Long-term effect of high-intensity laser therapy for persistent shoulder pain: A case report

Abstract

BACKGROUND AND OBJECTIVE:

This case report describes the long-term effect of the high-intensity laser therapy (HILT) in a patient with chronic shoulder pain refractory in comparison to other treatments.

CASE DESCRIPTION:

Ten sessions of HILT were applied in a thirty-one-year-old woman diagnosed with subacromial syndrome. Assessment was carried out through different tests: Shoulder Pain and Disability Index (SPADI), Numeric Pain Rating Scale (NPRS) and pressure pain threshold (PPT). All measurements were taken at four different points: at the end of the 10 sessions, after one month, three months after the intervention and nine months after the initial intervention.

RESULTS:

There was a clinically significant improvement in NPRS (decrease of 5 points), PPT (increase of 1.5 kg/cm ${}^{2}$ ) and SPADI (decrease of 24 points) one month after the intervention. After three months, the increase of NPRS and SPADI required a 5-session intervention to support the clinical improvement. Six months after these booster sessions an increase in PPT and a decrease in NPRS and SPADI were observed.

CONCLUSION:

Results indicate the suitability of developing new research lines which will optimize the use of HILT.

Keywords

Shoulder pain shoulder impingement syndrome high intensity laser therapy high power laser therapy

1. Introduction

The prevalence of shoulder injury is over 20% [1], and the shoulder joint is the third cause of musculoskeletal pain [2]. The tendency to chronification implies a high percentage of patients reporting ongoing symptoms three years after the initial episode [3]. Moreover, pain is the main symptom associated with shoulder pathologies [4]. Its treatment turns into a crucial element during the rehabilitation to prevent periarticular soft tissue and capsule stiffness and retraction pattern from installing.

Low-level laser therapy (LLLT) for the treatment of joint and musculoskeletal pain is normally used in rehabilitation. In the past years, high-intensity laser therapy (HILT) is also considered as a therapeutic option. HILT is able to reach and stimulate the large and/or deep joints that are difficult to reach with LLLT [5]. However, there is little evidence about the effectiveness of HILT. In some studies, HILT is used in combination with other therapies and/or short-term follow-up [5, 6, 7, 8]. In the present case report, HILT is used as monotherapy. A nine-months follow-up was performed which is essential in chronic pathologies.

2. Case description

A thirty-one-year-old woman with a trauma background after a bicycle fall in January 2016 was included in the study. The fall caused fracture of the left radius bone without radial cupule displacement.

The patient also reported left shoulder pain. This was diagnosed as subacromial syndrome with supra-spinatus tendinosis and bicipital tendinitis. Twenty sessions of analgesic electrotherapy (TENS: 80 Hz–120 $\mu$ s during 20 minutes) were prescribed in February 2016 as a supplement for the provided treatment related to radius fracture. Pain was more intense after two months, reported along the subacromial space. Jobe and Yocum’s maneuvers [9] were positive and a bicipital tendinitis-bursitis was evidenced by echography.

After three months of evolution, 15 sessions of iontophoresis (0.1–0.2 mA/cm ${}^{2}$ during 20 minutes) were taken with dexamethasone (4 mg/ml) and lidocaine (50 mg/ml), and a month later, 15 sessions of LLLT (amount of 68,64 J with sweeping method) combined with pulsatile short wave (110 Hz) showed a slight temporary pain relief.

Five months after the initial injury, echography evidenced subacromial bursitis and bone splinter in the bicipital groove and positive subacromial impingement. An infiltration with corticosteroids (triamcinolone acetonide 40 mg/ml) induced an improvement during a ten-days period.

After 8 months, the patient not only had pain without mobility limitations, but also a sensation of heaviness and a daily continuous pain which increased when performing slight efforts, and pain persistence at night. Furthermore, pain in the interscapular area was also reported.

At this point, ten HILT sessions were applied to the patient. Written informed consent was obtained for publication of this case report (appropriate Ethics Committee approval was also obtained for the research). The evaluation included the validated version of the Spain of Shoulder Pain and Disability Index (SPADI) [10], and the Numeric Pain Rating Scale (0–10) (NPRS) was used for pain and for sensation of heaviness. The evaluation of pressure pain threshold (PPT) was performed by an analogue algometry (algometer Wagner FPN100). This evaluation was made by the same researcher and was performed in five temporal points: before the intervention, at the end of 10 laser sessions, 1 month after the end of the intervention, 3 months after the intervention, after the 5 booster sessions applied 3 months after the intervention and 6 months after the 5 booster sessions (9 months after the initial episode).

The HILT was applied using a Nd-Yag (Neody-mium-doped yttrium aluminum garnet) laser device (“iLux laser”, Mectronic Medicale, Italy), which emits infrared light (wavelength of 1064 nm) and at a maximum power of 15 W. Each treatment session was divided into three phases: i) The laser emission with stochastic function $E^{2}$ C, in which the pulse frequency and width are modulated to reduce the thermal effects, was administered with a maximum power of 10 W for 3 minutes in two points, along the sub-acromial and bicipital area. A total of 810 Joules per point were administered. ii) The second phase consisted in a continuous modality 12 W of power and 100 J/cm ${}^{2}$ in the anterior shoulder area. iii) Finally, the third phase included a continuous laser emission in the interscapular area at a power of 15 W and 100 J/cm ${}^{2}$ .

Five booster sessions were applied into three separate phases, after a three-months period without treatment: i) In the anterior shoulder area, 100 J/cm ${}^{2}$ was applied with a power of 15 W (pulsed modality with increasing power) and ii) 100 J/cm ${}^{2}$ in continuous emission of 15 W. iii) The third application was indicated in the interscapular area (continuous – 100 J/cm ${}^{2}$ – 15 W).

3. Results

Results are synthesized in Fig. 1. Values of NPRS pain and NPRS sensation of heaviness, especially the former, significantly decreased clinically (Fig. 1A). Values from the SPADI showed improvement in pain and disability (Fig. 1B). Due to the inability to realize the measurement, basal value was 0 on the PPT graph. The positioning of the algometer was described as “very painful” (Fig. 1C).

Figure 1.

Results – (A) Numeric Pain Rating Scale (NPRS) – acute and heaviness – (B) Shoulder Pain and Disability Index (SPADI) – (C) Pressure Pain Threshold (PPT).

4. Discussion and conclusion

The minimum clinically significant effect has been defined over 2.17 for the NPRS [11] and 8 to 13 points for the SPADI [12]. The results show a clinically significant improvement even in the long-term effect. Paul et al. suggested a central sensitization phenomenon in patients with chronic subacromial syndrome [13]. Our results showed low values in the PPT measurement according to Paul et al. outcomes.

Only a few studies observed the effects of HILT in the subacromial syndrome [14]. Related to SPADI, different HILT phases were applied in the same session to our study. In the short term, our results are in line with those of Karaca [14]. Pekyavas et al. also perceived a greater decrease in the SPADI total values in HILT treated patients, however several treatments were combined [7]. Regarding the visual analogue scale (VAS), a study on the use of HILT in the frozen shoulder syndrome reported a greater decrease in the VAS scale during the intermediate follow-up compared with placebo [8]. However, HILT and placebo groups received anti-inflammatory drugs and a self-exercise programme. Santamato et al. also reported higher efficacy in the decrease of VAS in patients who received HILT compared to ultrasound therapy, but no follow-up was performed [6]. The only evidence on the medium and long-term use of HILT on shoulder pain have been recently published. These studies showed controversial effects compared to sham-device [15, 16].

In this case report, the PPT continued to improve compared to the values observed immediately and one month after the intervention, three months after the intervention without receiving any other treatment. Furthermore, the clinical improvement in SPADI and NPRS slightly decreased but maintained the clinical significance. After five HILT sessions at three months, a further improvement was evidenced again, which was maintained or even increased six months later. Effectiveness of booster sessions is still unclear in manual therapy and exercise therapy [17, 18], but these sessions could be considered for potential beneficial effects of HILT when other therapeutics interventions fail [19]. More studies with booster sessions and long-term follow up are necessary. Booster sessions of HILT are more suitable to applying higher intensity in chronic phase than in the acute phase.

In conclusion, the high-intensity laser therapy could be considered as a therapy for long-term relieving pain in the subacromial syndrome. However, new randomized and controlled clinical trials including a long-term follow-up are needed to confirm our findings. The use of booster sessions could be a new research line in chronic shoulder pathologies.

Footnotes

Acknowledgments

We thank Dr. Ávila-Martín of the Research Support Unit (Área Integrada de Talavera – SESCAM) for his collaboration.

Conflict of interest

None to report.

References

Kuijpers

van der Windt

van der Heijden

et al. Systematic review of prognostic cohort studies on shoulder disorders. Pain. 2004; 109: 420-431. doi: 10.1016/j.pain.2004.02.017.

Linsell

Dawson

Zondervan

et al. Prevalence and incidence of adults consulting for shoulder conditions in UK primary care; patterns of diagnosis and referral. Rheumatology (Oxford). 2006; 45: 215-221. doi: 10.1093/rheumatology/kei139.

Lewis

, Rotator cuff tendinopathy. Br J Sports Med. 2009; 43(4): 236-241. doi: 10.1136/bjsm.2008.052175.

Thornton

McCarty

Burgess

. Effectiveness of low-level laser therapy combined with an exercise program to reduce pain and increase function in adults with shoulder pain: a critically appraised topic. J Sport Rehabil. 2013; 22: 72-78.

Kheshie

Alayat

Ali

. High-intensity versus low-level laser therapy in the treatment of patients with knee osteoarthritis: a randomized controlled trial. Lasers Med Sci. 2014; 29: 1371-1376. doi: 10.1007/s10103-014-1529-0.

Santamato

Solfrizzi

Panza

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. Phys Ther. 2009; 89: 643-652. doi: 10.2522/ptj.20080139.

Pekyavas

Baltaci

. Short-term effects of high-intensity laser therapy, manual therapy, and Kinesio taping in patients with subacromial impingement syndrome. Lasers Med Sci. 2016; 31: 1133-1141. doi: 10.1007/s10103-016-1963-2.

Kim

Lee

et al. Short-term effects of high-intensity laser therapy on frozen shoulder: A prospective randomized control study. Manual Therapy. 2015; 20: 751-757. doi: 10.1016/j.math.2015.02.009.

Cleland

. Hombro. In: Netter. Exploración clínica en ortopedia. Un enfoque para fisioterapeutas basado en la evidencia. Barcelona. Masson. 2006.

10.

Luque-Suarez

Rondon-Ramos

Fernandez-Sanchez

et al. Spanish version of SPADI (shoulder pain and disability index) in musculoskeletal shoulder pain: a new 10-items version after confirmatory factor analysis. Health Qual Life Outcomes. 2016; 14: 32. doi: 10.1186/s12955-016-0436-4.

11.

Michener

Snyder

Leggin

. Responsiveness of the numeric pain rating scale in patients with shoulder pain and the effect of surgical status. J Sport Rehabil. 2011; 20: 115-128.

12.

Donado

Jiménez

Mejía

. Minimum clinically significant difference in some measurement scales used in musculoskeletal diseases. Rev Colomb Reumatol. 2014; 21: 125-133.

13.

Paul

Soo Hoo

Chae

et al. Central hypersensitivity in patients with subacromial impingement syndrome. Arch Phys Med Rehabil. 2012; 93: 2206-2209. doi: 10.1016/j.apmr.2012.06.026.

14.

Karaca

. Effectiveness of High-Intensity Laser Therapy in Subacromial Impingement Syndrome. Photomed Laser Surg. 2016; 34: 223-228. doi: 10.1089/pho.2015.4005.

15.

Elsodany

Alayat

MSM

Ali

MME

Khaprani

. Long-Term Effect of Pulsed Nd:YAG Laser in the Treatment of Patients with Rotator Cuff Tendinopathy: A Randomized Controlled Trial. Photomed Laser Surg. 2018; 36(9): 506-13. doi: 10.1089/pho.2018.4476.

16.

Aceituno-Gómez

Avendaño-Coy

Gómez-Soriano

García-Madero

Ávila-Martín

Serrano-Muñoz

, et al. Efficacy of high-intensity laser therapy in subacromial impingement syndrome: a three-month follow-up controlled clinical trial. Clinical Rehabilitation. 2019 May; 33(5): 894-903. doi: 10.1177/0269215518824691.

17.

Abbot

Chapple

Fitzgerald

et al. The Incremental Effects of Manual Therapy or Booster Sessions in Addition to Exercise Therapy for Knee Osteoarthritis: A Randomized Clinical Trial. J Orthop Sports Phys Ther. 2015; 45: 975-983. doi: 10.2519/jospt.2015.6015.

18.

Fitzgerald

Fritz

Childs

Brennan

Talisa

Gil

et al. Exercise, manual therapy, and use of booster sessions in physical therapy for knee osteoarthritis: a multi-center, factorial randomized clinical trial. Osteoarthritis and Cartilage. 2016; 24: 1340-1349. doi: 10.1016/j.joca.2016.03.001.

19.

White

Zafereo

Elvir-Lazo

Hernandez

. Treatment of drug-resistant fibromyalgia symptoms using high-intensity laser therapy: a case-based review. Rheumatology International. 2018 Mar; 38(3): 517-523. doi: 10.1007/s00296-017-3856-5.