Sports Medicine Research: In the Lab & In the Field: Low-level Laser Therapy with Exercise Improves Shoulder Pain (Sports Med Res)
Wednesday, May 25, 2011

Low-level Laser Therapy with Exercise Improves Shoulder Pain

Additive effects of low-level laser therapy with exercise on subacromial syndrome: a randomised, double-blind, controlled trial.

Abrisham SM, Kermani-Alghoraishi M, Ghahramani R, Jabbari L, Jomeh H, Zare M.  Clin Rheumatol. 2011 May 4. [Epub ahead of print]

Subacromial syndrome is a common cause of shoulder pain and is often managed with nonsteroidal anti-inflammatory drugs (NSAIDs), injections, and rehabilitation. Many clinicians may employ therapeutic modalities to assist in the rehabilitation of subacromial syndrome but more research with modalities is needed. Recently, low-level laser therapy (LLLT) has gained a lot of attention particularly because it has been hypothesized to accelerate tissue repair, improve microcirculation, and generate anti-inflammatory effects. To explore the clinical utility of LLLT, Abrisham SM et al conducted a randomized, double-blind, controlled trial to evaluate the effect of LLLT with exercise among patients with subacromial syndrome (diagnosed based on clinical presentation and physical examination). Eighty participants were treated by exercise therapy programs (e.g., strengthening, stretching, mobilizations) in clinic and at home (10 clinic sessions during 2 weeks).  Patients were randomized so that 40 patients received infrared laser radiation (wavelength 890 nm in pulse mode; 2 to 4 J/cm2) at three points on the shoulder (coracoid process, posterior glenohumeral joint, and lateral rotator cuff tendon)  for 2 minutes at each site (6 minutes total). Among patients with biceps tendonitis a fourth point was treated. The remaining 40 patients received a sham laser treatment from a unit that appeared to be working. Patients were not allowed to take analgesics or NSAIDs during the study period. A blinded physician measured active and passive shoulder range of motion (flexion, abduction, external rotation) with a goniometer. Pain was also recorded. Following treatments both groups had less shoulder pain and improved shoulder range of motion (all measures). Based on change over time, the LLLT with exercise group had more improvement in pain and shoulder range of motion (all measures) compared to the exercise-only group.

The authors suggest that results support the use of LLLT with exercise therapy in relieving shoulder pain and improving range of motion among patients with subacromial syndrome. They note that further studies with larger samples, longer follow-ups, and comparisons to other interventions may be informative. Conducting clinical trials with therapeutic modalities can be a methodological challenge and the authors should be commended on their research design. We need more research to evaluate the safety and efficacy of therapeutic modalities. It would be interesting to know if the treating physiotherapist was blinded because they could bias the results unintentionally by altering their manual therapy. While that bias may influence our evaluation of the efficacy of LLLT it was comforting to see that neither group had any adverse reactions or side effects to the treatments. What’s your experience with LLLT? Are you finding it beneficial? Have you noticed any adverse reactions or side effects?

Written by: Jeffrey Driban
Reviewed by:  Stephen Thomas

5 comments:

Amy Castillo said...

Interesting, but think I will stick to manual therapy and exercise right now.

Jeffrey B. Driban, PhD, ATC, CSCS said...

Amy, I too am holding off for more research. If I had one available I may try it...it's comforting to know that they did not have any reported adverse events among 40 patients treated for shoulder pain. What's your rationale for holding off?

Stephen J. Thomas, PhD, ATC said...

Jeff great post. I enjoy to see adjunct therapies to help with those patients that have a hard time especially during the early stages of PT.

A couple things in the paper were interesting to me. First the initial amount of ROM for all the patients. This seems like large deficits for patients with just subacromial impingement. I wonder if partial cuff tears were missed because of no MRI evaluation.

Second, I was wondering on their rational for locations of the LLLT treatment. They picked location that represent soft tissue restriction (pec minor and posterior capsule). I am wondering if that is why they chose these positions and this therapy would be best as a pre-stretching/mobilization "warm-up" to help increase tissue compliance.

Lastly, it is interesting they measured ever shoulder motion expect for IR. I would have liked to see the restriction in this motion and the improvements over time since previous research has identified this to be problematic in an impingement population.

What are your thoughts?

Jeffrey B. Driban, PhD, ATC, CSCS said...

Steve:

Nice observations. It would have been interesting if there were shoulder MRIs. I think it may influence which population LLLT would be optimal for (based on this particular study) but fortunately both groups had similar ROM deficits so the groups appear to be comparable.

I found it interesting how much their ROM improved during just two weeks. It is noteworthy that they had 10 clinic visits in 2 weeks (with a home exercise program). While some sports medicine clinics accommodate this many visits in a short time span many don't. Any thoughts?

Unfortunately, the paper doesn't justify the location of the LLLT treatments nor the absence of internal rotation measures. The locations they chose seems reasonable (maybe a few to many) but I wouldn't want to speak for their authors' hypotheses. Keep in mind that LLLT is considered a nonthermal modality. For the treatment locations, hopefully someone more familiar with LLLT for shoulder pain can offer some additional insights.

Thanks!

Tom Martin said...

Nice review Jeff

It is interesting to see research that tries to justify use of modalities, esp with a topic like this one (Shoulder pain and mobility.

Not that I am a huge fan of US, but after reading an article that looked at tissue temp after US (think it was on achilles and looked and temp rise and time of temp change till returned to baseline). I started to try to use this with tight posterior capsules pre-stretch, realized there was like a 3 minute window to stretch after the modality before the tissue temp returned to baseline. Can't say I noticed a difference, but this article seems to be heading in the right direction.

Thanks for the post.

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