Lasers Med Sci

DOI 10.1007/s10103-015-1716-7

ORIGINAL ARTICLE

Effectiveness of high-intensity laser therapy and splinting

in lateral epicondylitis; a prospective, randomized,
controlled study
Umit Dundar & Utku Turkmen & Hasan Toktas &
Alper Murat Ulasli & Ozlem Solak

Received: 11 September 2014 / Accepted: 12 January 2015

# Springer-Verlag London 2015

Abstract Lateral epicondylitis (LE) is a common disorder Keywords Lateral epicondylitis . High-intensity laser
that causes pain on the outside of the elbow, as well as pain therapy . Splinting . Pain . Disability . Quality of life
and weakness during gripping. In this prospective, random-
ized, controlled, assessor-blinded trial, we planned to investi-
gate the effects of high-intensity laser therapy (HILT) in pa-
tients with LE and to compare these results with those of a
brace and placebo HILT. Patients were randomly assigned to
three treatment groups. The first group was treated with HILT.
The second group (sham therapy group) received placebo Introduction
HILT, while the third group (brace group) used the lateral
counterforce brace for LE. The patients were assessed for grip Lateral epicondylitis (LE) or tennis elbow is a common disor-
strength, pain, disability, and quality of life. Outcome mea- der that causes pain on the outside of the elbow, as well as pain
surements and ultrasonographic examination of the patients and weakness during gripping. It has been found to occur in
were performed before treatment (week 0) and after treatment approximately 1.3–1.7 % of people between the third and
(after 4 and 12 weeks). HILT and brace groups showed signif- sixth decades of life in studied populations [1, 2]. Physical
icant improvements for most evaluation parameters (pain strain may play a part in the development of LE, as the dom-
scores, grip strength, disability scores, and several subparts inant arm is significantly more often affected than the non-
of the short-form 36 health survey (physical function, role dominant arm. LE is usually self-limiting, and symptoms
limitations due to physical functioning, bodily pain, general seem to resolve between 6 and 24 months in most patients [3].
health, and vitality)) after treatment (after 4 and 12 weeks). To date, a standardized, universally accepted program for
However, the improvements in evaluation parameters of the LE treatment has not been established. Various nonsurgical
patients with LE in HILT and brace groups were not reflected modalities have been described. In general, treatment can be-
to ultrasonographic findings. Furthermore, comparison of the gin with patient education, application of commonly available
percentage changes of the parameters after treatment relative treatments, physiotherapy, manual therapy, laser therapy, ten-
to pretreatment values did not show a significant difference nis elbow brace, exercises, massage, and local injection ther-
between HILT and brace groups. We conclude that HILT and apy, as well as oral or topical nonsteroidal anti-inflammatory
splinting are effective physical therapy modalities for patients drugs (NSAIDs) [4].
with LE in reducing pain and improving disability, quality of Laser treatment is a noninvasive and painless method that
life, and grip strength. can be easily administered in therapy units for a wide range of
conditions [5]. Effectiveness of low-level laser therapy
(LLLT) in LE is controversial. One meta-analysis of LLLT
U. Dundar (*) : U. Turkmen : H. Toktas : A. M. Ulasli : O. Solak for lateral epicondylitis found that LLLT was ineffective in
Department of Physical Medicine and Rehabilitation, Faculty of
the treatment of LE [6]. However, other two examinations of
Medicine, Afyon Kocatepe University, Afyonkarahisar 03200,
Turkey the literature based upon treatment protocol concluded a pos-
e-mail: umitftr@[Link] itive effect [7, 8].
 Lasers Med Sci

Recently, the pulsed neodymium-doped yttrium aluminum pathologies, (10) neurological deficit(s) in the ipsilateral upper
garnet (Nd:YAG) laser, a form of high-intensity laser therapy limb, (11) systemic metabolic diseases, (12) other cervical/
(HILT), was introduced as a new treatment option. The supe- shoulder disorders, and (13) bilateral elbow pain.
riority of HILT over LLLT is that HILT is able to reach and All enrolled patients were instructed not to take any anal-
stimulate the larger and/or deeper areas; accordingly, during gesic and/or NSAIDs during the treatment and control pe-
HILT therapy, significantly greater energy might be trans- riods. All patients were informed about the study procedure,
ferred into tissue compared to LLLT [9]. The effectiveness and they have given written consent to participate. This study
of HILT in LE is not yet clarified. was approved by the local ethical committee of the university.
As a conservative treatment intervention, splinting is one of
the most frequently used treatment modality for LE. Two pop- Treatment groups
ular methods of bracing include a forearm counterforce strap
and a wrist extension splint. Although braces are commonly Patients were randomly assigned to three treatment groups
prescribed for lateral epicondylitis, controversy still exits re- (HILT group vs sham therapy group vs brace group). Ran-
garding their effectiveness [10]. domization was allocated by using numbered envelopes meth-
Clinical examination is generally accepted to be appropri- od. HILT group (group 1) was treated with HILT. Sham ther-
ate for the diagnosis of LE in most patients [11]. However, in apy group (group 2) received placebo HILT. Patients in the
patients with persistent pain and disability despite treatment, brace group (group 3) used the lateral counterforce brace for
imaging methods including ultrasonography might be neces- LE. All enrolled patients were not treated with HILT before
sary. For this reason, ultrasonographic evaluation for injuries for any other disorders. The treatment modalities in all groups
of the extensor tendon, nearby soft tissues, and/or the cortex of (HILT, placebo HILT, or brace) were started 1 day after initial
the lateral epicondyle may be valuable [12]. assessment.
In this trial, we planned to investigate the effects of HILT in
patients with LE and to compare (clinically and HILT (pulsed Nd:YAG laser therapy)
ultrasonographically) these results with those of a brace and
sham HILT. Patients received pulsed Nd:YAG laser treatment, produced by
a HIRO 3 device (ASA Laser, Arcugnano, Italy). The apparatus
provided pulsed emission (1064 nm), very high peak power
Methods (3 kW), a high level of fluency (energy density; 360–
1780 mJ/cm2), a short duration (120–150 μs), a mean power
This prospective, randomized, controlled, assessor-blinded of 10.5 W, a low frequency (10–40 Hz), a duty cycle of about
study was conducted in Physical Medicine and Rehabilitation 0.1 %, a probe diameter of 0.5 cm, and a spot size of 0.2 cm2 [9].
Department of the university hospital between May 2013 and A standard handpiece endowed with fixed spacers was used
June 2014. Ninety-three patients (42 female/51 male; age to provide the same distance to the skin and perpendicularly to
range between 20 and 50 years) with the diagnosis of unilat- the zone to be treated with a laser beam diameter of 5 mm.
eral LE were enrolled in the study and assigned to three Three phases of treatment were performed for every session.
groups. Figure 1 summarizes the flowchart regarding patients’ The total energy delivered to the patient during one session was
enrollment. 1275 J through three phases of treatment. The first phase in-
Before inclusion, all subjects were examined by one of the volved fast manual scanning (100 cm2 per 30 s) of common
authors to confirm the diagnosis of LE. Patients were diag- extensor tendon (CET), soft tissues near the lateral epicondyle,
nosed based on the following criteria for LE: (1) pain in the and extensor muscles extending over forearm from lateral
lateral elbow region (lasting less than 3 months), (2) local epicondyle (extensor carpi radialis longus and brevis, extensor
tenderness on palpation over the lateral epicondyle, (3) carpi ulnaris, and extensor digitorum communis). Scanning
resisted wrist and/or middle finger extension produced typical was performed in both transverse and longitudinal directions.
pain at the origin on the lateral epicondyle, and (4) a positive In this phase, a total energy dose of 625 J was administered. In
Mill’s test [13]. Patients who fulfilled the above criteria were the first phase, the laser fluency was set to three subphases of
enrolled in the study. 510 mJ/cm2 (208 J), 810 mJ/cm2 (208 J), and 970 mJ/cm2
Exclusion criteria were as follows: (1) fibromyalgia, (2) (209 J), for a total of 625 J. The second phase involved apply-
previous treatment for ipsilateral LE, (3) substantial rheuma- ing the handpiece with fixed spacers vertically to 90° on CET
toid arthritis, osteoarthritis, or inflammatory arthropathy af- near the lateral epicondyle (trigger point inactivation phase).
fecting the elbow or wrist, (4) carpal tunnel syndrome, (5) The second phase was carried out on CET with a fluency of
cubital tunnel syndrome, (6) cervical radiculopathy, (7) previ- 360 mJ/cm2 (6 J), 510 mJ/cm2 (9 J), and 610 mJ/cm2 (10 J) and
ous elbow surgery, (8) previous radius/ulna fracture with re- a time of 6 s at each time, for a total of 25 J. The third phase
sultant deformity of the affected extremity, (9) other elbow involved slow manual scanning (100 cm2 per 60 s) of the same
Lasers Med Sci

Pateints with lateral epicondylis Excluded (n=21)

screened for eligibility (n=119)
Not meeng inclusion
criteria

Refused to parcipate
Eligible

(n=98) (n=5)

Agreed to parcipate and sign informed

consent statement

(n=93)

Randomizaon

HILT (n=31) Sham therapy (n=31) Brace (n=31)

1 drop out 1 drop out

Analyzed (n=30) Analyzed (n=31) Analyzed (n=30)

Fig. 1 Flowchart diagram for the participants who were randomized into three groups as receiving HILT, sham therapy, and brace

areas treated in the first phase until a total energy dose of 625 J given, but the laser instrument was switched off during appli-
was achieved (Table 1). The application time for one session cations. All laser applications were performed by the same
was approximately 15 min with the total energy delivered to the physiotherapist.
patient during one session of 1275 J. The energy received in
each phase and the total energy delivered to the patient during Brace
the treatment session were calculated by the device. HILT was
applied once a day for 15 days during a period of 3 weeks. In Patients in the brace group (group 3) used the lateral counter-
group 2 (sham therapy group), the same treatment protocol was force brace for LE (Aurafix, Turkey) during the daytime for
 Lasers Med Sci

Table 1 HILT therapy phases and applied frequency, fluency, and energy dose

HILT therapy phases Frequency (Hz) Fluency (energy density; mJ/cm2) Applied HILT energy dose (J)

Phase 1 fast manual scanning (100 cm2 per 30 s) 25 510 208

20 810 208
15 970 209
Phase 2 (trigger point inactivation phase) 15 360 6
15 510 9
14 610 10
Phase 3 slow manual scanning (100 cm2 per 60 s) 25 510 208
20 810 208
15 970 209
Total applied HILT energy dose 1275

HILT high-intensity laser therapy

4 weeks (Fig. 2). Brace removal was allowed only for bathing The Patient-Rated Tennis Elbow Evaluation (PRTEE)
and sleeping. questionnaire was used to measure the changes in functional
disability. The PRTEE questionnaire is a 15-item question-
naire specifically designed for patients with LE. The items
Outcome measurements investigate pain (five items) and the degree of difficulty in
performing various activities (six specific and four usual ac-
The patients were assessed for grip strength, pain, disability, tivity items) due to the elbow problem over the preceding
and quality of life. The same physician blinded to the random- week. Each item has one response option (0=no difficulty,
ization evaluated all the patients before treatment (week 0) and 10=unable to perform). The scores for the various items are
after treatment (after 4 and 12 weeks). Ninety-one patients used to calculate an overall scale score ranging from 0 (best
completed the study. One male patient in HILT group and score) to 100 (worst score) [15].
one male patient in brace group failed to complete the Quality of life was assessed by short-form 36 health survey
follow-up and dropped out of the study. (SF-36) [16].

Outcome measures Ultrasonographic evaluation

We measured grip strength at 90° elbow flexion with a hand Ultrasonographic examination of the patients was per-
dynamometer (baseline hydraulic hand dynamometer, formed before treatment (week 0) and after treatment (after
Irvington, NY, USA) and used the mean of three measure- 4 and 12 weeks) by a clinician with 4 years of experience in
ments [14]. musculoskeletal ultrasonography, who was blind to the pa-
Pain was assessed at rest and under strain by using a 10- tients’ clinical data. Ultrasonographic examination was per-
cm-long visual analog scale (VAS) (0 means no pain while 10 formed by using an Esoate Mylab 70 ultrasound machine
means worst pain). with an 18–6-MHz linear array transducer. The ultrasono-
graphic technique used in a previous study evaluating lat-
eral epicondylitis with ultrasonography was accepted as
reference [17]. The thickness/echogenicity of the CET and
bony cortex of the lateral epicondyle were assessed during
sonographic imaging (while patients were seated, elbows
flexed and pronated). For measurement of the thickness of
the CET, two lines were drawn; the first line was drawn
between the peak point and lowermost point of lateral
epicondyle. Then, the second line was drawn 90° perpen-
dicular to the lower end of first line. The second line gave
the thickness of the CET. The measurements were per-
formed three times and the mean of these measurements
Fig. 2 The lateral counterforce brace that was used was used for analysis (Fig. 3).
Lasers Med Sci

Fig. 3 Measurement of common

extensor tendon thickness (arrow
indicates the measured area of
common extensor tendon)

Statistical analysis correlation tests. All analyses were performed using the SPSS
for Windows 18.0 software program.
Descriptive statistics were expressed with mean±standard de-
viation. A level of significance of P<0.05 (two-tailed) was
accepted for this study. Chi-square test was used to compare
categorical variables (sex, occupation, side of involvement, Results
dominant hand, CET echogenicity, bony cortex of the lateral
epicondyle). Shapiro–Wilk test was used to analyze normality No adverse event was observed during HILT, sham therapy,
of the distribution of the data. Groups were compared with and/or brace therapy in the study. There were no statistically
one-way ANOVA (for normally distributed data (pain at rest, significant differences in the demographic features and pre-
pain under strain, CET thickness, all subgroups of SF-36); the treatment evaluation parameters of the patients between groups.
Tukey test was used as a post hoc test) and Kruskal–Wallis Demographic features of HILT group, sham therapy group, and
(the data without normal distribution (grip strength, PRTE brace group are given in Table 2. Pretreatment values for eval-
EQ); Mann–Whitney U test was used as a post hoc test). uation parameters of the groups are shown in Table 3.
Cochran Q test (for categorical data), Wilcoxon (the data with- The occupation of the patients were as follows: eight office
out normal distribution), and paired t test (for normally dis- workers, seven sales/marketing personnel, two heavy work
tributed data) were used to compare repeated measures/ workers, three unemployed, five full-time homemakers, one
evaluations within each group. The mean values of the per- part-time worker, and four farmers in HILT group; nine office
centage changes calculated for the groups were compared by workers, six sales/marketing personnel, two heavy work
using the independent sample t test (for normally distributed workers, three unemployed, six full-time homemakers, two
data) and Mann–Whitney U test (the data without normal part-time workers, and three farmers in sham therapy group;
distribution). The correlations were evaluated with Spearman and seven office workers, seven sales/marketing personnel,

Table 2 Demographic features of HILT group, sham therapy group and brace group

HILT group (n=30) Sham therapy group (n=31) Brace group (n=30) P

Age (years) 32.6±10.9 33.4±11.2 33.6±9.8 0.427

Sex (F/M) 13/17 14/17 15/15 0.866
Disease duration (days) 28.7±12.4 29.5±16.8 27.9±17.3 0.621
Body mass index 27.1±4.5 26.9±3.9 27.9±4.8 0.353
Side of involvement (R/L) 24/6 23/8 25/5 0.673
Dominant hand (R/L) 29/1 29/2 28/2 0.817

HILT high-intensity laser therapy, F female, M male, R right, L left

 Lasers Med Sci

Table 3 Pretreatment values for evaluation parameters of HILT group, sham therapy group, and brace group

HILT group (n=30) Sham therapy group (n=31) Brace group (n=30) P

Pain at rest (VAS) (cm) 4.3±1.3 4.4±1.2 4.2±1.5 0.683

Pain under strain (VAS) (cm) 6.2±2.3 6.3±1.9 6.2±2.6 0.809
Grip strength (kg) 46.5±17.1 45.7±15.8 46.1±13.4 0.729
PRTEEQ 56.8±21.2 58.1±24.3 55.9±19.7 0.492
CET thickness (mm) 52.7±7.7 53.8±9.6 54.1±9.7 0.596
CET echogenicity (hyperechohenic/hypoechogenic) 25/5 25/6 26/4 0.818
PEBCLE/AEBCLE 8/22 8/23 9/21 0.832
SF-36, PF 52.1±11.1 50.7±10.9 51.8±13.2 0.724
SF-36, RL 50.9±17.8 51.2±15.2 52.2±18.7 0.647
SF-36, BP 47.2±13.1 45.9±12.9 46.8±14.5 0.611
SF-36, GH 61.3±17.5 60.9±18.4 62.9±19.5 0.489
SF-36, V 48.3±14.8 49.4±11.6 49.1±9.9 0.714
SF-36, SF 67.3±17.9 69.1±25.2 69.9±31.7 0.326
SF-36, RLEP 68.3±29.7 69.3±28.8 68.7±24.6 0.650
SF-36, GMH 59.1±19.5 60.3±21.7 61.2±23.7 0.505

HILT high-intensity laser therapy, VAS visual analog scale, PRTEEQ Patient-Rated Tennis Elbow Evaluation Questionnaire, CET common extensor
tendon, PEBCLE presence of erosion in bony cortex of the lateral epicondyle, AEBCLE absence of erosion in bony cortex of the lateral epicondyle, SF-
36 short-form 36 health survey, PF physical function, RL role limitations due to physical functioning, BP bodily pain, GH general health, V vitality, SF
social functioning, RLEP role limitations due to emotional problems, GMH general mental health

three heavy work workers, two unemployed, five full-time functioning, bodily pain, general health, and vitality subparts
homemakers, two part-time workers, and four farmers in brace of SF-36 at the evaluations 4 and 12 weeks after treatment
group. Distribution of the patients according to occupation did (Tables 4 and 6). However, there were no statistically signif-
not show a significant difference between the groups (P>0.05). icant improvements in any evaluation parameter in sham ther-
HILT group and brace group showed significant improve- apy group after treatment (Table 5). Since HILT group and
ments for pain (VAS) scores, grip strength, PRTEEQ scores brace group showed significant improvements for most eval-
and physical function, role limitations due to physical uation parameters (for brace group, see Table 6), we compared

Table 4 The results and statistical comparisons of the pretreatment (week 0) and posttreatment (after 4 and 12 weeks) evaluation parameters in
HILT group

n=30 Baseline (week 0) After 4 weeks After 12 weeks P (week 0 to week 4) P (week 0 to week 12)

Pain at rest (VAS) (cm) 4.3±1.3 3.1±1.1 3.1±1.2 <0.001 <0.001

Pain under strain (VAS) (cm) 6.2±2.3 3.6±1.5 3.4±1.2 <0.001 <0.001
Grip strength (kg) 46.5±17.1 53.8±18.3 53.9±17.6 <0.001 <0.001
PRTEEQ 56.8±21.2 41.3±15.4 39.8±12.2 <0.001 <0.001
CET thickness (mm) 52.7±7.7 49.6±8.1 49.4±9.2 0.546 0.543
SF-36, PF 52.1±11.1 64.5±13.2 65.9±14.1 <0.001 <0.001
SF-36, RL 50.9±17.8 63.8±16.7 64.5±17.8 <0.001 <0.001
SF-36, BP 47.2±13.1 61.2±13.7 60.8±14.7 <0.001 <0.001
SF-36, GH 61.3±17.5 69.3±11.9 69.8±12.9 <0.001 <0.001
SF-36, V 48.3±14.8 55.3±15.7 55.7±16.4 <0.001 <0.001
SF-36, SF 67.3±17.9 68.8±15.6 69.6±18.3 0.716 0.523
SF-36, RLEP 68.3±29.7 68.9±26.2 69.3±27.6 0.612 0.578
SF-36, GMH 59.1±19.5 61.7±19.2 60.7±18.4 0.432 0.624

Bold shows statistically significant difference

HILT high-intensity laser therapy, VAS visual analog scale, PRTEEQ Patient-Rated Tennis Elbow Evaluation Questionnaire, CET common extensor
tendon, PEBCLE presence of erosion in bony cortex of the lateral epicondyle, AEBCLE absence of erosion in bony cortex of the lateral epicondyle, SF-
36 short-form 36 health survey, PF physical function, RL role limitations due to physical functioning, BP bodily pain, GH general health, V vitality, SF
social functioning, RLEP role limitations due to emotional problems, GMH general mental health
Lasers Med Sci

Table 5 The results and statistical comparisons of the pretreatment (week 0) and posttreatment (after 4 and 12 weeks) evaluation parameters in
sham therapy group

n=31 Baseline (week 0) After 4 weeks After 12 weeks P (week 0 to week 4) P (week 0 to week 12)

Pain at rest (VAS) (cm) 4.4±1.2 4.1±1.9 4.0±2.3 0.754 0.712

Pain under strain (VAS) (cm) 6.3±1.9 5.9±2.7 5.9±3.1 0.542 0.585
Grip strength (kg) 45.7±15.8 47.9±14.2 48.1±17.8 0.416 0.391
PRTEEQ 58.1±24.3 55.9±25.6 56.0±27.2 0.395 0.406
CET thickness (mm) 53.8±9.6 52.4±11.1 51.7±13.2 0.723 0.561
SF-36, PF 50.7±10.9 52.5±13.5 53.1±13.9 0.692 0.463
SF-36, RL 51.2±15.2 53.3±13.4 52.7±16.7 0.522 0.617
SF-36, BP 45.9±12.9 46.6±13.4 47.8±13.5 0.812 0.672
SF-36, GH 60.9±18.4 61.8±17.9 60.4±16.9 0.724 0.921
SF-36, V 49.4±11.6 51.6±12.3 50.6±12.4 0.678 0.825
SF-36, SF 69.1±25.2 69.7±23.6 70.7±26.3 0.816 0.693
SF-36, RLEP 69.3±28.8 68.8±22.2 68.5±29.3 0.854 0.716
SF-36, GMH 60.3±21.7 59.7±23.1 60.1±25.5 0.788 0.929

HILT high-intensity laser therapy, VAS visual analog scale, PRTEEQ Patient-Rated Tennis Elbow Evaluation Questionnaire, CET common extensor
tendon, PEBCLE presence of erosion in bony cortex of the lateral epicondyle, AEBCLE absence of erosion in bony cortex of the lateral epicondyle, SF-
36 short-form 36 health survey, PF physical function, RL role limitations due to physical functioning, BP bodily pain, GH general health, V vitality, SF
social functioning, RLEP role limitations due to emotional problems, GMH general mental health

the percentage changes of parameters after 4 and 12 weeks changes in CET thickness were also similar between the HILT
relative to pretreatment values in both groups. Comparison of and brace groups (Table 6). Also, cortical irregularities of the
the percentage changes of all parameters both after 4 and lateral epicondyle or echogenicity of the CET did not change
12 weeks relative to pretreatment values did not show a sig- significantly during follow-up. Comparison of the CET
nificant difference between HILT and brace groups (Table 7). echogenicity and presence or absence of erosion in bony cor-
Compared to the baseline measurements, the CET thick- tex of the lateral epicondyle of the three groups showed that
nesses did not change significantly after treatment (after 4 and there were no statistically significant differences between
12 weeks) in any group (Tables 3, 4, and 5). Further, the groups after treatment (data not shown). There was no

Table 6 The results and statistical comparisons of the pretreatment (week 0) and posttreatment (after 4 and 12 weeks) evaluation parameters in
brace group

n=30 Baseline (week 0) After 4 weeks After 12 weeks P (week 0 to week 4) P (week 0 to week 12)

Pain at rest (VAS) (cm) 4.2±1.5 3.0±1.4 2.9±1.3 <0.001 <0.001

Pain under strain (VAS) (cm) 6.2±2.6 3.7±1.7 3.5±1.5 <0.001 <0.001
Grip strength (kg) 46.1±13.4 53.2±13.5 53.6±14.8 <0.001 <0.001
PRTEEQ 55.9±19.7 43.7±16.5 42.1±13.7 <0.001 <0.001
CET thickness (mm) 54.1±9.7 51.8±10.2 50.9±11.3 0.411 0.336
SF-36, PF 51.8±13.2 63.9±11.5 64.7±15.3 <0.001 <0.001
SF-36, RL 52.2±18.7 64.7±19.2 64.8±20.3 <0.001 <0.001
SF-36, BP 46.8±14.5 60.8±16.8 61.5±17.9 <0.001 <0.001
SF-36, GH 62.9±19.5 71.6±17.2 71.9±18.3 <0.001 <0.001
SF-36, V 49.1±9.9 56.9±13.5 56.5±14.4 <0.001 <0.001
SF-36, SF 69.9±31.7 71.2±24.5 71.3±26.7 0.643 0.671
SF-36, RLEP 68.7±24.6 69.2±23.4 69.5±25.8 0.722 0.635
SF-36, GMH 61.2±23.7 62.2±21.5 62.5±24.7 0.542 0.525

Bold shows statistically significant difference

HILT high-intensity laser therapy, VAS visual analog scale, PRTEEQ Patient-Rated Tennis Elbow Evaluation Questionnaire, CET common extensor
tendon, PEBCLE presence of erosion in bony cortex of the lateral epicondyle, AEBCLE absence of erosion in bony cortex of the lateral epicondyle, SF-
36 short-form 36 health survey, PF physical function, RL role limitations due to physical functioning, BP bodily pain, GH general health, V vitality, SF
social functioning, RLEP role limitations due to emotional problems, GMH general mental health
 Lasers Med Sci

Table 7 Comparison of the HILT group and brace group on the basis of the posttreatment (after 4 and 12 weeks) percentage changes and difference
scores relative to pretreatment (week 0) values

Week 4 HILT group Week 4 Brace group P Week 12 HILT group Week 12 Brace group P

Pain at rest (VAS) (cm) −0.28±0.15 −0.28±0.17 0.823 −0.28±0.16 −0.31±0.18 0.512
Pain under strain (VAS) (cm) −0.42±0.20 −0.40±0.25 0.756 −0.45±0.24 −0.43±0.27 0.761
Grip strength (kg) 0.15±0.07 0.15±0.08 0.815 0.16±0.08 0.16±0.07 0.868
PRTEEQ −0.27±0.12 −0.22±0.15 0.498 −0.30±0.16 −0.25±0.18 0.453
CET thickness (mm) −0.06±0.03 −0.04±0.03 0.427 −0.06±0.04 −0.06±0.03 0.898
SF-36, PF 0.24±0.13 0.23±0.15 0.734 0.26±0.17 0.25±0.15 0.673
SF-36, RL 0.25±0.14 0.24±0.13 0.811 0.27±0.13 0.24±0.15 0.592
SF-36, BP 0.29±0.15 0.30±0.13 0.804 0.29±0.18 0.31±0.19 0.639
SF-36, GH 0.13±0.08 0.14±0.06 0.721 0.14±0.07 0.14±0.08 0.925
SF-36, V 0.14±0.07 0.16±0.09 0.562 0.15±0.08 0.15±0.09 0.891
SF-36, SF 0.02±0.01 0.02±0.01 0.845 0.03±0.02 0.02±0.01 0.721
SF-36, RLEP 0.01±0.01 0.01±0.01 0.921 0.01±0.01 0.01±0.01 0.849
SF-36, GMH 0.04±0.02 0.02±0.02 0.681 0.03±0.01 0.02±0.01 0.682

HILT high-intensity laser therapy, VAS visual analog scale, PRTEEQ Patient-Rated Tennis Elbow Evaluation Questionnaire, CET common extensor
tendon, PEBCLE presence of erosion in bony cortex of the lateral epicondyle, AEBCLE absence of erosion in bony cortex of the lateral epicondyle, SF-
36 short-form 36 health survey, PF physical function, RL role limitations due to physical functioning, BP bodily pain, GH general health, V vitality, SF
social functioning, RLEP role limitations due to emotional problems, GMH general mental health

correlation between ultrasonographic findings (CET thick- HILT and brace groups were not reflected to ultrasono-
nesses, echogenicity of the extensor tendon, and cortical irreg- graphic findings. (3) Comparison of the percentage changes
ularities of the lateral epicondyle) and clinical evaluations in of all parameters both after 4 and 12 weeks relative to pre-
the study (Table 8). treatment values did not show a significant difference be-
tween HILT and brace groups.
LLLT is a conservative treatment choice for patients with
Discussion LE. Trials on the effectiveness of LLLT in LE have shown
conflicting results. Earlier studies about the effectiveness of
The main findings of this study were as follows: (1) HILT LLLT on LE showed that LLLT is not effective in improving
and brace groups showed significant improvements for pain, grip strength, and global improvement on the short term
most evaluation parameters (pain (VAS) scores, grip in lateral epicondylitis [6, 18–23]. However, according to the
strength, PRTEEQ scores and physical function, role limi- results of other studies and a meta-analysis, LLLT may have
tations due to physical functioning, bodily pain, general some beneficial effects on pain reduction and grip strength
health, and vitality subparts of SF-36) after treatment (both increase [7, 8, 24–26]. Contradictory results may be consid-
after 4 and 12 weeks). (2) Improvements in pain scores, grip ered to be due to different treatment protocols regarding var-
strengths, and PRTEEQ scores of the patients with LE in iables such as dose, duration, and frequency [27].

Table 8 Correlations between ultrasonographic findings and clinical findings

n=91 CET thicknesses CET echogenicity Cortical irregularities of

the lateral epicondyle

Pain at rest (VAS) (cm) r 0.104 0.157 0.075

p 0.453 0.324 0.632
Pain under strain (VAS) (cm) r 0.212 0.196 0.109
p 0.175 0.286 0.542
Grip strength (kg) r 0.067 -0.045 -0.078
p 0.712 0.811 0.579
PRTEEQ r 0.168 0.068 0.110
p 0.272 0.382 0.456

VAS visual analog scale, PRTEEQ Patient-Rated Tennis Elbow Evaluation Questionnaire, CET common extensor tendon
Lasers Med Sci

LLLT is based on the belief that laser radiation, and possi- reducing the level of tension in the forearm extensors. Several
bly monochromatic light, are able to alter cellular and tissue trials have shown that elbow straps or sleeve orthoses have
function in a manner dependent on the characteristics of light superior results in terms of relief of pain and grip strength
itself [28]. Since LLLT works at low irradiation intensities compared with a placebo orthosis or wrist splints [40, 41]
(low energy doses), it is assumed that any biologic effects However, a meta-analysis did not find one type of brace to
are secondary to the direct effects of photonic radiation and be better than the others [6]. In our study, patients in the brace
are not the result of thermal processes. However, HILT uses group (group 3) used the lateral counterforce brace for LE.
higher-intensity laser irradiation and causes minor and slow Significant improvements were obtained for pain (VAS)
light’s absorption by chromophores, which has been utilized. scores, grip strength, PRTEEQ scores and physical function,
So that, some thermal processes in the target tissue may be role limitations due to physical functioning, bodily pain, gen-
triggered by HILT [29, 30]. eral health, and vitality subparts of SF-36 after treatment (both
A form of HILT, pulsed Nd:YAG laser therapy, has been after 4 and 12 weeks) in this group. According to the results of
used for a variety of diseases. Effectiveness of pulsed the current study, lateral counterforce brace for LE is not su-
Nd:YAG laser therapy in pain control has been shown in ankle perior to HILT therapy.
pain [31], subacromial impingement syndrome [32], low back Ultrasonography has been usually used as a convenient
pain [30, 33], and knee osteoarthritis [34, 35]. To the best of imaging method for the diagnosis and follow-up of soft tissue
our knowledge, no study has investigated the effectiveness of disorders. From this point, we tried to observe whether we
HILT in patients with LE. The results of this study revealed could quantify the changes also by using CET thickness mea-
that pulsed Nd:YAG laser therapy (HILT) is as effective as surements. However, there was no correlation between ultra-
brace therapy in the treatment of these patients with respect sonographic findings (CET thicknesses, echogenicity of the
to decreased pain and disability and improved quality of life. extensor tendon, and cortical irregularities of the lateral
The analgesic effect of HILT is based on multiple mecha- epicondyle) and clinical findings (pain scores, disability, and
nisms of action, including its ability to slow the transmission quality of life) in the study. Previously, in three different stud-
of the pain stimulus and to increase the production of ies, authors investigated whether ultrasonographic findings
morphine-mimetic substances in the body [9]. LLLT may were associated with clinical findings of the patients with
have a direct effect on nerve fibers, which could inhibit Aδ- LE or not. Clarke et al. [42] found no correlation with clinical
and C-fiber transmission [36]. Also, LLLT may increase blood findings and thickness of the tendon in patients with LE.
flow and cell metabolism [37]. We believe that the main dif- Zeisiq et al. [43] followed up the patients with LE after
ference between HILT and LLLT is the intensity of laser ther- intertendinous injection therapy but could not indicate a rela-
apy. So, we may hypothesize that HILT may also have these tionship with ultrasonographic findings and clinical results.
therapeutics effects of LLLT more strongly. In addition, we Gunduz et al [17] compared the therapeutic effects of physical
may hypothesize that by applying HILT over LE, some therapy modalities, local corticosteroid injection, and extra-
photothermal energy may be transferred into tissue. Moreover, corporeal shock wave treatment in LE. They found that ultra-
the photochemical and photothermic effects of HILT may sonographic findings did not change in the first 6 months of
stimulate collagen production within tendons and increase these treatment methods. Also, our ultrasonographic findings
blood flow, vascular permeability, and cell metabolism and were in line with the previous studies [17, 42, 43]. The ab-
thus help to repair damaged tendon and remove the painful sence of the correlation can be due to the shortness of evalu-
stimulus. ation period. Longer follow-up (more than 3 months up to
Traditional nonoperative therapy for lateral epicondylitis is 1 year) of the patients with ultrasonography may reveal a
directed toward control of inflammation, enhancement of mi- correlation between ultrasonographic findings and clinical
croscopic and macroscopic tissue healing, reconditioning of findings. Therefore, the changes would be ensuing later than
the extremity, and alteration of abusive force patterns. Among the third month posttreatment.
conservative treatment interventions, splinting is one of the Currently, there is no a standardized, universally accepted
most frequently used modalities for treating lateral program for LE treatment, and also, both treatment methods
epicondylitis [38]. However, studies on the effectiveness of (HILT and brace) are noninvasive and painless and easy for
splinting in LE also have shown conflicting results. Cochrane use. So that, we wanted to investigate the effects of HILT in
database systematic review found that no definitive conclu- patients with LE and to compare these results with those of a
sions can be drawn concerning effectiveness of orthotic de- brace or placebo HILT. Also, there is no universally accepted
vices for the treatment of LE [39]. But, in a meta-analysis, treatment protocol concerning number of session, duration,
Borkholder et al. reported one Sackett level 1b study and ten frequency, and dose for both HILT and brace therapies. Since
Sackett level 2b studies that offer early positive, but not con- both treatment groups used different regimens of treatment,
clusive, supporting the effectiveness of splinting lateral HILT was applied once a day for 15 days (15 min daily) during
epicondylitis [38]. Lateral counterforce braces work by a period of 3 weeks, while brace groups used lateral
 Lasers Med Sci

counterforce brace for a longer time (4 weeks and only re- 9. Zati A, Valent A (2006) Laser therapy in Medicine. In: Medica M
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with the same duration (4 weeks), we might find statistically
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1 year) follow-up results. Another limitation is that there was servative treatment of tennis elbow. AJR 185:1113–1118
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not any group treated with both HILT and brace therapy to-
ments at two different wrist extension positions in chronic lateral
gether. If we had such a group, we could discuss the additional epicondylitis-comparison of involved vs. uninvolved side in athletes
effect of HILT in LE. and non athletes: a case-control study. Sports Med Arthrosc Rehabil
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and splinting) of LE. As a result, it is concluded that pulsed
pinch grip strength in adults. Int J Rehabil Res 33(1):4–11
Nd:YAG laser treatment (HILT) and splinting are an effective 15. Cacchio A, Necozione S, MacDermid JC, Rompe JD, Maffulli N, di
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Conflict of interest The authors report no conflict of interest.
18. Stasinopoulos DI, Johnson MI (2005) Effectiveness of low-level la-
ser therapy for lateral elbow tendinopathy. Photomed Laser Surg 23:
Source of funding No funding was received for this study 425–30
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