Photomedicine and Laser Surgery Volume X, Number X, 2016 ª Mary Ann Liebert, Inc. Pp. 1–6 DOI: 10.1089/pho.2015.4005
Effectiveness of High-Intensity Laser Therapy in Subacromial Impingement Syndrome Burcu Karaca, MD
Abstract
Objective: The short-term effectiveness of high-intensity laser therapy (HILT) was investigated as a retrospective case series for the treatment of the pain and disability associated with subacromial impingement syndrome (SAIS). Materials and methods: A total of 42 patients, who were diagnosed with subacromial impingement syndrome, underwent a total of nine sessions (three sessions per week) of high-intensity laser therapy. The patients were evaluated before therapy and 8 weeks after therapy using the pain and disability subscales and the total scores of the Shoulder Pain and Disability Index (SPADI), as well as scores for the University of California at Los Angeles (UCLA) shoulder rating scale. Results: Significant differences were observed between SPADI pain, disability, and total scores and UCLA scores of the patients. Conclusions: HILT was found to be effective in the short term in the treatment of pain and disability in patients with SAIS.
chanical factors, which complement each other, play a role in etiopathogenesis and physiopathology of this condition.11 Neer classified subacromial impingement syndrome in three stages. Stage 1 is characterized by edema and hemorrhage observed in the rotator cuff in the early period. This stage is reversible. Stage 2 is characterized by fibrosis and tendinitis. Stage 3 is characterized by bone changes and partial or full thickness tendon ruptures.3 The treatment involves the use of nonsteroidal antiinflammatory drugs (NSAIDs), steroid injections to the subacromial region, and a conservative method including hot-cold packs, exercise, and various physical therapy methods. The goal of conservative therapy is to decrease the inflammatory response and restore the range of joint motion, improve shoulder functions, and provide pain relief.12 Physical therapy agents such as high- and low-energy extracorporeal shock wave therapy (ESWT), ultrasound (US), electrical stimulation, acupuncture, microwave diathermy, pulsed electromagnetic fields, and low-intensity laser therapy (LILT) are used in SAIS lesions. However, contradictory results exist concerning the efficacy of these applications, and therapeutic options for the physicians in physical therapy and rehabilitation are limited.13–15 Low-intensity laser therapy has been used for a long time on shoulder lesions. There are various studies regarding the use of low-intensity laser therapy in the treatment of subacromial impingement syndrome.16–20 High-intensity laser therapy (HILT) has recently been a preferred choice among the physical therapy modalities.21–23
Introduction
S
ubacromial impingement syndrome (SAIS) is one of the most common causes of shoulder pain, and it occurs when the supraspinatus tendon, subacromial bursa, or bicipital tendon become entrapped as they pass between the acromion, coracoacromial ligament, coracoid process, and/ or acromioclavicular joint during shoulder movements.1–3 This presents a painful clinical picture in patients of all age groups, particularly in those with occupations involving the use of the upper extremities above the head.4 The severity of the pain decreases productivity and impairs quality of life, with the condition progressing to adhesive capsulitis if left untreated.5 The patients typically experience pain in the anterolateral shoulder to the acromion, often radiating to the midlateral portion of the humerus, which worsens with shoulder elevation or during rest at night. The elevation of arm is painful between 60 and 120 degrees, which is called ‘‘the painful arc.’’6,7 Neer and Hawkins subacromial impingement tests were found to be positive on physical examination.3,8 The definitive diagnosis is established by subacromial injection test.1,9 Many factors are implicated in the development of subacromial impingement syndrome, including acromion morphology, weak rotator cuff, abnormal kinetic patterns of scapular muscles, capsular abnormalities, weak posture, repeated loading during elevation of the arm above 90 degrees, and overuse.10 Vascular, degenerative, traumatic, and me-
Department of Physical Medicine and Rehabilitation, Kırıkkale University Faculty of Medicine, Kirrikale, Turkey.
1
2
HILT, which uses high-intensity laser radiation leading to slow light absorption by chromophores in small amounts, has been introduced into practice. This absorption is achieved not with concentrated light, but with diffuse light in all directions (the scattering phenomenon), causing an increase in the mitochondrial oxidative reaction and adenosine triphosphate, RNA, or DNA production (photochemistry effects) and resulting in the phenomenon of tissue stimulation (photobiology effects). The analgesic effect of HILT relies on different mechanisms of action, such as slowing down the transmission of pain stimulus and increasing the production of morphine-mimetic substances.24 The number of studies regarding the efficacy of HILT in the treatment of shoulder lesions is very limited.21–23 In the present study, we aim to demonstrate the short-term effectiveness of HILT on SAIS. Materials and Methods
The present study was a retrospective case series that included a total of 42 patients (25 females and 17 males), who were admitted to the outpatient clinics of the Bolu Physical Therapy and Rehabilitation Hospital between January 2014 and June 2014 and who were diagnosed with stage 1 or 2 subacromial impingement syndrome and were receiving HILT. Patients with a restricted passive range of motion in the shoulder, severe cervical spondylosis, radicular arm pain, inflammatory rheumatoid disorders, acromioclavicular or glenohumeral osteoarthritis, calcium deposition, diabetes mellitus, thyroid disease, ischemic heart disease, or a cardiac pacemaker, and those with previous history of neurological disorders were excluded. Patients who had received physical therapy and rehabilitation, who had been injected steroids within the 6 months preceding the study, and those who underwent shoulder surgery, were also excluded. A total of 57 (31 female, 26 male) patients were screened and 15 patients were excluded from the study after investigation of the study selection criteria. Patients who attended our clinic with shoulder pain, and who had painful arc signs during shoulder abduction in the physical examination, and those who tested positive for Neer’s impingement sign and the Hawkins test, were administered a subacromial injection of 4 mL lidocaine plus 4 mL 0.9% NaCl via the posterior approach. Patients who reported complete or partial pain relief within 15 min after subacromial injection were diagnosed to have subacromial impingement syndrome. An experienced radiologist evaluated the magnetic resonance images in order to determine disease stage and establish a radiological diagnosis. Patients diagnosed as stage 1–2 SAIS were primarily advised to avoid excessive physical activity and to elevate the arm above the shoulder level. Codman’s pendulum exercises and NSAIDS were recommended. Patients with sustained complaints in the control evaluation after 4 weeks were admitted to a HILT program. Written informed consent from patients was taken before the treatment. An Nd:YAG laser device, using 1064 nm wavelength (BTL-6000 High Intensity Laser 12 W), was used in the present study. The device produces a maximum of 12 W power and has three different treatment modes. Analgesic and biostimulant modes were used in the present study.
KARACA
1. Analgesic. This is called the pulsed mode. It is often not perceived by the patient. It uses a standard frequency of 25 Hz. The higher the power, the higher the depth of penetration by the laser beams. In analgesic mode, a power of 8 W, a dose of 12 J/cm2, and a total maximal energy of 300 J were applied for 2.5 min. The beams were delivered to the subacromial space, forming a circle outside-to-inside. 2. Biostimulation. This is called continuous wave mode. In biostimulation mode, a power of 7 W, a dose of 100 J/cm2, and a total maximal energy of 2500 J were applied for 5 min and 57 sec. The beams were applied to the subacromial space in a longitudinal direction. In the present study, patients received nine sessions of HILT, three times per week on alternate days for 3 weeks. The first three therapy sessions were analgesic and the last six sessions were in biostimulation mode on the most painful area of the shoulder. During the application to patients with stage 1 and 2 SAIS, a distance holder of 3 cm was used. A space of 2.5–3 cm was kept between the skin and distance holder, which was then applied from a distance of 5.5–6 cm to 25 cm2 of the subacromial region by the same physiotherapist (Fig. 1). The device has the property of 30 degree beam divergence and the direct area on the skin’s surface is 3.14 cm2 with power density 3.2 W/cm2 in analgesic mode and 2.8 W/cm2 in biostimulation mode. The recommendations given during the first visit and admission of the patients taken to HILT were re-explained. It was recommended that the patients should avoid excessive physical activity, to elevate the arm above the shoulder level, and to perform Codman’s pendulum exercises. However, regular NSAID use was changed to the oral intake of etodolac 300 mg when required.
FIG. 1. Holding the probe during high-intensity laser therapy (HILT) application.
EFFECTIVENESS OF HIGH-INTENSITY LASER THERAPY
Table 1. Demographic and Clinical Properties of the Cases n = 42
Variables
56.6 – 11.2 38–81
Age (year) Age interval (year) Gender Male Female Profession Housewife Worker Civil servant Farmer Retired Dominant hand Right Left Shoulder pain Right Left Duration of complaint (month) Comorbid disease Hypertension Coronary artery disease Asthma Hypothyroidism
17 (40.5%) 25 (59.5%) 20 5 5 3 9
(47.6%) (11.9%) (11.9%) (7.1%) (21.4%)
38 (90.5%) 4 (9.5%) 23 19 12 21 19 2 1 1
(54.8%) (45.2%) (1–36) (50.0%) (45.2%) (4.8%) (2.4%) (2.4%)
The functional status was evaluated using the Shoulder Pain and Disability Index (SPADI). This is a self-administered shoulder-specific questionnaire including two subscales: pain and disability. The pain subscale consists of five questions and the disability subscale consists of eight. The patients were asked to answer each question using a 0– 100 mm visual analog scale (VAS). The possible score of SPADI ranged from 0 to 100. Higher scores indicate a high level of disability.25,26 The Turkish version of SPADI, as validated by Bumin et al.,27 was found to be reliable. The patients were evaluated using the University of California Los Angeles (UCLA) shoulder rating scale, which indicates their pain, function, patient satisfaction, strength of forward flexion, and active forward flexion according to the following point system: 34–35 points is considered excellent performance, whereas 29–33 points is considered good performance, and
Effectiveness of High-Intensity Laser Therapy in Subacromial Impingement Syndrome Burcu Karaca, MD
Abstract
Objective: The short-term effectiveness of high-intensity laser therapy (HILT) was investigated as a retrospective case series for the treatment of the pain and disability associated with subacromial impingement syndrome (SAIS). Materials and methods: A total of 42 patients, who were diagnosed with subacromial impingement syndrome, underwent a total of nine sessions (three sessions per week) of high-intensity laser therapy. The patients were evaluated before therapy and 8 weeks after therapy using the pain and disability subscales and the total scores of the Shoulder Pain and Disability Index (SPADI), as well as scores for the University of California at Los Angeles (UCLA) shoulder rating scale. Results: Significant differences were observed between SPADI pain, disability, and total scores and UCLA scores of the patients. Conclusions: HILT was found to be effective in the short term in the treatment of pain and disability in patients with SAIS.
chanical factors, which complement each other, play a role in etiopathogenesis and physiopathology of this condition.11 Neer classified subacromial impingement syndrome in three stages. Stage 1 is characterized by edema and hemorrhage observed in the rotator cuff in the early period. This stage is reversible. Stage 2 is characterized by fibrosis and tendinitis. Stage 3 is characterized by bone changes and partial or full thickness tendon ruptures.3 The treatment involves the use of nonsteroidal antiinflammatory drugs (NSAIDs), steroid injections to the subacromial region, and a conservative method including hot-cold packs, exercise, and various physical therapy methods. The goal of conservative therapy is to decrease the inflammatory response and restore the range of joint motion, improve shoulder functions, and provide pain relief.12 Physical therapy agents such as high- and low-energy extracorporeal shock wave therapy (ESWT), ultrasound (US), electrical stimulation, acupuncture, microwave diathermy, pulsed electromagnetic fields, and low-intensity laser therapy (LILT) are used in SAIS lesions. However, contradictory results exist concerning the efficacy of these applications, and therapeutic options for the physicians in physical therapy and rehabilitation are limited.13–15 Low-intensity laser therapy has been used for a long time on shoulder lesions. There are various studies regarding the use of low-intensity laser therapy in the treatment of subacromial impingement syndrome.16–20 High-intensity laser therapy (HILT) has recently been a preferred choice among the physical therapy modalities.21–23
Introduction
S
ubacromial impingement syndrome (SAIS) is one of the most common causes of shoulder pain, and it occurs when the supraspinatus tendon, subacromial bursa, or bicipital tendon become entrapped as they pass between the acromion, coracoacromial ligament, coracoid process, and/ or acromioclavicular joint during shoulder movements.1–3 This presents a painful clinical picture in patients of all age groups, particularly in those with occupations involving the use of the upper extremities above the head.4 The severity of the pain decreases productivity and impairs quality of life, with the condition progressing to adhesive capsulitis if left untreated.5 The patients typically experience pain in the anterolateral shoulder to the acromion, often radiating to the midlateral portion of the humerus, which worsens with shoulder elevation or during rest at night. The elevation of arm is painful between 60 and 120 degrees, which is called ‘‘the painful arc.’’6,7 Neer and Hawkins subacromial impingement tests were found to be positive on physical examination.3,8 The definitive diagnosis is established by subacromial injection test.1,9 Many factors are implicated in the development of subacromial impingement syndrome, including acromion morphology, weak rotator cuff, abnormal kinetic patterns of scapular muscles, capsular abnormalities, weak posture, repeated loading during elevation of the arm above 90 degrees, and overuse.10 Vascular, degenerative, traumatic, and me-
Department of Physical Medicine and Rehabilitation, Kırıkkale University Faculty of Medicine, Kirrikale, Turkey.
1
2
HILT, which uses high-intensity laser radiation leading to slow light absorption by chromophores in small amounts, has been introduced into practice. This absorption is achieved not with concentrated light, but with diffuse light in all directions (the scattering phenomenon), causing an increase in the mitochondrial oxidative reaction and adenosine triphosphate, RNA, or DNA production (photochemistry effects) and resulting in the phenomenon of tissue stimulation (photobiology effects). The analgesic effect of HILT relies on different mechanisms of action, such as slowing down the transmission of pain stimulus and increasing the production of morphine-mimetic substances.24 The number of studies regarding the efficacy of HILT in the treatment of shoulder lesions is very limited.21–23 In the present study, we aim to demonstrate the short-term effectiveness of HILT on SAIS. Materials and Methods
The present study was a retrospective case series that included a total of 42 patients (25 females and 17 males), who were admitted to the outpatient clinics of the Bolu Physical Therapy and Rehabilitation Hospital between January 2014 and June 2014 and who were diagnosed with stage 1 or 2 subacromial impingement syndrome and were receiving HILT. Patients with a restricted passive range of motion in the shoulder, severe cervical spondylosis, radicular arm pain, inflammatory rheumatoid disorders, acromioclavicular or glenohumeral osteoarthritis, calcium deposition, diabetes mellitus, thyroid disease, ischemic heart disease, or a cardiac pacemaker, and those with previous history of neurological disorders were excluded. Patients who had received physical therapy and rehabilitation, who had been injected steroids within the 6 months preceding the study, and those who underwent shoulder surgery, were also excluded. A total of 57 (31 female, 26 male) patients were screened and 15 patients were excluded from the study after investigation of the study selection criteria. Patients who attended our clinic with shoulder pain, and who had painful arc signs during shoulder abduction in the physical examination, and those who tested positive for Neer’s impingement sign and the Hawkins test, were administered a subacromial injection of 4 mL lidocaine plus 4 mL 0.9% NaCl via the posterior approach. Patients who reported complete or partial pain relief within 15 min after subacromial injection were diagnosed to have subacromial impingement syndrome. An experienced radiologist evaluated the magnetic resonance images in order to determine disease stage and establish a radiological diagnosis. Patients diagnosed as stage 1–2 SAIS were primarily advised to avoid excessive physical activity and to elevate the arm above the shoulder level. Codman’s pendulum exercises and NSAIDS were recommended. Patients with sustained complaints in the control evaluation after 4 weeks were admitted to a HILT program. Written informed consent from patients was taken before the treatment. An Nd:YAG laser device, using 1064 nm wavelength (BTL-6000 High Intensity Laser 12 W), was used in the present study. The device produces a maximum of 12 W power and has three different treatment modes. Analgesic and biostimulant modes were used in the present study.
KARACA
1. Analgesic. This is called the pulsed mode. It is often not perceived by the patient. It uses a standard frequency of 25 Hz. The higher the power, the higher the depth of penetration by the laser beams. In analgesic mode, a power of 8 W, a dose of 12 J/cm2, and a total maximal energy of 300 J were applied for 2.5 min. The beams were delivered to the subacromial space, forming a circle outside-to-inside. 2. Biostimulation. This is called continuous wave mode. In biostimulation mode, a power of 7 W, a dose of 100 J/cm2, and a total maximal energy of 2500 J were applied for 5 min and 57 sec. The beams were applied to the subacromial space in a longitudinal direction. In the present study, patients received nine sessions of HILT, three times per week on alternate days for 3 weeks. The first three therapy sessions were analgesic and the last six sessions were in biostimulation mode on the most painful area of the shoulder. During the application to patients with stage 1 and 2 SAIS, a distance holder of 3 cm was used. A space of 2.5–3 cm was kept between the skin and distance holder, which was then applied from a distance of 5.5–6 cm to 25 cm2 of the subacromial region by the same physiotherapist (Fig. 1). The device has the property of 30 degree beam divergence and the direct area on the skin’s surface is 3.14 cm2 with power density 3.2 W/cm2 in analgesic mode and 2.8 W/cm2 in biostimulation mode. The recommendations given during the first visit and admission of the patients taken to HILT were re-explained. It was recommended that the patients should avoid excessive physical activity, to elevate the arm above the shoulder level, and to perform Codman’s pendulum exercises. However, regular NSAID use was changed to the oral intake of etodolac 300 mg when required.
FIG. 1. Holding the probe during high-intensity laser therapy (HILT) application.
EFFECTIVENESS OF HIGH-INTENSITY LASER THERAPY
Table 1. Demographic and Clinical Properties of the Cases n = 42
Variables
56.6 – 11.2 38–81
Age (year) Age interval (year) Gender Male Female Profession Housewife Worker Civil servant Farmer Retired Dominant hand Right Left Shoulder pain Right Left Duration of complaint (month) Comorbid disease Hypertension Coronary artery disease Asthma Hypothyroidism
17 (40.5%) 25 (59.5%) 20 5 5 3 9
(47.6%) (11.9%) (11.9%) (7.1%) (21.4%)
38 (90.5%) 4 (9.5%) 23 19 12 21 19 2 1 1
(54.8%) (45.2%) (1–36) (50.0%) (45.2%) (4.8%) (2.4%) (2.4%)
The functional status was evaluated using the Shoulder Pain and Disability Index (SPADI). This is a self-administered shoulder-specific questionnaire including two subscales: pain and disability. The pain subscale consists of five questions and the disability subscale consists of eight. The patients were asked to answer each question using a 0– 100 mm visual analog scale (VAS). The possible score of SPADI ranged from 0 to 100. Higher scores indicate a high level of disability.25,26 The Turkish version of SPADI, as validated by Bumin et al.,27 was found to be reliable. The patients were evaluated using the University of California Los Angeles (UCLA) shoulder rating scale, which indicates their pain, function, patient satisfaction, strength of forward flexion, and active forward flexion according to the following point system: 34–35 points is considered excellent performance, whereas 29–33 points is considered good performance, and
