lame

,2,11I1,1/412-frit

40 7T

4,a~ perw."1 tuiltt~

e lefefe/K* 1~73,

Lt/tkr*

g 1.0150* ole& S-14.01.4

tmil~ TIX 1155 blett" R Ftt,i

Aerriussoor3

Share Centent

ngenta

. 4IStit ' li~ ,102,1§~

Laser Treatment on Acu punctu re Points I mproves Pain and Wrist Funictionality in Pattents Undergoing Rehabilitation Therapy ,after Wrist Bone Fracture. A Randornizedo Controfied, 8tinded Study

ikligh0131 AI:P104 -17C.dg. C.,PrIDW 54113'44DYISL,Pow~ahha lolkhátk-C ~ft», kehtl, ? 41draificli, Write

Scitittiit .A4.7,4~111 Elgterit0,1114~ tir-ribar eh!, 11/4:41~ larrrtiver sep, s-250

CALYI251)« Ca~kitruKiItiV'l e: 01 .:,,,20KéP"r1

privoet,n, ~e *weeilibb ttlr~ *Wat kfflictir

Abstract rhiecfá 2,tudyr Wffialt. r whipetw.i~ie~et 11~ boom Kv" twpsi* ~WAT ~Off the, ret~triorni ~MAI al cidgrooliseiplancW 'EUA re 0.5 VO4fir-D: Miiiktittáy ~tac» c ! riduld wittñ applimmt with ánimo tet~imuldip11Ithiprafly4e21nflri.. Pae.whiá

aidsta41,~ tracwiedrutedd potorviinwitS pék"rjri£ .ind ..315tion dhnt 1+1 levat Induckodaffilwiripmidrild tibeetwi epr~itiatir~». The efiCi2D11,1~.0 wAri 1~9 tii*Nilátitd lawr 4r.vorktirsellint Mitl 1hr 11,W #4iJe Che IMCiirri~ rOty, nteXitnid iner ~for, zok-,,tp,̂ 71»rt Qtrl. IntY

vithirtidiee sOlt, SC1 erMS tatue telaw it 1WLirkir hwiteoffideNtak) 4r1&ar,1*.rt. w.,14 urltd, 4,4d, 4irmiNnevire pont arlit 144i4,1 (Pf :10 ~MI LOOP 14 41( 4,40,1 thtiwty slrvpon NON liwernitr,c

acts~ ea etre Sbilewrne MirYIJ :ia51~0% Vairopi ír5.41.1»la tuir9 rsii sir varloo /u% Da41,4 oczt P.10~ oirsw [Un eiwnr41~0- 9714"1"n->11 ru.ii Pr$ Tm tm CW11771 11,1 Qílht p411ignitig Yruárs'ffirl 1140 13110 2,1~ De (Dinut"Ref rtt* DiY11•1 pef ~4_ Tvigo. refift trociumei ffi ttPailtim,~1 'kW ísm tiv~ri

J ,14 -w ms;a14l4y mon!" #t thie tkeOnmniipd trw~ent, thir asul gil the Will wini". *I 01

t'Dút ses~. krid poentk aftiv stradzok The paitTiu eftwittfikíthlarmef epposit" aairx~" pleft.th~1 nwluctwi philkni-~ 10140 irsprguerrilMt tri 01111.~411 Vbilva 40,0*~~ ,firkh file~1 Form. hoolkikeón .>41 Lodav bei" brmipu"tarit wlsbetweihrek acti~4~150 ~es ilhaart~t.r thr,-rit!utt itatlzri c4 pstr~ Yorth Orytairid Frre rri~ wei p~orhmten pánnine ,iteld a sheet tast.

itairmandie DM ~u% ~o" LA uft Act."Natitk occumicopol frif" tJCOUTit01Q-RE~014 MEDI"

Dectiment llypet nedvdt~i

Dek hapv,0114.~103727X*31€012517X14508026365~

Ptibr~ m: 1 dt ~I ti* 21/171'

Sign. in • Asr.tota.

Ph~

MI" I

ne.991~

e ■

42 flammdenkam

tMmlemkekk

1.1.5. Mema ~Ir ame aégsT

a 1".., la a» ..rd 37 77.777 t45 mr8 6611

rd. 7777~77 *7"..07.7

Share. Cer447a

113007.

i.• .7mrth..171.717.

cs Laser Treatment on Acupuncture ¿ri Points Improves Pain and Wrist

Functionality in Patients Undergoing Rehabilitation Therapy after Wrist Bone Fracture. A Randomized, Controlied, Blinded Study

airithans- 41:777443779a Cados 17147440774 ANL fax& Modfot ~110eraups, oh% IN006Ñibbs«. Ata'

Sirena* Elketra-ri77.07,4.7 7~h, •.~., 47 1.7~ 1 Ir 7 pp ,t .;3(r41

Prilited179. Cgiraint 0.hrr•s"s040,1

&y dad kr

»0.00 — Ttsdi

dmm0 mmdkok *dm..0k"

*he, Inrcyl

MIER ~00 .4.~2 I vífflow C4*. ifintror.s I a • ,110eXffirrn

Abstract oar,r.: atan 12L ~a 611dr*Ivrthrn .110,,, 4~1 d mak 0,9.0, gni achophata..., ~hl h.490

1X/54PM "ha C. aje ,ehot*.alSo9,70177,77.47 777, a ~esos el *su' 74771 rae" 175 .47es 1.777.4 Asaak.on,..A., maco tr. 1#14~ .04.110044 1.4410ibuy<a~riblnr4 Orobr.: 0111#41 orkint14t ..t41 4 ~I ~botan amere w*, camor ~vais" przylomml Prd • sh00 1444 sp, 7,7,01 777 ~id 7,757~7 ~1~ 7~4 ti so 177.34~ 7,70.74,0574 xw peen lar.41.7177w 7.477071774 1714 leart 701707114 4,047.7,777101ip46474*1*7.4 144.17717. aruthonwne 047777 41~ ~17.07.144104•77. SCITYPi 411011/ faEt 11141r caza loworomdm0 emmik wat taseL*771S 41,4~.4.41,~Bigt4 $1,11) W7,-,41.1.'114900,* !S'ora arlo. 41 brIP grokor., wart~t

rAX•rol rao poriva YampriaVrargaa, ,MLawororn Mon ~ara Draw 0(7k atrwrr- °no Wel tar~tal NI LA 4.44.. 04*0 T." gkIDItt 4194 O" Pd*WM ....de~ e 1~ ‘0,149~94 **1*~~ aft** p.< ~mit Thiymvo*.777445.71777aInt ~VAS. 0.4 7.14747ii.he tacar # 054alr. 0 47777,1" 47717.70 7144441/77~ 17717~77144 1~74 7,7 7,47 774 4,17* 7̀177, 7~3̂ 01 7'7 mms 441111)... and ame" atm the ata samica Tsse palien/7 175477717,17t1)727f b77.7, ~Cal" un baghtia.-91

If~ MIL .e",~ IN* »kW P.101.~.9.04 ISt flmalorol Th."5 pg ~0.0 ,..2"pér.<1~. 77174~ #7747 7~44~ 77 1i~ 44777 a *0.**0004. mdm satda~ *0,4. rowa$ ••0,.¿Awy 1~777. zrn 757 7074~747.7.7 004~ 7771, • 4770 74474 777747 .77~ weh pewr..*.anwn" 444 a 4774 att

lerosilés; rwx. 1.0,944 rartturr,1 Llar* arzalAratáa:. atta 177 7477: akkk CON firat-

74~474 KW kif CTIONt

09****** my*, rarmeetein Anklit

4011 ata, alai rrynaralzghlaYlia~aSsary

9h4170717. 4477 • 4a. 74.1 41 Z17

177., rtsasarnan4

ACUPUNCTURE & ELECTRO-THERAPEUTICS RES., INT. J., Vol. 42, pp. 11-25, 2017 Copyright ©2017 Cognizant Communication Corp. Printed in the USA. 0360-1293/17 $60.00 + .00 https://doi.org/10.3727/036012917X14908026365007

Laser Treatment on Acupuncture Points Improves Pain and Wrist Functionality in Patients Undergoing Rehabilitation Therapy after Wrist

Bone Fracture. A Randomized, Controlled, Blinded Study.

Carlos Acosta-Olivo, MD, PhD Orthopaedics and Traumatology, Hospital Universitario "Dr. José E. Gonzalez", Universidad

Autónoma de Nuevo León, Monterrey, Nuevo León, México, ZC 644801 Ana Siller-Adame, MD1

Yadira Tamez-Mata, MD1 Felix Vikhez-Cavazos, MD, PhDI Victor Peña-Martinez, MD, PhD1

(Corresponding Author): Carlos Acosta-Olivo, MD, PhD Orthopaedics and Traumatology, Hospital Universitario "Dr. José E. González", Universidad Autónoma de Nuevo León. Ave

Madero Gonzalitos, S/N Mitras Centro, CP. 64480 Tel/Fax: +52(81)83476698 Email. dr.carlosacosta@gmail.com)

(Received: February 1, 2017; Accepted with revisions: March 25, 2017)

ABSTRACT The objective of this study was to determine whether application of laser beam on acupuncture points has a positive effect on the rehabilitation of patients with a diagnosis of distal radius fracture (1.5 inches proximal to distal articular surface of the radius) when applied with active conventional physical therapy exercises. Patients with a distal radius fracture treated with closed reduction, percutaneous pinning, and a short cast for six weeks was included and were assigned to one of two study groups. The control group was given simulated laser acupuncture with the laser off, while the experimental group received laser beam on acupuncture points. A low power infrared 980 nm, 50 mW laser (Diller & Diller Laser Performance) electric energy, was used; each acupuncture point was irradiated for 30 seconds at 8,000 Hz at each therapy session. In both groups, treatment was applied to the following points: Ipsilateral- Yanggu (SI5), Yangchi (SJ4), Waiguan (SJ15), Yangxi (LI5), Daling (PC7); Bilateral- Hegu (L14); Contralateral- Shenmail (VL62), Kulun (V60), Taixi (KID3). All of the patients underwent a total of 10 sessions, at a frequency of three times per week. They were evaluated using the VAS, the Patient-Rated Wrist Evaluation (PRWE), and wrist mobility ranges at the beginning of treatment, at the end of the fifth session, at the 10th session, and a week after the 10th session. The patients treated with laser beam exposure on acupuncture points showed 44% reduction in pain and 33% of improvement in the functional status of the wrist compared with the control group. Application of laser beam on acupuncture points combined with

11

12 ACOSTA-OLIVO, C., SILLER-ADAME, A., TAMEZ-MATA, Y., VILCHEZ-CAVAZOS, F., PEÑA-MARTINEZ, V.

active rehabilitation exercises show benefits in the rehabilitation of patients with a distal radius fracture managed with percutaneous pinning and a short cast.

Keywords: Distal radius fracture; Laser acupuncture; Pain control; Occupational therapy; Rehabilitation medicine

INTRODUCTION

The possible complications of distal radius (Figure 1) fractures include limited joint mobility, recurrent pain, edema, and muscle weakness, particularly if appropriate physical rehabilitation is not completed. Research has demonstrated that patients must undergo a physical therapy protocol to achieve proper functional recovery (1,2). This is especially important for the elderly, as the pain after a distal radius fracture can cause a functional disability even two years after surgical intervention (3). Mehta et al (4) reported that patients with a score of 35 out of 50 points on the pain subscale of the Patient-Rated Wrist Evaluation (PRWE) had an eightfold greater risk of developing chronic wrist pain compared with those with a lower score on the scale, regardless of the treatment applied. Patients with a distal radius fracture achieve maximum force, mobility and function approximately three to six months after treatment, whether the injury is managed conservatively or surgically (5).

Figure 1. The forearm is conformed by the radius and the ulna bones. Distal radius is situated away from the point of origin of the radius (in the elbow). Distal radius fractures occur in the wrist joint.

The rate of distal radius fractures increases significantly among women over 50 years, with a lifetime risk up to 15%, while the incidence in men remains low even at 80 years (6). The risk profile associated with age and gender in epidemiological studies suggests that the incidence of these fractures is increasing. Factors such as advanced age, female gender, poor bone consolidation (or association with ulnar styloid fracture), poor economic compensation, or low socioeconomic and educational level contribute to a poor progression. Therefore, these factors should be identified as early as possible to establish educational programs that are easily applied to ensure a patient's successful progression (7).

LASER TREATMENT ON ACUPUNCTURE POINTS IMPROVES PAN AND WRIST... 13

Treatment options for this type of fracture include reduction using external maneuvers and fixation with percutaneous pinning using two or three Kirschner wires (8,9). Previous studies indicate that intrafocal pinning better maintains the volar inclination three months post-surgery compared with immobilization using only a cast (10). However, with this type of fracture, funetional limitations may develop in the short or long term, including the loss of range of movement, pain, edema, and muscle weakness (11-14). Because such complications can result in a loss of joint function, it is common to refer the patient for rehabilitation and physical therapy. The objectives of physical therapy alter a distal radius fracture are to regain the full movement of joint and functional capacity to allow the patient to resume his or her daily work activities (14). Physical therapy involves two types of intervention: active and passive. Active interventions include exercises conducted by the patient him- or herself as well as structured recommendations, while in passive interventions, the therapist manipulates the patient's joints (15). Currently, active rehabilitation is most commonly used for the treatment of distal radius fractures. Together with structured recommendations, active rehabilitation significantly improves wrist mobility (16). Recently, the use of laser acupuncture to treat musculoskeletal injuries has been studied for pathologies such as adhesive capsulitis (17), lumbago (18), carpal tunnel syndrome (19), and jumper's knee, Achilles tendinitis, and tennis elbow with good results in general (20). This type of treatment is considered an effective alternative to the traditional use of needles, with the advantage that it can be used on acupuncture points that require complicated needle applications (21, 22). It allows the safe stimulation of acupuncture points using a non-invasive technique that is accepted by patients with a phobia of needles (23). Another benefit is that it can be used in inflamed arcas with hematoma or dermatosis where the insertion of needles would be contraindicated. The objective of this study was to determine whether application of laser beam on acupuneture points has a positive effect on the rehabilitation of patients with a diagnosis of distal radius fracture when applied with conventional active physical therapy exercíses.

MATERIALS AND METHODS

A controlled, randomized, longitudinal, comparative, prospective double blind clinical trial was performed. The inclusion criteria were patients of either gender who had mature skeletons; had type A2, A3, B1 and B2 fractures based on the international AO classification for distal radius fracture (1.5 inches proximal to distal articular surface of the radius) that were managed with closed reduction, percutaneous pinning and immobilization with a cast below the elbow for six weeks; had their cast removed not more than seven days prior; were mentally intact; and liad volunteered to participate in the study. The exclusion criteria were patients with previous hand and wrist injuries, prior treatment of the injury, associated fractures, neurological disorders, pregnancy, or cancer. Those who abandoned treatment and those who developed adverse reactions to laser acupuneture were excluded. The Research Ethics Committee of our institution approved the study. This trial was registered in Clinical Trials.gov NCT02522403. The patients were randomized, and sealed envelopes were used to assign them to one of the two study groups. The control group was given simulated laser acupuncture with the laser off, while the experimental group received laser acupuncture (Figure 2).

14 AGOSTA-OLIVO, C., SILLER-ADAME, A., TAMEZ-MATA, Y., VILCHEZ-CAVAZOS, E, PEÑA-MARTINEZ. V.

Dista' radius fracture (wrist fracture) AO type A2, A3, B1 and B2

(n=36)

Excluded patients (n=10) -declined to participate

-last follow-up

Randomizecl (n=26)

1

Laser beam exposure on acupuncture point (LBEA) plus home

rehabilitation (n=13)

Fake laser beam exposure on acupuncture point (FLBEA) plus

home rehabilitation (n=13)

VAS score, PRWE scale, wrist mobility initial, Sth, 10th

session and four weeks (n=26)

Figure 2. Flow chart of patient randomization.

In both groups, treatment was applied at the following points: Ipsilateral- Yanggu (SI5), Yangchi (SJ4), Waiguan (SJ15), Yangxi (LI5), Daling (PC7); Bilateral - Hegu (LI4). Contralateral-Shenmail (VL62), Kulun (V60), Taixi (KID3) (Figure 3-5). All of the patients attended a total of 10 sessions at a frequency of three times per week. A low power infrared 980 nm, 50 mW laser (Diller & Diller Laser Performance; Mexico City, Mexico) (Figure 6) was used; each acupuncture point was irradiated for 30 seconds at 8,000 Hz at each therapy session (Electrical power supply, no battery, 110V). In addition, all of the patients received a leaflet describing exercises to perform at honre that included images to dernonstrate correct flexion, extension, pronation, supination, and radial and ulnar deviation. All of the patients were instructed to perform the exercises three times a day during the study and to use the limb without restriction for their daily activities.

o

F) Clinical Practice

¡ItyW 1.¡

1~1 WitaZT11

LASER TREATMENT ON ACUPUNCTURE POINTS IMPROVES PAIN AND WRIST... 15

Figure 3. Laser beam exposure on acupuneture points: Ipsilateral- Yanggu (SI5), Yangchi (SJ4), Waiguan (SJ15), Yangxi (LI5), Daling (PC7); Bilateral- Hegu (L14); Contralateral- Shenmail ',VL62), Kulun (V60), Taixi (KID3). Forearm and Hand: A) Lateral, B) Anterior, C) Medial view. Leg and Foot: D) Lateral, E) Medial views. F) Clinical Practice, laser beam exposure on Taixi (KID3) point for 30 second, at 980 nm, infrared laser applied.

D) Hegu (L14)* F) Daling (PC7) E) Yangxi (L15)

16 AGOSTA-OLIVO, C., SILLER-ADAME, A., TAMEZ-MATA, Y., VILCHEZ-CAVAZOS, F., PEÑA-MARTINEZ, V.

Figure 4. Forearm and Hand laser beam exposure on acupuncture points. Ipsilateral: Yanggu (SI5), Yangchi (SJ4), Waiguan (SJ15), Hegu (114)*, Yangxi (LI5), Daling (PC7). *Bilateral, For 30 second on each point, at 980 nm, infrared laser applied.

C) Waiguan (5.115) A) Yanggu (515) 13) Yangchí (SJ4)

LASER TREATMENT ON ACUPUNCTURE POINTS IMPROVES PAIN AND WRIST... 17

A) Shenmail (VL62) B) Kunlun (BL60) C) Taixi (KID3)

Figure 5. Leg and Foot laser beam exposure on acupuncture points: Contralateral- Shenmail (VL62), Ipsilateral: Kulun (V60), Taixi (KID3). For 30 second on each point, at 980 nm, infrared laser applied.

Diller & Diller Laser Performance

Figure 6. Diller & Diller Laser Performance. A low power infrared 980 nm, 50 mW laser was used. Each acupuncture point was irradiated for 30 seconds at 8,000 Hz at each therapy session (Electrical power supply, no battery, 110V; Mexico City, Mexico).

The scales used to assess pain were the visual analog scale (VAS) and the Patient-Rated Wrist Evaluation (PRWE). The VAS has a score of O to 10; 0 represents the absence of pain, while 10 corresponda to the maximum pain possible. The PRWE assesses pain and the inability to perform

18 AGOSTA-OLIVO, C., SILLER-ADAME, A., TAMEZ-MATA, Y., VILCHEZ-CAVAZOS, E, PEÑA-MARTINEZ, V.

daily activities; it yields a score of O to 100, with lower scores indicating better performance. The degrees of wrist mobility in flexion, extension, pronation, supination, radial and ulnar deviation were also measured. All of the measurements were performed at the start of the therapy, during the fifth session, at the end of the 10th session, and one month after the injury; a blinded researcher conducted these evaluations.

Statistical analysis Using a formula for hypothesis testing and the difference of two means, with a z alpha of 1.96, a 95% two-tailed level of significance, a z beta of 0.84, and 80% power, a sample of 13 participants per group was obtained. The demographic data of the studied population were analyzed with the chi2 test and Fisher's exact test. The data obtained from the scales and ranges of movement were evaluated using Student's t-test to determine differences between the two groups. The statistical tests were carried out using the software SPSS 23.0 for Windows 7.0.

RESULTS

Demographic data A total of 26 patients were analyzed, including vine males (35%) and 17 females (65%) with an average age of 54.8 ± 13.07 years (range 26-85 years). There were no significant differences in the average age of the two groups of patients (p=0.062). Most of the patients were right-hand dominant; however, the affected side showed a uniform distribution between right and left. The distribution of fractures according to AO classification was uniform. (Table 1) (Figure 7, 8 and 9).

LBEA (n=13)

FLBEA (n=13)

Gender Male 5 (38%) 4 (31%) Female 8 (62%) 9 (69%)

Age 53.2 (+9.7) 59.2 (+14.7) Affected side

Rigth 6 (46%) 7 (64%) Left 7 (64%) 6 (46%)

Dominant side Rigth 13 (100%) 12 (92%) Left 0 (0%) 1 (8%)

Type of fracture A2 5 (39%) 3 (23%) A3 2 (15%) 4 (31%) B1 3 (23%) 3 (23%) B2 3 (23%) 3 (23%)

Table 1. Demographic data of patients with distal radius fracture. Type of fracture is according to AO classification system. Laser beam exposure on acupuncture point (LBEA) plus home rehabilitation; Fake laser beam exposure on acupuncture point (FLBEA) plus home rehabilitation.

LASER TREATMENT ON ACUPUNCTURE POINTS IMPROVES PAIN AND WRIST... 19

Figure 7. Shown the initial fracture (A) and reduction with fixation with percutaneous pinning (B). Laser beam exposure on acupuncture point (LBEA) plus borne rehabilitation patient.

Figure 8. Final result of a patient treated with Laser beam exposure on acupuncture point (LBEA) plus home rehabilitation.

20 ACOSTA-OLIVO, C., SILLER-ADAM E; A., TAMEZ-MATA, Y., VILCHEZ-CAVAZOS, F., PEÑA-MARTINEZ, V.

Figure 9. Patient treated with Fake laser beam exposure on acupuncture point (FLBEA) plus home rehabilitation; in (A) fixation with percutaneous pinning and in (B) final X-ray.

Visual analog scale At the beginning of treatment, both groups of patients presented a similar degree of pain. In the second evaluation, there was a difference in favor of the group receiving laser acupuncture; in the fmal evaluation patients subjected to treatment showed a significant decrease relative to the group that received no treatment. (Table 2)

LBEA FLBEA P value

VAS initial 5.9 (±1.7) 5 (±2.2) 0.24

VAS 5th session 3.4 (±2.2) 5.3 (±2.6) 0.05 VAS lOth session 2.1 (±1.8) 3.3 (±2.1) 0.12

VAS final 1.1 (±1.4) 2.6 (±1.9) 0.02 Table 2. Visual Analogue Scale (VAS) Data for Laser beam exposure on acupuncture point (LBEA) plus home rehabilitation; Fake laser beam exposure on acupuncture point (FLBEA) plus home rehabilitation groups at initial, 5 h̀ and 101h session and final evaluations. Note: Data are presented as mean ± standard deviation. The LBEA group was significantly better than FLBEA group at 51 and final evaluations (P <0.05).

Patient-Rated Wrist Evaluation During the initial assessment, both groups of patients presented similar scores with no difference between groups; however, the patients who received laser acupuncture showed significant improvement starting at the second evaluation and persisting through the final evaluation. (Table 3)

LASER TREATMENT ON ACUPUNCTURE POINTS IMPROVES PAIN AND WRIST... 21

LBEA FLBEA P value

PRWE Initial 69.1 (±12.2) 70.9 (±13.6) 0.725

PRWE 5th sesion 33.5 (±12.7) 52.6 (±20.9) 0.010

PRWE 10th sesion 22.2 (±16.8) 34.3 (±22.2) 0.142

PRWE final 15.2 (±11.8) 30.4 (±22.4) 0.048

Table 3. Patient Rated Wrist Evaluation (PRWE) Data for Laser beam exposure on acupuncture point (LBEA) plus home rehabilitation; Fake laser beam exposure on acupuncture point (FLBEA) plus home rehabilitation groups at initial, 5th and 10th session and final evaluations. Note: Data are presented as mean ± standard deviation. The LBEA group was significantly better than FLBEA group at 5th and final evaluations (P <0.05)

Ranges of wrist mobility Comparing the degree of improvement in range of motion between the two groups showed that the flexion of the wrist at the start of treatment was similar in both groups. However, in the assessments at the tenth session and the final evaluation, there was significant improvement in the treated group. For wrist extension, only the fifth evaluation showed a significant improvement in the treated group. For forearm pronation, only the final evaluation showed a significant improvement in the treated group. For supination, there was no significant difference between the groups. For ulnar deviation, only the fifth evaluation showed a significant improvement in the treated group, while for radial deviation, the fifth and the final evaluations showed a significant improvement in the treatment group. (Table 4)

LBEA FLBEA P value

Flexion Initial 34.2 (±10.5) 33.3 (±18.6) 0.87

5th session 42.3 (±16.5) 34.5 (±20.3) 0.29

10th session 53.4 (±14.7) 38.4 (±20.3) 0.04

Final 60.2 (±18.9) 39.8 (±18.1) 0.01

Extension Initial 22 (±14.4) 14.9 (±15.1) 0.23

5th session 37.2 (±15.0) 24.2 (±13.0) 0.02

10th session 46.0 (±12.2) 36.9 (±17.1) 0.13

Final 52.6 (±13.0) 41.1 (±20.6) 0.10

Pronation Initial 54.8 (±25.2) 44.2 (±23.2) 0.27

5th session 78.8 (±11.5) 73.4 (±15.0) 0.31

10th session 85 (±6.7) 76.9 (±14.7) 0.86

Final 88.4 (±3.1) 80 (±9.3) 0.005

22 ACOSTA-OLIVO, C., SILLER-ADAM E, A., TAMEZ-MATA, Y., VILCHEZ-CAVAZOS, F., PEÑA-MARTINEZ, V.

Supination Initial 42.6 (+21.3) 40.3 (=21.2) 0.78

5th session 58.4 (+19.8) 52.3 (=23.7) 0.48

10th session 68.0 (±20.1) 63.0 (+24.3) 0.57

Final 76.1 (±13.7) 67.6 (=22.5) 0.25

Ulnar Initial 20 (±7.6) 15.7 (±6.8) 0.14 Deviation 5th session 25.7 (±6.0) 18.8 (±7.5) 0.01

10th session 30 (±6.4) 25.7 (±9.0) 0.18

Final 31.3 (±6.8) 27.0 (±9.8) 0.20

Radial Initial 4.6 (±4.1) 7.1 (±5.5) 0.13 Deviatíon 5th session 16.1 (±7.8) 9.3 (=6.9) 0.02

10th session 14.3 (±7.2) 11.0 (±4.9) 0.18

Final 18.0 (±5.9) 10.3 (±5.1) 0.002

Table 4. Mobility Ranges of the Wrist Data for Laser beam exposure on acupuncture point (LBEA) plus home rehabilitation; Fake-laser beam exposure on acupuncture point (FLBEA) plus home rehabilitation groups at initial, 5th and 10th session and fmal evaluations. Note: Data are presented as mean ± standard deviation. The LBEA group was significantly better than FLBEA group in flexion at 10th and final evaluations; in extension at 5th session; in pronation at final evaluation; ulnar deviation at 5th session and radial deviation at 5th session and fmal evaluation (P <0.05).

DISCUSSION

Both groups were instructed to perform rehabilitation exercises at home. In addition, they were told that they should perform their normal daily activities. None of the patients received rehabilitation at a specialized center. During the first visit at the start of the study, the patients were evaluated and were instructed regarding how to perform the exercises at home by one of the researchers, who was performed a session with them and then gave them a brochure with photos indicating the correct execution of the exercises as part of the structured recommendations described by Krischak et al (23). Those authors reported that patients with a history of distal radius fracture who performed exercises at home according to a structured program achieved better results for gripping and wrist mobility than patients who saw a therapist (23). As described in that study, patients with a distal radius fracture that was surgically managed using fixation with a volar plate were evaluated using the PRWHE as the primary assessment, with wrist mobility and gripping force at 12 weeks as secondary measures; no significant differences were found between a group that saw a therapist and a group that exercised at home (24). In the treated group, the patients managed with laser acupuncture improved significantly on the evaluations of pain according to the VAS and achieved significant improvement in functional status and according to the PRWE scale, which is indicated for the evaluation of patients with wrist problems. Regarding the wrist range of motion, the patients treated with laser therapy showed significant improvement in all areas except supination, which showed no significant difference.

LASER TREATMENT ON ACUPUNCTURE POINTS IMPROVES PAIN AND WRIST... 23

There are reports of the use of laser acupuncture for disorders of the musculoskeletal system. Ip et al (17) indicated the use of laser acupuncture for adhesive capsulitis with a follow-up at two years in which they irradiated six anatomical points and two acupuncture points, Tianzong (SI-11) and Bingfeng (SI-12). Three sessions were conducted per week for eight weeks. A total of 50 shoulders were treated, and all but four showed improvement on the Constant-Murley evaluation at the end of eight weeks. The researchers also found that the use of laser acupuncture had a positive effect on the range of motion, the level of pain and activities of daily life. They showed that this improvement was maintained up to two years later, making laser acupuncture an option for the management of patients with adhesive capsulitis. On the other hand, Lin et al, demonstrated a functional improvement in chronic low back pain using electro-acupuncture, although pain relief was better in pulsed radiofrequency patients (25). Besides, others have employed the acupuncture against sham acupuncture, and they found no differences between the groups, although both groups of patients improved their symptoms. They believe that this results could be related with the use of needles in the experimental group and not in control group (26). Furthermore, the use of deep acupuncture tends to have better outcomes in patients with shoulder pain, compared with superficial acupuncture (27). However in these studies employed needles, we did not use needles ín our study to avoid bias of the patients.

The use of laser acupuncture has also been reported for the treatment of sports injuries in 41 patients with various injuries and an average age of 38.9 years. The rate of effectiveness was 65.9%. The best results were obtained for jumper's knee, tennis elbow, and Achilles tendinitis (18). To assess the effects of laser acupuncture on the pain and functional evolution of patients with musculoskeletal disorders, a meta-analysis that evaluated 49 randomized clinical trials was performed. It determined that there is moderate-quality evidence supporting the effectiveness of laser acupuncture for managing musculoskeletal pain when an appropriate dose is applied; however, these effects may appear in the long-terco and not immediately at the end of treatment (28). These results are contrary to those of the present study because our control group showed a significant improvement in pain reduction halfway through the evaluation (5th session) that persisted to the end of the evaluation. Similar results were observed for the PRWE, which showed significant improvement in pain and in the functional status of the wrist. The strengths of this study are that it is a randomized, double-blind study with close monitoring of patients who completed their appointments. Overall, there was an improvement in all ranges of wrist mobility in patients treated with laser acupuncture; they specifically showed significant improvement in flexion, pronation, and radial deviation. Therefore, we conclude that laser acupuncture in conjunction with joint rehabilitation is a feasible option for the rehabilitation of patients with distal radius fractures that have been immobilized for a period of time and that such treatment reduces pain and improves the functional joint status, allowing patients to quickly resume their daily activities. The study's weaknesses were a short follow-up time, although all of the patients resumed their activities of daily life without restrictions, and the limited number of patients included, although the sample size (n) determined by the statistical analysis was reached. Ten patients were lost to follow-up; some of them attended half of the sessions, while some of the patients stopped attending right at the end of the evaluation. This finding is consistent with the study by Hickey et al (29), who assessed the factors that prevented adherence to physical therapy alter surgical management of distal radius fracture. Those authors found that factors such as male gender, lack

24 ACOSTA-OLIVO, C., SILLER-ADAME, A., TAMEZ-MATA. Y., VILCHEZ-CAVAZOS, F., PEÑA-MARTINEZ, V.

of a car, living far from the therapy location in terms of time and distance, and being taken to therapy by another person were the main conditions that limited attendance. Although we did not analyze why our patients stopped attending sessions, severa! of the reasons presented in that study could be applicable to our sample. We conclude that patients with dista! radius fracture showed improvement in wrist function and reductions in pain after laser acupuncture combined with guided rehabilitation therapy at home.

Conflict of interest. None

Laser beam manufacturer Name: Alonso Suarez Romero, Adress: Kansas 71, Ampliacion Napoles Z.C. 03840, Mexico City, Mexico Phone: (55) 57015584 Email: alonsosuarez.rom@gmail.com Website: www.laserperformance.com.mx

REFERENCES

1. Atkins, R.M. Aspects of current management: complex regional pain syndrome. The Journal of Bone Joint Surgery Bristol Vol. 85, no. 8, pp. 1100-06, 2003.

2. Cooney, W.P.; Dobyns, J.H.; Linscheid, R.L. Complications of Colles' fractures. The Journal of Bone Joint Surgery American. Vol. 62, no. 4, pp. 1100-06, 1980.

3. Swart, E.; Nellans, K.; Rosenwasser, M. The effects of pain, supination, and grip strength on patient-rated disability after operatively treated distal radius fractures. The Journal of Hand Surgery Vol. 37, no. 5, pp. 957-962, 2012.

4. Mehta, S.P.; MacDermid, J.C.; Richardson, J.; Maclntyre, N.J.; Grewal, R. Baseline pain intensity is a predictor of chronic pain in individuals with distal radius fracture. The Journal of Orthopaedics Sport Physcical Therapy. Vol. 45, no. 2, pp. 119-127, 2015.

5. MacDermid, J.C.; Roth, J.H.; McMurty R. Predictors of time lost from work following a distal radius fracture. Journal of Occupational Rehabilitation. Vol. 17, no. 1, pp. 47-62, 2007.

6. Cummings, S.R.; Black, D.M.; Rubin, SM. Lifetime risks of hip, Colles', or vertebral fracture and coronary heart disease among white postmenopausal women. Archives of Interna! Medicine Vol. 149, no. 11, pp. 2445-48, 1989.

7. Maclntyre, N.J.; Dewan, N. Epidemiology of distal radius fractures and factors predicting risk and prognosis. Journal of hand therapy: official journal of the American Society of Hand Therapists. Vol. 29, no. 2, pp. 136-145, 2016.

8. Koval, K.; Haidukewych, G.J.; Service, B.; Zirgibel, B.J. Controversies in the management of distal radius fractures. The Journal of the American Academy of Orthopaedic Surgeons. Vol. 22, no. 9, pp. 566-75, 2014.

9. Lichtman, D.M.; Bindra, R.R.; Boyer, M.I. AAOS Clinical practice guideline summary: treatment of distal radius fractures. The Journal of the American Academy of Orthopaedic Surgeons. Vol. 18, no. 3, pp. 180-89, 2010.

10. Rosenthal, A.H.; Chung, K.C. Intrafocal pinning of distal radius fractures: A simplified approach. Annals of plastic surgery. Vol. 48, no. 6, pp. 593-99, 2002.

11. Belsole, R.J.; Hess, A.V. Concomitant skeletal and soft tissue injuries. The Orthopedic clinics of North America. Vol. 24, no. 2, pp. 327-31, 1993.

12. Handoll, HH; Madhok, R. Conservative interventions for treating distal radial fractures in adults (review). The Cochrane database of systematic reviews. No. 2, CD000314, 2002:2.

13. Weinstock, TB. Management of fractures of the distal radius: therapist's commentary. Journal of hand therapy: official journal of the American Society of Hand Therapists. Vol. 12, no. 2, pp. 99-102, 1999.

LASER TREATMENT ON ACUPUNCTURE POINTS IMPROVES PAIN AND WRIST... 25

14. World Confederation for Physical Therapy. Description of Physical Therapy. Declarations of principie and positions statement revised and re-approved at the 17th General Meeting of WCPT, June 2011. London 2011

15. Hengeveld, E.; Banks, K. Matiland's peripheral manipulation. 4th ed. Edinburgh: Elseiver Butterworth-Heinemann; 2005.

16. Bruder, A.M.; Shields, N.; Dodd, K.J.; Hau, R; Taylor, N.F. A progressive exercise and structured advice program does not improve activity more than structured advice alone following a distal radial fracture: a multi-center, randomised trial. Journal of Physiotherapy. Vol. 62, no. 3, pp. 145-52, 2016.

17. Ip, D.; Fu, N.Y. Two-year follow-up of low-level laser therapy for elderly with painful adhesive capsulitis of the shoulder. Journal of Pain Research. Vol. 8, pp. 247-52, 2015.

18. Shin, J.Y.; Ku, B.; Kim, J.U.; Lee, Y.J.; Kang, J.H.; Heo, H.; Choi, H.J.; Lee, J.H. Short-term effect of laser acupuncture on lower back pain: A randomized, placebo-controlled, double-blind trial. Evidence-based complementary and alternative medicine: eCAM. Epub 2015 Oct 1.

19. Hadianfard, M.; Bazrafshan, E.; Momeninejad, H.; Jahani, N. Efficacies of acupuncture and anti-inflammatory treatment for carpal tunnel syndrome. Journal of acupuncture and meridian studies. Vol. 8, no. 5, pp. 229-235, 2015.

20. Morimoto, Y.; Saito, A.; Tokuhashi, Y. Low level laser therapy for sports injuries. Laser Therapy. Vol. 22, no. 1, pp. 17-20, 2013.

21. Whittaker, P. Laser acupuncture: past, present and future. Lasers in Medical Science. Vol. 19, no. 2, pp. 69-80, 2004.

22. Litscher, G. High-tech laser acupuncture is Chinese medicine. Medical Acupuncture. Vol. 20, no. 4, pp. 245-54, 2008.

23. Krischak, G.D.; Krasteva, A.; Schneider, F.; Gulkin, D.; Gebhard, F.; Kramer, M. Physiotherapy alter volar plating of wrist fractures is effective using a home exercise program. Archives of physical medicine and rehabilitation. Vol. 90, no. 4, pp. 537-44, 2009.

24. Valdes, K.; Naughton, N.; Burke, C.J. Therapist-supervised hand therapy versus home therapy with therapist instruction following distal radius fracture. The Journal of hand surgery Vol. 40, no. 6, pp. 1110-16, 2015.

25. Lin ML, Lin MH, Fen JJ, Lin WT, Lin CW, Chen PQ. A comparison between pulsed radio frequency and electro-acupuncture for relieving pain in patients with chronic low back pain. Acupuncture & Electro-Therapeutics Research. Vol. 35, no 3-4, pp 133-46, 2010.

26. Sahin N, Emel O, Sezen K, Karatas O, Issever H, Efficacy of acupuncture in patients with chronic neck pain — A randomised, sham controlled trial. Acupuncture & Electro-Therapeutics Research , Vol 35, no 1-2, pp.17-27, 2010

27. Ceccherelli F, Bordin M, Gagliardi G, Caravello M. Comparison between superficial and deep acupuncture in the treatment of the shoulder's myofascial pain: A randomized and controlled study. Acupuncture & Electro-Therapeutics Research, Vol 26, no 4, pp. 229-238, 2001

28. Law, D.; MCDonough, S.; Bleakley, C.; Baxter, G.D.; Tumilty, S. Laser acupuncture for treating musculoskeletal pain: A systematic review with meta-analysis. Journal of acupuncture and meridian studies. Vol. 8, no. 1, pp. 2-16, 2015.

29. Hickey, S.; Rodgers, J.; Wollstein, R. Barriers to adherence with post-operative hand therapy following surgery for fractures of the distal radius. Journal of Hand and Microsurgery Vol. 7, no. 1, pp. 55-60, 2015.