Arch Rheumatol 2020;35(1):60-67

doi: 10.5606/ArchRheumatol.2020.7347
ORIGINAL ARTICLE

Short-Term Efficacy Comparison of High-Intensity and

Low-Intensity Laser Therapy in the Treatment of Lateral Epicondylitis:
A Randomized Double-Blind Clinical Study

Ercan KAYDOK1, Banu ORDAHAN2, Sezin SOLUM3, Ali Yavuz KARAHAN4

Department of Physical Medicine and Rehabilitation, Niğde Ömer Halisdemir University Faculty of Medicine, Niğde, Turkey
1

2
Department of Physical Medicine and Rehabilitation, Necmettin Erbakan University Faculty of Meram Medicine, Konya, Turkey
3
Department of Physical Medicine and Rehabilitation, Niğde Bor Physical Medicine and Rehabilitation
Training and Research Hospital, Niğde, Turkey
4
Department of Physical Medicine and Rehabilitation, Uşak University Faculty of Medicine, Uşak, Turkey

ABSTRACT
Objectives: This study aims to evaluate and compare the short-term efficacies of high-intensity laser therapy (HILT) and low-intensity laser therapy
(LILT) in the treatment of lateral epicondylitis (LE).
Patients and methods: Sixty patients (16 males, 44 females; mean age 44.2±9.3 years; range, 18 to 65 years) with unilateral elbow pain were
randomized into two groups as 30 patients treated with HILT (9 males and 21 females) and 30 patients treated with LILT (7 males and 23 females).
The HILT (1,064 nm) and LILT (904 nm) were administered three times a week for three weeks, and each treatment was combined with an
epicondylitis bandage. A visual analog scale (VAS), quick Disabilities of the Arm, Shoulder, and Hand (QDASH) questionnaire, Medical Outcomes
Study Questionnaire Short Form 36 Health Survey (SF-36), and hand grip strength test were used to evaluate the patients before and three weeks
after treatment.
Results: The two groups had similar demographic characteristics, including age, sex, occupation, and body mass index (p>0.05). There were no
statistically significant differences between the two groups in terms of the pretreatment VAS, QDASH, hand grip strength, and SF-36 scores (p>0.05).
After three weeks, both groups showed significant improvements in all of the parameters (p<0.05). However, in the HILT group, the QDASH, hand grip
strength, and SF-36 physical component summary (PCS) scores showed superior improvement compared to the LILT group (p<0.05).
Conclusion: Each treatment modality was found to be effective and safe for the short-term treatment of LE. However, the HILT exhibited more
significant effects on the hand grip strength, QDASH, and SF-36 PCS scores than the LILT.
Keywords: Hand grip strength, high-intensity laser therapy, lateral epicondylitis; low-intensity laser therapy, pain.

Lateral epicondylitis (LE) is a common cause carpi ulnaris) to the lateral epicondyle.1,2 LE
of elbow pain. Rather than an inflammatory occurs in 1-3% of the general population between
condition, it is an overuse-underuse tendinopathy 30 and 50 years of age, and it is often seen
(i.e., chronic symptomatic degeneration of the in females in the dominant hand.3 In LE, the
tendon) that affects the common attachment pain in the tendons of the wrist and finger
of the tendons of the extensor muscles of the extensor muscles increases with wrist extension
forearm (extensor carpi radialis brevis, extensor in both supination and pronation.4 Moreover, LE
digitorum, extensor digiti minimi and extensor is frequently seen in people who are prone to

Received: December 08, 2018 Accepted: April 04, 2019 Published online: April 24, 2019
Correspondence: Ercan Kaydok, MD. Niğde Ömer Halisdemir Üniversitesi Tıp Fakültesi Fiziksel Tıp ve Rehabilitasyon Anabilim Dalı, 51000 Niğde, Turkey.
Tel: +90 388 - 313 00 33 e-mail: ercankaydok@[Link]

Citation:
Kaydok E, Ordahan B, Solum S, Karahan AY. Short-Term Efficacy Comparison of High-Intensity and Low-Intensity Laser Therapy in the Treatment of Lateral
Epicondylitis: A Randomized Double-Blind Clinical Study. Arch Rheumatol 2020;35(1):60-67.
©2020 Turkish League Against Rheumatism. All rights reserved.
Comparison of High and Low Intensity Laser Efficacy in Lateral Epicondylitis 61

repetitive wrist movements, strong pronounced with unilateral elbow pain who presented to the
forearm supination movements, and constant outpatient clinic of the Bor Physical Medicine and
vibrations.5 In these cases, repeated activity leads Rehabilitation Training and Research Hospital
to chronic pain syndrome. between April 2018 and July 2018 were screened
for enrollment. According to the study design, the
In LE cases, treatment is administered
physician evaluating and following the patients
to reduce the pain, accelerate and improve
(data collector) and the patients themselves were
patient recovery, prevent excessive arm use,
blinded to the study design and treatment groups.
and help patients in enhancing their quality of
Only the clinical staff (physiotherapist for this
life and functional capacity. Treatment can be
study) who was administering the treatment
divided into three main types: the first one is was aware of the treatment approaches. The
medical therapies combined with local injection flow diagram of the study is shown in Figure 1.
and non-electrotherapeutic approaches such as The study protocol was approved by the Selcuk
manipulation, acupuncture, banding, orthotics, University Medicine Faculty Ethics Committee
and exercises; the second one is electrotherapeutic (No: 2018/168). A written informed consent
methods such as extracorporeal shock wave was obtained from each patient. The study was
therapy (ESWT), laser therapy, electromagnetic conducted in accordance with the principles of
field treatments, and phonophoresis; and the last the Declaration of Helsinki.
approach is surgical treatment.6 Laser treatment
is noninvasive, painless and can be combined After collecting each patient’s medical history
with other treatment methods. Also, it can be and physical examination, patients diagnosed
easily applied in physical therapy clinics with a with unilateral LE were randomly divided into
two groups as the HILT treatment group and
wide range of conditions. Over the last decade,
the LILT treatment group. The exclusion criteria
high-intensity laser therapy (HILT) has gained
were pain history of less than four weeks,
importance for the treatment of different kinds of
upper extremity entrapment neuropathy, major
sports injuries such as tendon injuries, contusions,
psychiatric disease, upper extremity surgical
and muscle spasms. Low-intensity laser therapy
treatment history, malignancy history, chronic
(LILT) has exhibited contradictory results when
rheumatic disease, cervical radiculopathy, cervical
used for the treatment of LE.7,8 However, Tumilty
myelopathy, local corticosteroid injection prior to
et al.9 reported that LILT, with an appropriate
LE, and receiving physical therapy.
dosing regimen, may be an effective tendinopathy
treatment modality. In their study, Akkurt et A computer-generated randomized table of
al.10 showed that HILT is an effective and safe numbers for concealed allocation was used for
treatment for LE over both the short- and the randomization, and it was created prior to the
long-terms. Moreover, in 2017, it was reported initiation of the study. The PASW version 18.0
that HILT was more effective than LILT in the software (SPSS Inc., Chicago, IL, USA) was used
treatment of patients with plantar fasciitis (PF).11 to generate the block sizes and randomization
However, to our knowledge, there have been schedules. The physicians remained blinded to
no randomized controlled trials comparing the these schedules.
efficacies of these two treatments on LE, which Each patient was questioned regarding when
is a more superficial tissue pathology than PF. their pain had started and the duration from
Therefore, in this study, we aimed to evaluate and the onset was recorded in weeks. The pain and
compare the short-term efficacies of HILT and functional levels of the patients were evaluated
LILT in the treatment of LE. using a 0 to 10 cm visual analog scale (VAS)
and the quick Disabilities of the Arm, Shoulder,
and Hand (QDASH) questionnaire. The QDASH
PATIENTS AND METHODS is a self-reported questionnaire that measures
the physical functions and symptoms of patients
This study was designed as a randomized with upper limb problems. The reliability of the
clinical trial with a follow-up of three weeks. A Turkish version of the QDASH has been tested
total of 60 patients (16 males, 44 females; mean previously.12,13 It includes 11 items from the DASH
age 44.2±9.3 years; range, 18 to 65 years) survey, and to calculate the QDASH score, at
62 Arch Rheumatol

Enrollment Assessed for eligibility (n=60)

Randomization and allocation

HILT group (n=30) LILT group (n=30)

Follow-up parameters
Third week follow-up (n=29) Third week follow-up (n=30)
Follow-up

1 patients dropped out, VAS All patients participated in

who did not partcipate in QDASH the LILT regularly
the HILT regularly Hand grip strength
SF-36
Analysis

Analyzed (n=29) Analyzed (n=30)

Figure 1. Flow diagram of study.

HILT: High-intensity laser therapy; LILT: Low-intensity laser therapy; VAS: Visual analog scale; QDASH:
Quick Disabilities of Arm, Shoulder, and Hand; SF-36: Short form-36.

least 10 of the 11 items should be answered. Each The quality of life of the participants was
item contains five answer options, and the total evaluated with the Medical Outcomes Study
score of the scale is calculated from the individual Questionnaire Short Form 36 Health Survey
item scores (0=no disability and 100=the most (SF-36), which is a reliable and valid method that
serious disability). The first eight items of the can be used as a standardized questionnaire to
QDASH questionnaire measure the patient’s daily evaluate patients with musculoskeletal disorders.
life function and social activity limitations. The The SF-36 includes 36 questions that span eight
ninth question assesses the pain intensity, and the areas, including physical function, role limitations
10th question evaluates the feeling of “pins and due to physical function, bodily pain, general
needles” in the upper extremity. The last question is health perception, vitality, social functioning,
designed to evaluate the sleep problem due to pain. role limitations arising from emotional problems,
and general mental health. These domains are
Hand grip strength measurements taken with a
scored from 0 to 100 (worst and best health).
JAMAR hydraulic hand dynamometer (Lafayette
Additionally, there are two summary scales, the
Instrument, Lafayette, IN, USA) are known to
physical component summary (PCS) and mental
provide reliable results,14 and these measurements
component summary.16 The validity and reliability
were obtained while the patient was standing
testing of the Turkish version of the SF-36 was
with a full extension of the elbow and wrist. Each
performed by Koçyi¤it et al.17
patient was asked to squeeze the dynamometer
with full force for a maximum of three sec. First The HILT was performed using a BTL-6000
on the healthy side and then on the LE side, three high-intensity laser (12 W; BTL Industries, Inc.,
measurements were taken, and the averages were Greeneville, TN, USA) at 1,064 nm, which is
obtained. Between each measurement, a 30-sec considered to be a hot laser (neodymium-doped
rest period was given. Each patient was asked yttrium aluminum garnet laser source).18 In the
to perform a maximum grip for the maximum HILT group, we applied the device to the most
grip strength measurement. The measurement painful area of the lateral epicondyle in two
results were recorded on the follow-up form in phases. In both phase I and phase II, the laser
kilograms.15 was applied using continuous circular movements.
Comparison of High and Low Intensity Laser Efficacy in Lateral Epicondylitis 63

The first three sessions (phase I) were used to analysis. The Kolmogorov-Smirnov test was used
provide analgesic effects at an intermittent phase, to determine the conformity of the continuous
applying a 75 sec, 8 W, 6 J/cm2 treatment for variables with normal distributions, and all of
a total of 150 J of energy. The subsequent six the variables were normally distributed. The
sessions (phase II) were to provide a biostimulatory descriptive data were presented as the mean ±
effect at a continuous phase, applying a 30 sec, standard deviation. The Chi-squared test was
6 W, 120 to 150 J/cm2 treatment. The HILT was used to compare the demographic and clinical
applied for a total of nine treatment sessions over characteristics, and the within- and between-group
a period of three consecutive weeks. differences were investigated. The paired samples
The LILT treatment was administered at t-test was used to determine the differences
a wavelength of 904 nm, output power of between the baseline and post-treatment values,
240 MW, and frequency of 5,000 Hz using a and the independent samples t-test was used to
gallium aluminum arsenide infrared diode laser compare the two groups. A p value of less than
(Chattanooga Medical Supply Inc., Chattanooga, 0.05 was considered to be statistically significant.
TN, USA). The standard treatment was provided,
which consisted of super-pulsed irradiation over
the most painful areas. The spot area was RESULTS
approximately 0.5 cm2, with six areas over the
facet of the lateral epicondyle, while administering The initial demographic and clinical
a power density of 2.4 J/cm2 at a treatment characteristics of the patients are shown in
duration of 30 sec per point. Three LILT treatment Table 1. A total of 60 patients were included
sessions per week were administered over a in the study; however, one patient in the HILT
period of three weeks.7 group was excluded due to the lack of regular
participation. The results showed no differences
The strapped epicondylitis bandages apply between the two experimental groups in the
moderate pressure to the forearm muscles via gel demographic data, including sex, age, occupation,
like pads. The patients in both treatment groups and body mass index. Also, there were no
were given LE bandages for regular use during statistically significant differences between the
the follow-up period. All participants were asked HILT and LILT groups regarding the VAS,
to wear the bandages during the daily activates QDASH, and hand grip strength values (p>0.05).
and wrist extensor strengthening exercises and The disease durations were similar between the
remove them while sleeping and bathing. two groups (p>0.05).
Statistical analysis No treatment-related adverse reaction was
The PASW version 18.0 software (SPSS Inc., observed in any of the patients. In both the HILT
Chicago, IL, USA) was used for the statistical and LILT groups, the VAS and QDASH scores

Table 1. Baseline demographic and clinical data of study groups

HILT group (n=29) LILT group (n=30)
n Mean±SD n Mean±SD p
Age (year) 45.4±10.3 43.1±8.3 0.361
Sex 0.506
Female 20 23
Male 9 7
Body mass index (kg/m2) 26.7±4.5 26.2±3.7 0.627
Duration of complaints (weeks) 10.0±4.2 9.1±4.6 0.461
Employment 0.490
Housewife 18 14
Worker 6 9
Officer 2 1
Other (retired etc.) 3 6
HILT: High-intensity laser therapy; LILT: Low- intensity laser therapy; SD: Standard deviation (Chi-squared test).
64 Arch Rheumatol

Table 2. Assessment of pain and functional parameters

HILT group (n=29) LILT group (n=30) HILT vs. LILT groups
Mean±SD Mean±SD p
Visual analog scale pain score
Baseline 7.2±1.4 7.1±1.5 0.783
After treatment 2.9±1.5 3.3±1.5 0.360
p <0.001* <0.001*
Hand grip strength (kg)
Baseline 21.4±8.8 19.2±5.4 0.245
After treatment 27.3±9.1 22.5±5.6 0.018‡
p <0.001* <0.001*
QDASH score
Baseline 54.8±14.5 59.1±13.3 0.234
After treatment 24.2±10.8 30.1±11.1 0.046‡
p <0.001* <0.001*
HILT: High-intensity laser therapy; LILT: Low-intensity laser therapy; SD: Standard deviation; QDASH: Quick Disabilities of Arm, Shoulder, and Hand;
* Baseline versus after treatment. Paired samples t-test; p<0.05; ‡ High-intensity laser therapy versus low-intensity laser therapy. Independent samples t-test;
p<0.05.

Table 3. Comparison of Short Form-36 physical and mental scores

HILT group (n=29) LILT group (n=30) HILT vs. LILT groups
Mean±SD Mean±SD p
SF-36 (physical component)
Baseline 38.6±5.3 38.2±4.9 0.725
After treatment 63.2±5.1 59.4±4.9 0.014‡
p <0.001* <0.001*
SF-36 (mental component)
Baseline 43.3±5.8 41.1±5.4 0.133
After treatment 60.1±6.3 58.9±4.3 0.809
p <0.001* <0.001*
HILT: High-intensity laser therapy; LILT: Low-intensity laser therapy; SD: Standard deviation; SF-36: Short Form-36; * Baseline versus after treatment. Paired-
samples t-test; p<0.05; ‡ High-intensity laser therapy versus low-intensity laser therapy. Independent samples t-test; p<0.05.

were significantly improved after the treatment LE in recent years. Both LILT and HILT have
in all of the parameters evaluated, including been used to treat LE, and many studies have
the SF-36 scores and hand grip strength values shown both the short- and long-term results.
(p<0.05). In the HILT group, the improvements However, to our knowledge, there have been no
in the hand grip strength, QDASH (Table 2), and studies comparing the efficacies of these two LE
SF-36 PCS scores were significantly higher than treatment modalities. Therefore, in this study,
those of the LILT group (p<0.05) (Table 3). we investigated the short-term effects of HILT
and LILT in the treatment of LE, and we found
that both treatment modalities were effective and
DISCUSSION safe in terms of pain, functional capacity, hand
grip strength, and quality of life. Additionally,
Lateral epicondylitis is one of the most we detected statistically significant differences
commonly seen painful pathologies of the between the two groups in terms of the handgrip
musculoskeletal system. Nonsurgical treatment
strength, QDASH, and SF-36 PCS scores in favor
methods, such as local and oral nonsteroidal anti-
of the HILT group.
inflammatory drugs, steroid injections, patient
education, exercises, ESWT, physiotherapy, and The use of LILT began in Europe and Russia
splinting, are frequently used in the treatment of in the 1960s, and it has been accepted that the
LE. One physiotherapy method, laser therapy, primary biological effects of this treatment are
has been used more often for the treatment of through the light radiation effect, instead of the
Comparison of High and Low Intensity Laser Efficacy in Lateral Epicondylitis 65

thermal effects.19 However, it is unclear how LILT within the tendons, and may increase the blood
provides analgesic effects. In the case of pain, flow and vascular permeability and cause anti-
LILT may affect the release of neurotransmitters inflammatory effects. Thus, HILT can help repair
like serotonin,20 which increases the production damaged tissues and remove painful stimuli.
of mitochondrial adenosine triphosphate (ATP),21
A number of previous studies have investigated
increases endorphin release,22 and exhibits anti-
the efficacy of HILT in LE. For example, Salli et
inflammatory effects.23 Moreover, LILT increases
al.31 investigated the HILT treatment efficacy with
the production of intracellular secondary
epicondylitis bandages and observed significant
messengers, such as ATP and calcium ion (Ca2+).
improvement in favor of the HILT in all of the
Additionally, it can mediate the proliferation
hand grip strength, pain, disability, and quality
of tenocytes and collagen synthesis,24 which
of life parameters. Additionally, Akkurt et al.10
prevents oxidative stress and reduces tendon
investigated the long-term HILT treatment effects
fibrosis.25 Through these mechanisms, it can
accelerate tendon healing and alleviate tendinous and reported significant improvements in the
inflammation and pain. VAS (in both activity and rest), DASH, hand grip
strength, and SF-36 scores starting at the second
Contrary results have been reported regarding week after treatment, which continued to increase
the efficacy of LILT in the treatment of LE. through the sixth month.
Some LE studies have shown that LILT provides
better results than placebo.9 In one meta-analysis There have been a limited number of studies
performed by Bjordal et al. in 2008,26 which comparing LILT and HILT in the treatment of
evaluated the effects of LILT treatments of musculoskeletal disorders. In comparative studies
different wavelengths, the LILT treatment at of the treatment of knee osteoarthritis32 and
the 904 nm wavelength was reported to cause PF,11 it was shown that HILT was more effective
short-term improvement in the pain and physical on pain and other clinical parameters than LILT
functions of the patients. In contrast, in their due to its ability to reach and stimulate wider
2005 meta-analysis, Bisset et al.27 claimed that and deeper local areas. In contrast, in one
LILT was ineffective in the treatment of LE. In recent study of knee osteoarthritis, Taghizade
our study, the LILT treatment was performed at a et al.33 reported that both treatments resulted
wavelength of 904 nm, and it caused a significant in significant improvements in the pain and
decrease in the pain of the patients, improved physical functions, but they found no statistically
their forearm functions, increased the quality of significant differences between the two treatment
life, and exhibited a significant increase in the groups. In a comparison study by Alayat et al.34 in
hand grip strength. patients with Bell’s palsy, both the HILT and LILT
treatments resulted in statistically significantly
The HILT mechanism of action is not precise. superior functional recovery than traditional
Unlike LILT, it is considered to have both therapy. Additionally, this improvement was more
photochemical and photothermal effects, which significant in the HILT group than in the LILT
result in anti-inflammatory, anti-edema, analgesic, group.
and restorative treatment effects.28 The analgesic
effects of HILT are thought to be based on different In our study findings, there were significant
mechanisms of action, such as slowing the improvements in the pain VAS scores, upper
transmission of the pain stimulus and increasing extremity functions, hand grip strength, and life
the production of morphine-mimetic substances in quality scores in both treatment groups. These
the body.17 In addition, it may have direct effects improvements were found to be more significant
on nervous structures, which may increase the in favor of the HILT group in the handgrip
improvement rate of conduction blocks or inhibit strength, QDASH and SF-36 PCS scores (p<0.05).
transmission through the A-delta and C pain Although there was more improvement in the
fibers.29 This treatment provides changes in blood HILT group (59.7%) according to the LILT group
flow, an increase in permeability of blood vessels (53.5%) in pain VAS scores, the change was not
and accelerates the cellular metabolic response.30 statistically significant (p>0.05). This result may
Moreover, the photochemical and photothermal be due to the lack of precision evaluation of VAS
effects of HILT can stimulate collagen production for pain, such as during strenuous activity, routine
66 Arch Rheumatol

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