared to the placebo treatment. Tascioglu,
Degirmenci, Ozkan, and Mehmetoglu (2012) found
no significant differences among the groups at the
end of treatment, while Fusakul, Aranyavalai, Saensri,
Table 4. Means, Standard Deviations (SD) and P-values for symptom severity score and functional status score.
Symptom Severity Score Functional Status Score
Baseline Baseline
Score EOT within F/U within 12wks F/ 12wks F/U Score EOT within F/U within 12wks F/ 12wks F/U
[mean & EOT [mean same group F/U [mean same group U [mean within same [mean & EOT [mean same group F/U [mean same group U [mean within same
SD] & SD] P Value & SD] P Value & SD] group P value SD] & SD] P Value & SD] P Value & SD] group P value
Irvine et al LLLT 81±9 85±11 p = 0.043
(2004)# Placebo 72±8 77±10 p = 0.034
Chang et al LLLT 30.80±0.75 21.67±0.58 19.35±0.63 18.72±0.84 13.11±0.63 11.04±0.43
(2008)# Placebo 27.51±0.5 25.53±0.62 28.71±0.85 18.72±0.68 17.04±0.70 19.60±1.02
LLLT versus p = 0.226 p = 0.138 p = 0.006 p = 0.997 p = 0.121 p < 0.05
Placebo P Value
Jiang et al Mild LLLT 2.68±0.68 1.9 ± *
(2011)‡ group Placebo 2.50±0.52 2.42 ± *
LLLT p < 0.001
versus
Placebo P
Value
Mode- LLLT 2.89±0.90 1.98 ± *
rate Placebo 2.49±0.43 2.44 ± *
group LLLT p>0.05
versus
Placebo P
Value
Abid Ali et al LLLT 35.9±5.2 23.8±3.7 p < 0.01 21.8 ± 2.8 p < 0.01 24.2±8.1 19.7±7.5 p = 0.07 18.8±8 p = 0.08
(2012)° Placebo 36.6±5 36.9±5 p=1 37.2 ± 4.4 p = 0.9 27.7±3.6 27±4 p = 0.9 28.5±3.5 p = 0.8
LLLT versus p < 0.001 p < 0.001 p < 0.001 p < 0.001
Placebo
P Value
Tascioglu et LLLT A 23.8±7.53 19.05±8.71 p < 0.001 19.20±6.57 14.60±5.73 p < 0.001
al (2012)# LLLT B 23.4±6.46 17.70±4.68 p < 0.001 16.25±5.78 12.85±3.54 p < 0.001
Placebo 24.65±7.22 20.40±8.4 p < 0.01 17.25±4.89 14.65±6.31 p < 0.05
Fusakul et al LLLT 2.10±0.68 1.68±0.66 p < 0.05 1.49±0.58 p < 0.05 2.07±0.67 1.75±0.62 p < 0.05 1.53±0.57 p < 0.05
(2014) ‡ Placebo 1.68±0.56 1.43±0.49 p < 0.05 1.35±0.51 p < 0.05 1.77±0.62 1.54±0.62 p < 0.05 1.37±0.49 p < 0.05
LLLT versus p = 0.291 p<0.05 p = 0.886 p = 0.712 p = 0.406 p = 0.313
Placebo
P Value
* SD for mean at EOT not provided.; Grey blocks indicate missing information; LLLT = Low-level laser therapy; VAS = Visual Analog Scale; EOT = End of Treatment; F/U = Follow Up; ‡ = Used the Boston Questionnaire; # = Used the
Levine Questionnaire; ° = did not indicate which questionnaire they have used
PHYSIOTHERAPY THEORY AND PRACTICE
9
 10
M. BURGER ET AL.

Table 5. Means, Standard Deviations (SD) and P-values for hand and pinch grip strength.
Hand Grip Strength Pinch Grip Strength
12wks F/U
Baseline 12wks F/ within
Baseline EOT within F/U within 12wks F/U 12wks F/U Score EOT EOT within F/U F/U within U same
Score [mean EOT [mean same group F/U [mean same group [mean & within same [mean & [mean & same group [mean & same group [mean & group
& SD] & SD] P Value & SD] P Value SD] group P value SD] SD] P Value SD] P Value SD] P value
Evcik et al LLLT 19.4 ± 6.3 22.4±6.7 p<0.01 22.8 ± 6.9 p = 0.005 4.4±1.5 5.2±1.5 p<0.001 5.7±1.6 p<0.001
(2007)*
Placebo 18.0 ± 7.3 19.7±6.5 p>0.05 19.6 ± 7.3 p>0.05 4.1±1.3 4.6±1.5 p<0.01 4.8 ± 1.5 p = 0.03
Chang et al LLLT 17.77 ± 4.37 19.71±4.67 21.19±4.12 4.33±1.37 4.95±1.30 5.20±0.83
(2008)*
Placebo 18.34 ± 5.17 18.26±4.55 17.38±3.56 4.69±1.2 4.7±1.17 4.43±1.06
LLLT versus p = 0.748 p = 0.415 p<0.05 p = 0.466 p = 0.583 p<0.05
Placebo P
Value
Shooshtari LLLT 19.81 ± 5.6 22.86±5.3 p<0.001
et al
(2008)*
Placebo 21.46 ± 6.23 21.52 ±6.05 p = 0.801
Tascioglu LLLT A 47.25 ± 14.37 52.25±10.82 p<0.05
et al
(2012)#
LLLT B 53.25 ± 20.21 58.75±17.54 p<0.05
Placebo 49.25 ± 13.79 53.85±16.34 p<0.05
Fusakul et al LLLT 21.22±1.25 22.65±1.17 p<0.05 24.49±1.15 p<0.05 4.29±0.42 8.0±3.56 p<0.05 5.40±0.28 p<0.05
(2014)#
Placebo 22.56±1.07 23.2±0.99 p>0.05 23.60±1.0 p>0.05 4.21±0.27 4.65±0.30 p>0.05 5.47±0.31 p<0.05
LLLT versus
Placebo
P Value p = 0.414 p = 0.313 p = 0.554 p = 0.169 p = 0.112 p = 0.806
Grey blocks indicate missing information; LLLT = Low-level laser therapy; VAS = Visual Analog Scale; EOT = End of Treatment; F/U = Follow Up; # = measurements in pounds; * = measurement in kilograms
 PHYSIOTHERAPY THEORY AND PRACTICE 11

and Thiengwittayaporn (2014) reported a significant Discussion

improvement (p < 0.05) in favor of the LLLT group at
This is the first systematic review on the effectiveness of
end of treatment.
LLLT alone, utilizing different dosages and treatment
methods, compared to placebo or sham treatment for
Functional Status Score (FSS). Abid Ali, Ja’afar, and
adults with CTS. The nine RCT’s that qualified for this
Hasan (2012) was the only study that found a signifi-
systematic review were classified as evidence Level II
cant improvement in favor of the LLLT group for both
according to the NHMRC and were all of high metho-
end of treatment (p < 0.001) and follow up assessment
dological quality, scoring an average of 8.2/10 on the
(p < 0.001).
PEDro scale. LLLT has been clinically applied to a
Chang, Jiang, Yeh, and Tsai (2008) reported no sig-
variety of disorders and is widely used for its unique
nificant difference between the two groups at end of
advantages in analgesia and lack of adverse effects
treatment; however, they found a significant difference
(Rola, Doroszko, and Derkacz, 2013). The mechanisms
in favor of LLLT at 2-week follow-up (p < 0.05) All
for analgesic effects of LLLT are, however, poorly
other included studies measuring FSS (Fusakul,
understood and several different biochemical mechan-
Aranyavalai, Saensri, and Thiengwittayaporn, 2014;
isms have been proposed (Bjordal et al, 2006; Chow
Irvine, Chong, Amirjani, and Ming Chan, 2004;
et al, 2011; Falaki, Nejat, and Dalirsani 2014). One of
Tascioglu, Degirmenci, Ozkan, and Mehmetoglu,
the most frequently used, and sensitive pain rating
2012) found no significant differences between LLLT
scales is the 100mm VAS (Gallagher, Liebman, and
and placebo groups.
Bijur, 2001) and eight of the included studies utilized
the VAS to determine the effect of LLLT. The VAS
Grip strength. At 2-week post cessation of treatment
allows the measurement of small numeric changes in
Evcik et al. (2007) reported significant improvement in
pain severity which can equate to statistical significant
both hand (p < 0.01) and pinch grip (p < 0.001)
changes in pain scores (Bird and Dickson, 2001), parti-
strength for LLLT and a significant improvement in
cularly in larger sample sizes (Salaffi et al, 2004).
pinch grip strength (p < 0.01) for the placebo group
Statistical significant changes in pain scores on the
compared to baseline. Chang, Jiang, Yeh, and Tsai
VAS however, may not imply that the patient will
(2008) reported no significant difference between
experience a clinical significant change in pain intensity
LLLT and placebo groups at the end of treatment for
(Salaffi et al, 2004). None of the included studies deter-
digital prehension (lateral prehension was not tabu-
mined a predefined minimal clinical important differ-
lated); however, a significant difference was reported
ence on the VAS for their study patients. Todd, Funk,
in favor of the LLLT group at 2-week follow-up for
Funk, and Bonacci (1996) were the first to determine
hand grip strength (p < 0.05). Shooshtari et al. (2008)
that a mean difference of 13 mm (95% confidence
reported significant improvement in hand grip strength
interval, 10–17 mm) measured with a 100 mm VAS,
in only the LLLT group (p < 0.001) at cessation of
indicates a clinically significant change in patient pain
treatment comparing to baseline. Tascioglu,
severity. Clinical significant changes in pain are how-
Degirmenci, Ozkan, and Mehmetoglu (2012) reported
ever not uniform along the VAS spectrum. Bird and
a significant improvement in all three groups at the end
Dickson (2001) found that for initial pain scores of
of treatment compared to baseline, but found no sig-
67–100 mm a mean minimum difference of 28 ±
nificant difference between the groups. Fusakul,
21mm was needed for a clinical significant change,
Aranyavalai, Saensri, and Thiengwittayaporn (2014)
indicating that patients with a higher level of pain
reported no significant differences between the LLLT
(≥67 mm) would require a greater absolute change in
and placebo groups at the end of treatment for both
VAS score to experience clinical pain relief. Patients
pinch grip and hand grip strength.
with a mean VAS score between 34–66 mm displayed a
minimal clinical significant change in pain of 17 ±
Long-term effectiveness reported for pain, symptom
10 mm, while in the patients with a VAS score of less
severity score, functional status score, and grip
than 34 mm was the mean clinical significant change
strength
similar to Todd, Funk, Funk, and Bonacci (1996),
Evcik et al. (2007) and Fusakul, Aranyavalai, Saensri,
namely 13 mm.
and Thiengwittayaporn (2014) reported no significant
Five of the included studies (Abid Ali, Ja’afar, and
differences at 12 weeks between the LLLT and the
Hasan, 2012; Fusakul, Aranyavalai, Saensri, and
placebo groups for pain, symptom severity score, self-
Thiengwittayaporn, 2014; Jiang et al, 2011; Shooshtari
reported hand function and grip strength (Tables 3, 4,
et al, 2008; Tascioglu, Degirmenci, Ozkan, and
and 5).
12 M. BURGER ET AL.
Mehmetoglu, 2012) provided mean scores for baseline
and follow-up assessment of pain on the VAS (Table 3).
Shooshtari et al. (2008) indicated that the baseline
values for pain in both the LLLT and placebo groups
were ≥67 mm. Although both groups had a significant
reduction in pain (p < 0.001), the mean reduction in
the LLLT group was 28.2.mm, while the mean reduc-
tion in the placebo was only 3.9 mm (Table 3). VAS
score baseline values for pain in the moderate LLLT
and placebo groups in Jiang et al. (2011) were ≥ 67 mm.
There was a significant reduction in pain by the end of
treatment in favor of the moderate LLLT group (p <
0.01) and although both groups displayed considerable
reduction in pain (LLLT group: –31.7 mm; placebo
group: –20.1 mm), pain reduction was only clinical
significant in the LLLT group. The mean baseline
VAS score value for the LLLT group in Abid Ali,
Ja’afar, and Hasan (2012) was ≥ 67 mm and the
group displayed a significant reduction in pain (p <
0.01) with a mean clinical significant change of –
45.5 mm at the end of treatment and –50.4 mm at
follow-up. Both the mean baseline values for VAS for
the LLLT and placebo groups in Tascioglu, Degirmenci,
Ozkan, and Mehmetoglu (2012) and Fusakul,
Aranyavalai, Saensri, and Thiengwittayaporn (2014)
were between 34–66 mm. Although both the LLLT
groups (A and B) and the placebo group in Tascioglu,
Degirmenci, Ozkan, and Mehmetoglu (2012) had a
significant reduction in pain compared to baseline (p
< 0.001 and p < 0.01 respectively); only the LLLT
groups A and B showed a clinical significant mean
change in pain (–23 mm and –17 mm, respectively).
Similarly, Fusakul, Aranyavalai, Saensri, and
Thiengwittayaporn (2014) reported no difference in
pain VAS scores between the LLLT and placebo groups
at the end of treatment (p = 0.243); however, only the
LLLT group displayed a clinical significant change of –
20.1mm. Overall, the included RCTs’ conclusions
regarding the effect of LLLT on pain were misleading
and did not reflect the clinical significant improve-
ments or effect sizes for the LLLT groups.
It is interesting to note that during the 12-week
follow-up assessment of pain the placebo group in
Fusakul, Aranyavalai, Saensri, and Thiengwittayaporn
(2014) also demonstrated a clinical significant decrease
in pain compared to baseline measurements (–23.5 mm).
Although the results showed a mixture of statistical
significant and non-significant effectiveness for LLLT
on pain, there was a trend of clinical significant
improvements in the LLLT groups at the end of treat-
ment and short-term follow-up when taking the mean
reduction in the VAS into account. The five included
studies (Abid Ali, Ja’afar, and Hasan, 2012; Fusakul,
Aranyavalai, Saensri, and Thiengwittayaporn, 2014;
Jiang et al, 2011; Shooshtari et al, 2008; Tascioglu,
Degirmenci, Ozkan, and Mehmetoglu, 2012) that pro-
vided mean scores for baseline and follow-up assessment
of pain on the VAS demonstrated a clinical significant
improvement for pain on the VAS in the LLLT group
for end of treatment and short-term follow-up.
Bird and Dickson (2001) stated that when utilizing
the VAS to assess changes in pain, the patients’ initial
pain level would provide greater understanding as to
the clinical effectiveness of therapy compared to only
providing mean VAS score changes or p-values for
between group changes. Since the effect of LLLT in
pain reduction seems promising, future research should
clearly indicate patients’ initial pain level scores on the
VAS and identify the minimal clinical important dif-
ference to use as a criterion for assessing the effects of
therapy. Setting a minimal clinical important difference
will also assist with calculating the correct sample size
to show efficacy of treatment (Salaffi et al, 2004).
The results of this review do not provide sufficient
evidence to guide clinical practice on the use of LLLT
in adults with CTS to improve symptom severity, func-
tional score and grip strength. There are multiple fac-
tors that could have impacted the lack of clear evidence
for the benefit of LLLT. The efficacy of laser therapy
depends on its treatment method, dose and type of
laser used. It was difficult to compare the results of
the studies due to the heterogeneity in laser dosage,
time frames of outcome measurement and inconsistent
reporting of the results in the studies. The greatest
variations between the studies were noticed in the
laser specifications, dosages used and treatment area.
Chang, Jiang, Yeh, and Tsai (2008) and Jiang et al.
(2011) used exactly the same laser settings, as they are
from the same research group in Taiwan. The wave-
lengths, power output, frequency, and dosage of the
laser settings ranged widely, which could influence the
outcomes of the studies and thus their comparability.
For example, dosages included double versus single
beams, pulsed versus continuous modes, 15 seconds
versus 15 minutes session duration. Therefore, there is
a need to identify optimal laser settings to be able to
compare individual studies, as indicated by our findings
on a dose response. The World Association of Laser
Therapy (WALT) (2006) recommended in 2006 that
energy dose should be expressed in Joules (J) instead
of Joules/cm2 (J/cm2), but these two parameters were
still being used interchangeably in the included studies.
A therapeutic window for the treatment of CTS with
LLLT has been proposed by WALT in 2010 for
780–860 nm GaAlAs Lasers (continuous or pulsed,
mean output: 5–500 mW), namely a recommended

dose of 8J with a minimum of 4J per point (cm2) and
2–3 points (or cm2) of irradiation per treatment ses-
sion. For 904 nm GaAs Lasers, a minimum dose of 2 J
per point for 2–3 area points (cm2) are recommended
(World Association of Laser Therapy, 2010). An impor-
tant observation was made when comparing the indi-
vidual studies’ LLLT energy dosages to the general
effectiveness of the treatment. Studies that used
780–860 nm Lasers and energy dosages of 9–11 J/cm2
or 10.8J reported a more favorable outcome for the
LLLT groups for pain, symptom severity and functional
ability as well as grip strength compared to a control/
sham group (Chang, Jiang, Yeh, and Tsai, 2008; Jiang
et al, 2011; Lazovic, et al, 2014; Shooshtari et al, 2008).
Energy dosage of 3J and 6J (Tascioglu, Degirmenci,
Ozkan, and Mehmetoglu, 2012) was reported only to
be clinical effective for pain for the LLLT group, while
no differences were found for symptom severity, func-
tional status, and grip strength between the LLLT and
placebo groups. Energy dosages of 14–18 J (Evcik et al,
2007; Fusakul, Aranyavalai, Saensri, and
Thiengwittayaporn, 2014) were only significant for the
LLLT group for hand grip strength (end of treatment
and follow up) and for end of treatment pinch grip
strength (Fusakul, Aranyavalai, Saensri, and
Thiengwittayaporn, 2014). An energy dosage of 6 J/
cm2 (Irvine, Chong, Amirjani, and Ming Chan, 2004)
was reported as not being more effective compared to
placebo laser in any of the outcomes measured. Abid
Ali, Ja’afar, and Hasan (2012) reported a significant
reduction in end of treatment and follow up pain and
symptom severity scores, but did not indicate the
energy dosage (J/cm2) that they have applied
(Table 2). No other correlation was seen between the
rest of the treatment specifications and effectiveness.
This suggests that LLLT energy dosage of 9–11 J/cm2
or 10.8 J for 780–860 nm Lasers results in a more
favorable outcome for CTS for pain, symptom severity,
and functional ability as well as grip strength which is
in accordance with the recommended treatment
dosages by WALT.
The strengths of this review are that a systematic
search strategy was conducted utilizing seven scientific
databases. Each step of the review was completed inde-
pendently by at least two investigators and data were
cross checked by all seven investigators. In keeping
with the findings of the review, the following recom-
mendations for clinical practice and research can be
made. Treatment sessions in the included studies ran-
ged from 10 to 20 sessions (three–five times per week)
which make the treatment protocol extremely labor
intensive. Therapists should thus consider the financial
costs and inconvenience to the patient (e.g. travel time
PHYSIOTHERAPY THEORY AND PRACTICE 13
and time off from work) before they decide to include
LLLT in their treatment program for CTS. Careful
consideration needs to be given to using optimal ther-
apeutic dosages as recommended by WALT. Bjordal
(2012) proposed that if future research trials follow
the WALT-recommended doses it shall lead to at least
80% positive predictive values for the therapeutic
effects for LLLT. Researchers should try to identify
the minimal clinical meaningful difference as a criter-
ion for assessing the clinical significant effects of LLLT
therapy not only for pain but also for symptom sever-
ity, function and strength. Clinical trials can only influ-
ence clinical practice if researchers not only determine
whether the treatment has an effect, but also if they
determine how big the effect is (Herbert, 2000).
Researchers should thus not only focus on and report
statistical significant values, but also provide effect sizes
to help readers to understand the magnitude of differ-
ences found and the meaningful clinical effect of the
therapy (Sullivan and Feinn, 2012).
Conclusion
The heterogeneous nature of the interventions of the
included research papers made it difficult to synthesize
and compare the outcomes of the various studies.
Although, no strong evidence exists concerning the
effects of LLLT on CTS in adults, there was a trend of
clinical significant improvements for pain in the LLLT
groups at the end of treatment and short-term follow-
up. Studies that used 780–860 nm Lasers and energy
dosages of 9–11 J/cm2 or 10.8 J reported a more favor-
able outcome for the LLLT groups for pain, symptom
severity and functional ability as well as grip strength at
the end of treatment and short-term follow up.
Currently, there is a lack of evidence for the long-
term effectiveness of LLLT for CTS.
Conflict of interests
The authors have stated that they had no interests that might
be perceived as posing a conflict or bias.
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