Daniel Woodward, SPT

East Tennessee State University, Year II

Healing Hands Physical Therapy Clinic

LOW LEVEL LASER THERAPY (LLLT)AN ALTERNATIVE INTERVENTION FOR SHOULDER IMPINGEMENT

OVERVIEW

• Introduction to Laser Therapy

• Case Study

• Research Findings

• Clinical Implications

1. What is a Laser?

a) Light Amplification by Stimulated Emission of Radiation

b) Device that generates intense beam of coherent, monochromatic, and collimated light by stimulated emission of photons from excited atoms or molecules

c) Light Amplifier: If radiation produced is within the visible range (400nm – 750 nm)

d) Radiation (laser) Amplifier: If the radiation produced is within the infrared range (750 nm –1mm)

2. Laser Requirements

a) Energy Source (power supply)

b) Population Inversion

c) Amplifying Medium (solid, gas, or liquid)

d) Resonating Cavity (mirrors)

• A 100% reflecting mirror

• A selective filter mirror

LASER INTRODUCTION7,8,10

1. Endre Mester

a) Hungarian Physician

b) Father of Laser Therapy

2. 1967 Experiments with mice

a) Could laser be used to treat cancerous tumors?

b) Used low power ruby laser (694 nm)

b) Laser treatments did NOT kill tumor cells

c) Laser treatments DID enhance healing of incisions and hair growth

d) First to observe photobiostimulation

HISTORY OF LASER THERAPY7

1. What is LLLT?

a) Application of light (low power laser or LED) to pathological tissue to promote healing, reduce inflammation, and relieve pain.

2. Terraquant Solo Portable Cold Laser

a) Laser Type: "Cold Laser"

• No thermal effect

b) Class 1M

• Has the power of a Class IV laser

c) Battery powered handheld device

• 18 hours on one charge

d) Frequency Modes: 5 Hz, 50Hz, Variable

e) Semiconductor Laser

• Amplifying Medium = Gallium Arsenide

LOW LEVEL LASER THERAPY (LLLT)7,14

1. 1 Super Pulsed Laser Diodea) Power = 15 Wb) Wavelength = 905 nmc) Very low duty cycle (100-200 ns)

• Relatively low average power outputd) Deep Focused Penetration (4-5")

2. 4 Infrared LED'sa) Power = 60 mWb) Wavelength = 875 nmc) Pulsed Duty Cycle: 50%d) Medium and Broad Penetration

3. 4 Red LED'sa) Power = 7.5 mWb) Wavelength = 660 nmc) Pulsed Duty Cycle: 50%d) Shallow and Broad Penetration

4. Static Magnetic Fielda) Facilitates circulation and healing

MULTI-RADIANCE TECHNOLOGY3,7

Optimal Parameters/Dosage• Highly debatable and complex

• Depends on Treatment Tissue (Depth/Type)

• Dosage (J), Power/Energy Density (joules/cm2),

Frequency (Hz) and Wavelength (nm) are all

important parameters

• Greater Wavelength = Deeper Penetration

• TQ Solo Treatment Parameters Preset (1-4

joules/cm2) except for pulse frequency

• WALT Dose Recommendations

1. FDA approved for temporary relief of:

a) Minor muscle and joint pain

b) Arthritis and muscle spasm

c) Joint stiffness

d) Promoting relaxation of muscle tissue

e) Temporarily increasing local blood circulation

2. Other musculoskeletal applications:

a) Chronic and Acute Pain

b) Reduces Inflammation

c) Tendinopathies

d) Epicondylitis

e) Back Pain

f) Fibromyalgia

g) Wound Healing

h) Bone Healing (Dental)

i) Carpal Tunnel Syndrome

INTRODUCTIONBENEFITS OF LLLT7,8,10

7. Stimulates long term production of NO

8. Decreases the formation of bradikynin,

histamine, and acetylcholine

9. Stimulates production of endorphins

1. Increases ATP synthesis

2. Stimulates cell growth

3. Increases cell metabolism

4. Improves cell regeneration

5. Invokes an anti-inflammatory

response

6. Promotes edema reduction

7. Reduces fibrous tissue formation

8. Stimulates nerve function

9. Reduces the production of

substance P

PHOTOBIOSTIMULATION BENEFITS8

1. Irradiation over the eyes

2. Pregnancy (over the pregnant uterus)

3. Cancers (over the tumor site)

4. Patients with Hemorrhage

5. Directly over Thyroid Gland

6. History of Epilepsy

7. Directly over Pediatric Joint Epiphysis

• There are no known permanent or serious side effects from laser therapy

LOW LEVEL LASER THERAPYCONTRAINDICATIONS8

1. Locate Treatment Area

• Tender Points

• Use of Pain-Relieving Guide

2. Turn on TQ Solo

3. Select Frequency (5 Hz, 50 Hz, or Variable Frequency)

4. Press "Start" and place laser device over treatment area

5. Treatment Duration: 5 minutes

Modes of Operation

HOW IT WORKSHOW TO ADMINISTER LASER

Program / Mode 1 2 3

Pulse Frequency 5 Hz 50 Hz 1000 to 3000 Hz

Time 5 Minutes 5 Minutes 5 Minutes

Systemic Effect Tissue Repair / Healing Anti-inflammatory Acute Pain Treatment

Depth Of Penetration Deepest Medium Superficial

TREATMENT TECHNIQUES

Patient Description

1. 51 year old WF

2. Height: 5' 7'' Weight: 210 lbs.

3. (R) Shoulder pain began 3 weeks

before evaluation

4. Pain progressively worsened

Mechanism of Injury

Too embarrassed to tell but mentioned that it

involved the arm being twisted behind her

back….

Medical History

1. GERD, IBS, Restless Leg Syndrome, Panic Attacks, and Depression

2. Normal mental/cognitive function

Medical Diagnosis

1. (R) Shoulder Pain

2. (R) Shoulder Rotator Cuff Syndrome

PT Diagnosis

1. Severe (R) shoulder pain with UE activity

2. Increased inflammation

3. Severe decrease in AROM/PROM

4. Decrease in muscle and functional strength

CASE DESCRIPTIONCASE DESCRIPTION

CASE DESCRIPTIONCurrent Level of Function

1. Pain Free (R) Shoulder @ rest

• ↑ to severe pain with UE activity

2. Palpation tenderness over anterior/lateral aspect of (R) shoulder

3. Moderate-severe difficulty with ADL's

4. Avoids reaching above 90 degrees

5. Pain worse with reaching behind back

• "Increased difficulty undoing bra"

6. Unable to sleep on (R) Side

Special Tests:

1. Empty Can Test: Positive

2. Hawkins Kennedy Test: Positive

3. Subscapularis Lift Off Test: Positive

Patient Goals

1. "I just want my (R) Shoulder to be pain free"

CASE DESCRIPTION

OUTCOME MEASURES

Motion Initial ROM

Flexion 160

Abduction 150

Extension 40

External Rotation 50

Internal Rotation 50

Range of Motion

Strength

Pain RatingUE Quick Dash6

• 11 item, self reported questionnaire

• Measures physical function and

symptoms of UE musculoskeletal

disorders

• Strong reliability/validity and high

response rate (a = 0.94)(r-values = 0.7-

0.8 correlating to VAS)

• Scoring: Out of 100 (higher score =

greater disability

Initial Quick Dash Score = 52/100

At Rest = 0 / 10

With Movement = 10 / 10

Description: Sharp

Unable to test secondary to pain

* Pain during and at the end of available ROM

Low Level Laser Therapy

1. Irradiated tender point over lateral

aspect of (R) Shoulder

• 2 x / week

2. Frequency: 5 Hz

3. Duration: 5 minutes

4. Technique: Contact

Other Modalities

1. Hot Pack – 15 minutes (Warm-up)

2. Cold pack – 15 minutes (Cool-down)

Stretch Exercises

1. Pulley Exercises (Flex/Abd)

2. Doorway Stretch

3. IR stretching

4. Shoulder Flex/Ext (Cane)

5. Wall Circles (Small → Big)

6. PROM (patient in supine)

Strengthening Exercises

1. Thera-band scapular squeeze

2. Thera-band (Flex, Ext, IR, ER)

3. Submaximal Isometrics

4. Shoulder Shrugs

APPLICATION OF TREATMENT

RATIONALE FOR LLLTPatient Demonstrated Classic RC Impingement Symptoms

• Specifically in the Supraspinatus muscle tendon

Treatable Symptoms with LLLT:

1. Pain

2. Inflammation

3. Decreased ROM

4. Decreased Strength

LLLT Promotes:

1. Cell proliferation

2. Healing of damaged tissue

Low Level Laser Therapy

• Treatment parameters remained

the same throughout her

rehabilitation

Exercise

• Increased frequency, resistance,

and duration of various shoulder

stretching and strengthening

exercises

PROGRESSION OF INTERVENTIONS

Treatment over tender point on lateral

aspect of shoulder

Treatment Procedure

"Sometimes I can sense a slight tingling in the treatment area, but other times I don't feel a thing"

Benefits of Treatment

"I feel like the laser treatments are helping, but I am not sure if it is because of the laser therapy, the exercises, or the other modalities (heat/cold)"

PATIENT'S PERCEPTION OF LLLT

Does Laser

Therapy Work

for you?

MEASUREMENT COMPARISON

Motion Initial ROM Final ROM

Flexion 160 170

Abduction 150 160

Extension 40 50

External Rotation 50 74

Internal Rotation 50 60

Pain Rating Initial Rating Final Rating

At Rest 0/10 0/10

With Movement 10/10 3/10

Strength Initial Score Final Score

Flexion Not tested 4+/5

Abduction Not tested 4/5

Extension Not tested 4+/5

External Rotation Not tested 5/5

Internal Rotation Not tested 5/5

Initial Quick Dash Score Final Quick Dash Score

52/100 15/100

Range of Motion Strength

Pain Rating

UE Quick Dash Score

Evaluation Date: 4/30/13 Final Treatment Date: 6/13/13 Worked with patient for 6 visits

Laser vs. Ultrasound in the Treatment of Supraspinatus Tendinosis: RCT

• 36 subjects with supraspinatus tendinosis

• Laser Group, Ultrasound Group, Control Group (advice only)

• Laser Dose = 30 j/cm2, 50 mW 820 nm (infrared) laser probe, 5000 Hz frequency

• Duration: 90 seconds on 2 locations; 3 x week x 3 weeks

• Locations:

• 1) Anterior shoulder (point of max tenderness)

• 2) On tendon just below the acromion with subjects hand placed behind back

• Conclusion: Laser reduces pain, disability, and tenderness more than US and significantly more than advice alone in the treatment of supraspinatus tendinosis

SAUNDERS, 2003

Muscle Force Change in Pain

Pain Diary

Improvements

Force Required to

Produce Tenderness

Results

• Statistically significant improvements in pain severity and shoulder ROM in both groups

Group 1 (LLLT + Exercise)

• More significant pain reduction (VAS scores)

• More significant improvement for all active/passive movements

Conclusion

• LLLT + Exercise Therapy was more effective than exercise therapy alone in the improvement of pain and active and passive ROM in patients with sub-acromial syndrome.

ABRISHAM ET AL. 2011 Efficacy of LLLT + Exercise on Subacromial

Syndrome

OTHER RESEARCHOther Supporting Research not involving Rotator Cuff 9,15,18

1. LLLT + Eccentric Exercise = Accelerated Recovery for Chronic Achilles Tendinopathy (Pain VAS, ↓ Morning Stiffness, ↓ Palpation Tenderness, ↓ Crepitation, and ↑ active Dorsiflexion

2. LLLT = Significant ↑grip strength, ↑ pinch strength, and significant ↓ in overall diameter of tendon sheaths in patients with de Quervains Tenosynovitis

3. LLLT = Significant ↑ mechanical pain threshold and VAS in patients with lateral epicondylitis

Opposing Research regarding LLLT 2,11,17

1. Vecchio et al; 1993 – Active Laser vs. Dummy Laser = Both Groups improved but no significant difference between groups

2. Mulcahy et al. 1995 – Showed no differences between LLLT group and placebo group for pain VAS and verbal pain score "Elaborate Placebo"

3. Dogan et al. 2010 – LLLT + Exercise + Cold Pack showed no difference when compared to Placebo Laser in patients with subacromial impingement

CLINICAL IMPLICATIONS15

• Low level laser therapy may be a beneficial modality to utilize for improving pain and function in individuals with shoulder impingement symptoms as well as various other musculoskeletal conditions

• No research specifically on the TQ Solo Portable Cold Laser

• The true impact that LLLT had on the patient is unknown as there were many other forms of treatment which she was receiving

Literature Conflict:

• 25 trials (22 were RCT's)

• 12 trials reported positive effects of LLLT

• 13 trials reported no effects or inconclusive

results for LLLT

• Therefore, the efficacy of this modality is still

under much debate

High Level Laser Therapy (HLLT)

• 70 participants with SAIS symptoms

• HLLT vs. US

• VAS, CMS, and SST scores

• Laser Specifications:

• Neodymium-yttrium aluminum garnet laser

• Peak Power = 1 Kw (1000 Watts)

• Wavelength = 1064 nm

• Pulsating waveform (5000 W/cm2)

• 10 treatment sessions (10 minutes/session) over 2 weeks

Treatment Phases

• Initial Phase: Fast manual scanning over upper trap, deltoid, and pectoralis minor

• Intermediate Phase: Static treatment over trigger points

• Final Phase: Slow manual scanning in same areas treated in initial phase

Results

• HLLT = greater reduction in pain

• HLLT = greater improvement in articular movement, functionality, and muscle strength

ALTERNATIVE INTERVENTION FOR SAIS11

HLLT

FUTURE RESEARCH SUGGESTIONS1. Most Effective Treatment Parameters?

• Laser wavelength (nm), power (W), power density (W/cm2), dose (J/cm2), type of pulsing,

pulse frequency (Hz), pulse duty cycle, and treatment intervals

• Several of these parameters are missing in the research or have been inaccurately

recorded

• Premature conclusions should not be made about the negative results obtained while

using LLLT

• Further research is needed to determine the most effective parameters

2. Application Procedures?

• Tissue saturation (Contact vs. Scanning)

• Trigger points

• Acupuncture points

• Tender Points

3. Larger Scale Clinical Trials with Long Term Outcomes

Future Research

(Probe vs. no probe)

REFERENCES1. Abrisham SMJ, Kermani-Alghoraishi M, Ghahramani R, Jabbari L, Jomeh H, Zare M. Additive effects of low-level laser

therapy with exercise on subacromial syndrome: a randomised, double-blind, controlled trial. Clinical rheumatology. 2011;30(10):1341–6. Available at: http://www.ncbi.nlm.nih.gov/pubmed/21538218. Accessed June 1, 2013.

2. Dogan SK, Ay S, Evcik D. The effectiveness of low laser therapy in subacromial impingement syndrome: a randomized placebo controlled double-blind prospective study. Clinics. 2010;65(10):1019–1022. Available at: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1807-59322010001000016&lng=en&nrm=iso&tlng=en. Accessed August 1, 2013.

3. Effective Treatment Strategies for Low-Level Laser Therapy. Advance for Physical Therapy and Rehab Medicine. 2012. Available at: http://physical-therapy.advanceweb.com/sharedresources/Downloads/2012/062512/PT_LaserTherapy.pdf.

4. Eslamian F, Shakouri SK, Ghojazadeh M, Nobari OE, Eftekharsadat B. Effects of low-level laser therapy in combination with physiotherapy in the management of rotator cuff tendinitis. Lasers in medical science. 2012;27(5):951–8. Available at: http://www.ncbi.nlm.nih.gov/pubmed/22052627. Accessed July 12, 2013.

5. Gedevanishvili G. What is Laser Therapy and Does it Really Work? The American Chiropractor. 2012. Available at: http://www.theamericanchiropractor.com/articles-alternative-therapies/8514-what-is-laser-therapy-and-does-it-really-work.html. Accessed August 1, 2013.

6. Gummesson C, Ward MM, Atroshi I. The shortened disabilities of the arm, shoulder and hand questionnaire (QuickDASH): validity and reliability based on responses within the full -length DASH. BMC musculoskeletal disorders. 2006;7:44. Available at: http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1513569&tool=pmcentrez&rendertype=abstract. Accessed August 1, 2013.

7. Huang Y-Y, Chen AC-H, Carroll JD, Hamblin MR. Biphasic dose response in low level light therapy. Dose-response : a publication of International Hormesis Society. 2009;7(4):358–83. Available at: http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2790317&tool=pmcentrez&rendertype=abstract. Accessed August 1, 2013.

8. Kneebone W. Practical Applications of Low Level Laser Therapy. Practical Pain Management. 2006;(December). Available at: http://www.multiradiance.com/articles/Principal Application of Laser Therapy_PPM_nov06_kneebone -4_c.pdf.

9. Lam LKY, Cheing GL. Effects of 904-nm low-level laser therapy in the management of lateral epicondylitis: a randomized controlled trial. Photomedicine and laser surgery. 2007;25(2):65–71. Available at: http://www.ncbi.nlm.nih.gov/pubmed/17508839. Accessed July 18, 2013.

REFERENCES10. Michlovitz, Susan L., James W. Bellew, and Thomas Nolan. Modalities for Therapeutic Intervention.

Philadelphia: F.A. Davis, 2012. Print.

11. Mulcahy D, Mccormack D, Mcelwain J, Conroy C. a prospective double trial of its use in an orthopaedicpopulation Low level laser therapy : blind. International Journal of the Care of the Injured . 1995;26(5):315–317.

12. Santamato A, Solfrizzi V, Panza F, et al. Short-term effects of high-intensity laser therapy versus ultrasound therapy in the treatment of people with subacromial impingement syndrome: a randomized clinical trial. Physical therapy. 2009;89(7):643–52. Available at: http://www.ncbi.nlm.nih.gov/pubmed/19482902. Accessed August 1, 2013.

13. Saunders L. Laser versus Ultrasound in the Treatment of Supraspinatus Tendinosis. Physiotherapy. 2003;89(6):365–373.

14. Schnee A. History of Cold Laser Therapy. Spine-Health. Available at: http://www.spine-health.com/treatment/pain-management/history-cold-laser-therapy. Accessed August 1, 2013.

15. Stergioulas A, Stergioula M, Aarskog R, Lopes-Martins R a B, Bjordal JM. Effects of low-level laser therapy and eccentric exercises in the treatment of recreational athletes with chronic achilles tendinopathy. The American journal of sports medicine. 2008;36(5):881–7. Available at: http://www.ncbi.nlm.nih.gov/pubmed/18272794. Accessed August 1, 2013.

16. Tumilty S, Munn J, McDonough S, Hurley D a, Basford JR, Baxter GD. Low level laser treatment of tendinopathy: a systematic review with meta-analysis. Photomedicine and laser surgery. 2010;28(1):3–16. Available at: http://www.ncbi.nlm.nih.gov/pubmed/19708800. Accessed August 2, 2013.

17. Vecchio P, Cave M, King V, Adebajo AO, Smith M, Hazleman BL. A double-blind study of the effectiveness of low level laser treatment of rotator cuff tendinitis. British journal of rheumatology. 1993;32(8):740–2. Available at: http://www.ncbi.nlm.nih.gov/pubmed/8348278. Accessed August 1, 2013.

18. Words K. Effect of Low Level Lasers in de Quervains Tenosynovitis. Physiotherapy. 2002;88(12):730–734.