ELECTROTHERAPY II

LASER (LIGHT AMPLIFICATION BY

STIMULATED EMMISSION OF
RADIATION)
TOPIC – LOW LEVEL LASER THERAPY
FOR ANKYLOSING SPONDYLITIS PATIENTS

DOSIMETRY CHECKED BY:

APOORVRDGARG
B. P. T. 3 YEAR
ROLL THNUMBER 04
20 BATCH
SESSION 2020-21
Lasers Med Sci
DOI 10.1007/s10103-016-1874-2

ORIGINAL ARTICLE

LLLT for the management of patients with ankylosing spondylitis

D. Stasinopoulos 1 & K. Papadopoulos 1 & D. Lamnisos1 & A. Stergioulas2

Received: 16 October 2015 / Accepted: 12 January 2016

# Springer-Verlag London 2016

Abstract This study aimed to compare the effectiveness of passive stretching exercises decreased pain more
the combined low-level laser therapy (LLLT) and passive effectively than placebo LLLT along with the same passive
stretching with combined placebo LLLT laser and the same stretching exercises in patients with Αnkylosing
passive stretching exercises in patients suffering from spondylitis. Future stud- ies are needed to establish the
Αnkylosing spondylitis. Forty-eight patients suffering from relative and absolute effective- ness of the above protocol.
Αnkylosing spondylitis participated in the study and were
ran- domized into two groups. Group A (n = 24) was Keywords LLLT . Ankylosing spondylitis . Passive
treated with a λ= 820 Ga-Al-As laser CW, with power stretching
intensity = 60 mW/ cm2, energy per point in each session =
4.5 J, total energy per session = 27.0 J, in contact with
specific points technique, plus passive stretching exercises.
Introduction
Group B (n = 24), received pla- cebo laser plus the same
passive stretching exercises. Both groups received 12
Ankylosing spondylitis (AS) is the most common of the
sessions of laser or placebo within 8 weeks; two sessions
five subtypes of spondyloarthritides [1]. AS is more
per week (weeks 1–4) and one session per week (weeks 5–
prevalent than undifferentiated spondyloarthritides and
8). Pain and function scales were completed before the
psoriatic arthritis and is a disease that involves joints and
treatment, at the end of the fourth and eighth week of
ligamentous attachments of the spine with the most typical
treatment, and 8 weeks after the end of treatment (follow-
findings to be a result from enthesitis and sacroiliitis [2].
up). Group A revealed a significant improvement after 8
AS is a chronic inflammatory disease that progressively
weeks of treatment in all pain and function scales. At 8-
deteriorate and predominantly affects the spine and may
week follow- up, the improvement remained only for the
cause serious functional impairment. This process is
pain, while for all other function outcomes the differences
characterized by the infiltration of tissue destruction,
were not statistically significant. The results suggested that
mononuclear inflam- matory cells, and attempts at healing
after an 8-week treat- ment and after a follow-up, the
by fibrosis and angio- genesis. Macrophages are the central
combination of LLLT and
and dominant cells in chronic inflammation; they are
activated by clinical mediators such as interferon-γ,
produced by T lymphocytes [3, 4].
* K. Papadopoulos
[email protected] The prevalence of AS is 0.4–1.4 % and affects males
more than female patients with a ratio of about 2:1 to 3:1
and usually starts in the third decade of life [5]. The
1
Physiotherapy Program, Department of Health Sciences, School disease is known to have definite socio-economic
of Sciences, European University Cyprus, Laureate International implications [6].
Universities, 6 Diogenes Street, 2044 Engomi, Nicosia, Cyprus AS treatment aims to reduce morning stiffness and pain;
2
Lab of Health, Fitness and Disability Management, Faculty of to delay the evolution of the disease; to maintain posture;
Human Movement and Quality of Life, University of to prevent malfunction, deformity, disability, and handicap;
Peloponnese, Efstathiou & Stamatikis Balioti & Plateon, 231 00 and preserve physical condition and psychosocial
Sparta,
Laconia, Greece health. Additionally, treatment points to suppress the
inflammation
 Lasers Med Sci

process at the early stages in order to slow the progression

Methods
of the disease [7].
Magnetic resonance imaging (MRI) showed an
The present investigation was a randomized, placebo-
inflamma- tion at the interphase of cartilage and bone and
controlled, double-blinded trial, performed at the Lab of
has been con- vincingly demonstrated by biopsies [8]. This
Health, Fitness and Disability Management, Faculty of
process was re- ported by immunohistological
Human Movement and Quality of Life, Peloponnese
investigations of sacroiliac joint biopsies [9]. Dense
University, between January 2012 and December 2014. The
mononuclear infiltrates invading the cartilage have been
Panarkadikon Hospital Ethics Committee approved the study
described and TNF-a messenger RNA (mRNA) has been
in January 2012.
detected in inflamed sacroiliac joint. Enthesitis is the
condition in which bony spurs is developed very slowly, and
Selection of patients
at the end of inflammation phase. Bones are
intramembranous, endochondral, and chondroidal without
Patients with AS were recruited through advertisement in
local hypervascularity or cellular hypertrophy [10].
the local newspapers of Peloponnese prefecture cities:
Progression of AS is slow and irregular. Structural
Sparta (Laconikos typos and Paratiritis); Kalamata
progression involve a new bone which can be likened to be
(Εleftheria, Tharros, and Peloponnesos); and Tripolis
a reparative or stabilizing
(Arkadic news, Kalimera Arcadia, Arcadia press and Notos
response to mechanical and inflammatory stress [11, 12].
press). Also, do- mestic radio stations announced the study
Electrotherapy modalities (EMs), started to be used by
and the possibility of suffering by AS patients to
physiotherapists since the early days of physiotherapy. It is
participate. These are Politeia and Fly and different blogs
supported that the application of EMs and the produced
as apela.gr, Laconicorama, and Notos.gr.
ener- gy can modify the biological processes of the living
The diagnosis of AS was made on the basis of modified
body. The heating of the tissue and the biophysical effects
New York criteria [31] scale by rheumatologists of the
of EMs can affect the homeostasis and metabolic reactions
Hospitals Kalamata, Panarkadikon, and Korinthos or by
of the body and induce specific tissue changes.
rheu- matologists in private practice in the mentioned
Vasodilatation, fluids viscosity, and tendon extensibility are
Peloponnese prefecture cities.
the main results of EMs applica- tions [13, 14].
Eligible patients were given a detailed description of the
One of the recent EMs modality used in physiotherapy
intended treatment procedure and were informed about the
as an alternative non-invasive treatment is therapeutic
possibility of receiving placebo therapy, and their right to
laser. Low-level laser therapy has been used as a non-
withdraw from the study at any time. After receiving this
invasive, non-thermal modality to treat a variety of
information in a participant information sheet, the patients
musculoskeletal conditions [15–21].
gave their informed consent.
The application of low-level laser therapy (LLLT)
The criteria were as follows: (a) a moderate degree of
inhibits significantly the expression of interferon-γ and IL-
pain [between 4 to 7 according to the visual analogue scale
1β, and decreases inflammation process by changing the
(VAS)],
expression of genes encoding inflammatory cytokines [22].
(b) stiffness, (c) a score of 2 or higher (according to the 1–
Stretching exercises are widely used both for the injury
5 score) for patient’s global evaluation, and (d) able to
prevention and the rehabilitation programs [23, 24]. In the
speak and read Greek. The exclusion criteria is if the
case of AS patients, the effects of different stretching tech-
patient had the following: (a) active peripheral arthritis, (b)
niques (number of repetitions, holding time, and the
secondary FMS,
holding time of stretching exercise), does not apply alone,
(c) total spinal ankylosis, (d) an erythrocyte
but as part of an exercise program [25–29]. Only one study
sedimentation rate (ESR) of 50 mm/h, and (e) a C-
reported the effects of passive stretching in patients
reactive protein (CRP) more than 10 times the normal
suffering from AS, and the study showed positive results
value [32, 33].
[30].
Seventeen patients (nine from the experimental group
To our knowledge, there has been no previous report of
and eight from the control group) left the study to seek
the effects of LLLT combined with passive stretching in
another treatment method because they still had symptoms
the treat- ment of patients suffering from ankylosing
after six treatments. The study was completed with 48
spondylitis. Therefore the purpose of this investigation
patients. The active laser group was made up of 14 men
was to compare the effectiveness of active laser and
and 10 women, and the placebo laser group was made up
passive stretching with placebo laser and passive
of 15 men and 9 women (Fig. 1).
stretching, in patients suffering from AS. It was
hypothesized that LLLT with passive stretching would be
Randomization
more effective than placebo laser with passive stretching in
pain, mobility, functional capacity and activity, physical
The laboratory director A.T. randomized patients into one of
function, fatigue, morning stiffness, tenderness, and spinal
two groups with the following procedure: he asked patients
or joint pain of patients with AS.
to select any of the 65 identical opaque-sealed envelopes.
The
Lasers Med Sci

The above-mentioned specific points were found by the

researcher (A.T.). This procedure was based largely on pain
description and patient complaints and according the
clinical characteristics. These included (a) pain produced
on active or passive stretch of the erector spine muscles,
(b) dysesthesias and tenderness referred in relative defined
zones, and (c) the contraction of erector spine that produce
pain [13, 14].
The specific points were delineated with a waterproof
marker during the first visit. Before laser treatment was ap-
plied, the target area was cleaned with alcohol (95 %) to
min- imize any backscatter or reflection from oily skin.
Treatment was given two times per week (weeks 1–4)
and 1 treatment per week (weeks 5–8), for a number of 12
treat- ments during the study period. For protection from
the laser’s beam, all subjects wore protective glasses. Both
groups were treated under the same conditions, and the
patients were treat- ed individually to avoid influencing
one another. No compli- cations were reported.
The placebo laser apparatus appeared to be identical to
the active laser device. The laser’s output was checked by
an independent party before the start and at the end of the
study, and also at regular intervals during the study.
Fig. 1 Flow chart

Passive stretching exercises

envelopes contained a group number and a study number, 1
(active laser) or 2 (placebo laser). This is based upon a
The passive stretching exercise program used for both
computer-generated random number list and the group
groups was adapted according to the guidelines by Alter
num- ber corresponded to the setting of a switch on the
[24], Key and Blazevich [34], Kisner and Colby [35], and
laser unit. Neither the director of the lab, the treating
Page [36]. This exercise regime included analytic passive
physiotherapists, nor the patients had any knowledge of
stretching ex- ercises of the cervical spine, thoracic, and
which group was re- ceiving the active laser treatment.
erector spine mus- cle. Also, the program included passive
stretching of ham- strings and shoulder muscles. At the end
Laser protocol of each session, breathing exercises were performed.
The passive stretching exercises were performed with
The laser apparatus used in the present investigation was the help of the physical educator teacher (PET) of the lab,
the Model Biotherapy 3ML semiconductor laser who was a specialist in the use of stretching in the
manufactured by Omega Laser Systems Limited (2 Deans rehabilitation of musculoskeletal spine problems. The PET
Hall Business Park, Oak Road, Little Maple stead, was masked to the treatment plan. The PET helps the AS
Halstead, Essex C09 2RT, UK), as reported in the subjects to execute full range of motion of each exercise
manufacturer’s handbook). according to the patient’s tolerance. The PET held the final
This device was a Ga-Al-As laser, wavelength 820 nm, range position of the patient for 20 s each time and then
continuous mode. Laser parameters are presented in Table relaxed. Each passive stretching exercise repeated six
1. The contact technique was used. Laser treatment was times, while a 20-s rest between each repetition. Passive
deliv- ered with the patient lying prone. The following stretching exercises were given two times a week for 16
specific points were chosen: (a) paraspinal at weeks [23].
cervicothoracic junction. The above-mentioned are motor
points of segmental erector spinae, which correspond to Measurements
local bladder meridian acupunc- ture points (between
transverse processes) with nerve inner- vation, that overlie The physical therapist at the lab, D.Κ., who was unaware
segmental posterior primary rami (b) On midline at level of of the treatment type being received by each patient,
T12-L1. Segmental posterior primary rami nerve performed the measurement before the intervention and at
innervation: segmental posterior primary rami and (c) weeks 4, 8, and 16.
paraspinal at lubrosacral junction nerve innervation: Each patient’s evolution was closely followed, with four
overlie segmental posterior primary rami. checks made during the study: one check at the beginning
 Lasers Med Sci

Table 1 Laser parameters

clinical trial, measurements were evaluated independently.
Active medium Ga-Al-As Patients repeated all movements three times, and the mean
of these values was employed in the analysis.
Wavelength 820 nm The Bath Ankylosing Spondylitis Functional Index
Class 3B laser diode (BASFI) is one of the instruments that has been
Mode CW recommended by the Assessment in Ankylosing
Power output 30 mW Spondylitis Working Group (ASAS) for measuring
Power density 60 mW/cm2 physical function [43]. This scale eval- uates the functional
Irradiation area Cervical, thoracic & lumbar status of AS patients and consists of two questions that
spine assess patients’ ability to cope with everyday life and eight
Spot size 0.5 cm2 questions on daily activities.
Number of irradiation points 6 (2 CS; 2 TS; 2 LS) The questions are arranged on a 10-horizontal visual
Energy 4.5 J ana- logue Likert scale, from Beasy^ to Bimpossible.^ The
Total energy per session 27.0 J BASFI score is obtained from the sum of all values. Lower
score of
Total energy delivered in 12 324.1 J the BASFI reflects lower limitation. For the present study,
sessions we used the Greek version of the Bath Ankylosing
Spondylitis
Treatment time 150 s per each point index. In the present
Irradiation technique: In skin contact, probe
held stationary

(pretreatment), a second check at the end of the 4 weeks

(post treatment 1), a third at the end of the treatment (8
weeks, post treatment 2), and a fourth check at the 8 weeks
after the end of the treatment (follow-up).

Pain

Pain intensity during daily activities was assessed using a

visual analog scale (VAS). The VAS consisted of a
continuous horizontal line of 100 mm in length, with
anchor points Bworst pain^ and Bno pain.^ The subject
was asked to use the VAS to rate the magnitude of pain
felt. The distance from the extreme left on the VAS to the
patient’s mark was then was then mea- sured to the nearest
millimeter [37].
Changes in mobility, functional capacity, and activity,
were evaluated using the Bath Ankylosing Spondylitis
Metrology Index (BASMI), that was previously validated
from authors Jenkinson, Mallorie, and Whitelock [38]. The
BASMI con- sists of five clinical measures used to assess
the status of the parts of the spine: the modified Schöber
test [39], tragus to wall distance [40], lumbar side flexion,
cervical rotation [41], and intermalleolar distance. A
cervical goniometric device manufactured by Perfomance
Attainment Associates (St. Paul, MN) was employed for
active cervical rotation assessment.
Both sides were measured and the mean of the obtained
values was calculated. Psychometric properties of this
index are good interobserver reliability on each clinical
measure (r = 0.99, p = <0.001), and criterion validity (total
metrology score) of r = 0.092, p < 0.001. BASMI authors
reported that these clinical measures could be analyzed
independently. However, Sieper et al. [42], suggested cut
points on a 0–10 scale to assess a total score of the BASMI
Functional Index. Chatzitheodorou et al. [44] found out while the independent samples Mann–Whitney U test was
that BASFI-GrV had a good internal consistency and a used for the continuous non-normally distributed
correlation coefficient for test-retest was high on average variables. The chi- squared test was used to test for
(r = 0.91, p < 0.001). difference between the two groups with respect to the
Τhe Bath Ankylosing Spondylitis Disease Activity categorical variable gender. The distribution of all
Index (BASDAI) was used to evaluate the evolution of dependent variables was examined by Shapiro–Wilk and
the disease in AS patients. In the BASDAI, questionnaire found that the distribution of the dependent variables VAS,
included six ques- tions, that is relating to five symptoms BASFI, Schöber test (STEST), cervical rota- tion (CervR),
during the last week: fatigue, morning stiffness, lumbar side flexion (LsideF), and intermalleolar distance
tenderness, and spinal or joint pain. All questions are (IntMD) did not differ significantly from normal dis-
arranged on a 10-cm horizontal visual ana- logue scale. tribution while the distribution of the remaining dependent
The score on the BASDAI is obtained from the sum of the variables, tragus to wall distance (TrwallD) and BASDAI,
values from the first five questions. Higher score of the was significantly different from normal. Mixed ANOVA
BASDAI reflects greater disease activity [45]. with time as a within-subjects factor and treatment as the
between- subjects factor was used to analyze the dependent
Statistical analysis variables VAS, BASFI, STEST, CervR, IntMD, and lumbar
side flex- ion. Tragus to wall distance (TrwallD) and
Independent samples t test was used to test the difference BASDAI were analyzed with a generalized mixed effect
at baseline between the treatment and control groups with model with treat- ment as a fixed factor, time as a random
re- spect to continuous normally distributed variables factor, and inverse as the link function. Linear contrasts
were constructed to
 Lasers Med Sci

determine the between-group difference (simple main The main effect of the group was statistically significant
effects) at each time point. In the case of the generalized (p < 0.05) for all outcomes indicating significant
mixed effect models, the likelihood ratio test (LRT) was improvement in the treatment group in comparison to the
performed to test for a significant main effect of group and control group. The difference between the treatment and
a significant inter- action between the effect of group and control groups was sta- tistically significant at 8 weeks for
time. all outcomes (the adjusted effect size from mixed ANOVA
The LME4 package of the statistical software R (version was for VAS = −32.5, 95 % confidence interval [CI] =
2.12.1; R Foundation for Statistical Computing, Vienna, −40.0 to −25.0; BASFI = −13.1,
Austria) was used for fitting the generalized mixed effect 95 % CI = −22.2 to −4.1; STEST = 0.7, 95 % CI = 0.1 to
model. All the other analyses were performed using the 1.3;
Predictive Analytics Software Statistics 20 (SPSS Inc, CervR = 15.9, 95 % CI = 6.2 to 25.5; LsideF = 2.2, 95 %
Chicago, IL, USA). Significance test and confidence CI = 0.8 to 3.6; and IntMD = 8.3, 95 % CI = 2.3 to 14.4
intervals were calculated at a significance level of 0.05. while for BASFI and TrwallD, the p values of the adjusted
effect size from the generalized linear mixed models were
p < 0.01). However, with the exception of VAS, the
Results difference between the two groups was not statistically
significant at 8-week fol- low-up for all other outcomes
Sixty-five patients who met the inclusion criteria and had a (the adjusted effect size from mixed ANOVA was for
diagnosis of AS were included in the study. Patient character- VAS = −41.9, 95 % CI = −49.4 to
istics are presented in Table 2. There were no significant dif- −34.5, BASFI = −8.9, 95 % CI = −18.1 to 0.1; STEST =
ferences in gender, age, DISDUR, ESR, and baseline mea- 0.5,
surements between the treatment and control groups (Table 95 % CI = −0.1 to 1.1; CervR = 4.9, 95 % CI = −4.7 to
1). 14.6;
The interaction between the effect of group and time LsideF = 1.1, 95 % CI = −0.3 to 2.5; and IntMD = 4.3, 95
was statistically significant only for two outcomes, %
BASFI (F(3138) = 2.84, p = 0.04) and Tragus to wall CI = −1.8 to 10.4 while the p values of the adjusted effect
distance (p for LRT = 0.003). The simple main effects size for BASFI and TrwallD were 0.36 and 0.14,
analysis with linear contrasts showed that there was respectively).
significant difference between treatment and control
groups at 8 weeks (p < 0.01) for both outcomes, but there
was no difference between the two groups at 4- and 8-week Discussion
follow-up (Tables 3 and 4).
Τhe present study was conducted to ascertain whether a
combination of LLLT with passive stretching for 8 weeks
and an 8-week follow-up period for patients with anky-
losing spondylitis, would indicate any effects on pain and

Table 2 Anthropometric
characteristics and baseline Variable Treatment (n = 24) Control (n = 24) p value
measurements of the treatment
and control groups (n = 48) Gender, n (%)
Male 14 (58.3 %) 15 (62.5 %) 0.77†
Female 10 (41.7 %) 9 (37.5 %)
Age 46.4 (7.5) 47.0 (8.9) 0.59+
DISDUR 8.9 (2.6) 8.0 (2.8) 0.58+
ESR, median (IQR) 28.8 (17.6) 35.0 (21.9) 0.22*
VAS 70.0 (14.9) 67.5 (15.8) 0.59+
BASFIα 51.5 (16.7) 48.6 (17.5) 0.55+
Schöber test 2.2 (0.9) 2.2 (1.0) 0.91+
Cervical rotation 51.3 (17.9) 49.5 (19.9) 0.73+
Lumbar side flexion 4.8 (2.1) 5.0 (2.2) 0.66+
Intermalleolar distance 80.9 (11.4) 77.5 (21.7) 0.53+
Tragus to wall distance, median (IQR) 5.8 (3.3) 5.3 (3.3) 0.56*
BASDAI, median (IQR) 28.2 (13.3) 25.9 (12.0) 0.42*

Values are mean (SD) unless otherwise stated

†
χ2 test
+
Independent sample t test *Mann–Whitney U test
α
Range of scores = 0–50; higher scores represent higher levels of disability
 Lasers Med Sci

Table 3 Results of analysis comparing outcomes between treatment and control groups

Outcome variable Unadjusted mean (SD) for each group Unadjusted Mean p value Adjusted mean difference p value
Difference between groups† (95 %
between groups (95 % CI) CI)
Treatment Control

VAS
4 weeks 52.9 (14.8) 66.5 (15.2) −13.6 (−22.3, −4.9) <0.01 −13.6 (−21.0, −6.1) <0.01
8 weeks 33.1 (8.6) 65.6 (14.3) −32.5 (−39.4, −25.6) <0.01 −32.5 (−40.0, −25.0) <0.01
8 weeks follow-up 26.7 (6.8) 68.6 (11.7) −41.9 (−47.5, −36.5) <0.01 −41.9 (−49.4, −34.5) <0.01
BASFI
4 weeks 41.7 (15.4) 46.5 (16.9) −4.8 (−14.1, 4.6) 0.31 −4.8 (−13.9, 4.3) 0.30
8 weeks 37.4 (13.7) 50.6 (15) −13.2 (−21.7, −4.6) <0.01 −13.1 (−22.2, −4.1) <0.01
8 weeks follow-up 43.9 (15.6) 52.8 (16.4) −8.9 (−18.2,0.4) 0.06 −8.9 (−18.1, 0.1) 0.05
Schöber test
4 weeks 2.6 (1.1) 2.2 (1.0) 0.4 (−0.2, 1.0) 0.20 0.4 (−0.2, 1.0) 0.21
8 weeks 2.8 (1.6) 2.1 (0.9) 0.7 (−0.0, 1.5) 0.06 0.7 (0.1, 1.3) 0.02
8 weeks follow-up 2.7 (1.0) 2.2 (0.9) 0.5 (−0.1, 1.1) 0.07 0.5 (−0.1, 1.1) 0.10
Cervical rotation
4 weeks 59.3 (17.1) 47.4 (18.9) 11.9 (1.4, 22.4) 0.03 11.9 (2.2, 21.5) 0.02
8 weeks 66.1 (14.1) 50.2 (16.0) 15.9 (7.1, 24.6) <0.01 15.9 (6.2, 25.5) <0.01
8 weeks follow-up 58.5 (15.4) 53.6 (16.3) 4.9 (−4.3, 14.1) 0.29 4.9 (−4.7, 14.6) 0.32
Lumbar side flexion
4 weeks 5.8 (2.9) 4.9 (2.2) 0.9 (−0.6, 2.4) 0.22 0.9 (−0.5, 2.3) 0.19
8 weeks 7.4 (2.9) 5.2 (2.2) 2.2 (0.7, 3.7) <0.01 2.2 (0.8, 3.6) <0.01
8 weeks follow-up 6.1 (2.9) 5.0 (1.9) 1.1 (−0.3, 2.5) 0.13 1.1 (−0.3, 2.5) 0.13
Intermalleolar distance
4 weeks 86.8 (8.3) 77.0 (10.8) 9.7 (4.1, 15.3) <0.01 9.7 (3.7, 15.8) <0.01
8 weeks 89.8 (11.6) 81.4 (10.6) 8.3 (1.9, 14.8) 0.01 8.3 (2.2, 14.4) <0.01
8 weeks follow-up 84.2 (10.7) 79.9 (10.4) 4.3 (−1.8, 10.4) 0.16 4.3 (−1.8, 10.4) 0.16

Values are mean (SD) unless otherwise stated

†
Adjusted values from mixed model analysis
α
Range of scores = 0–50; higher scores represent higher levels of disability

functional activities of the patients. The parameters condition and their modulation at the early stages may
followed were daytime pain intensity, the BASMI, slow the progression of AS. However, the planning of
BASFI, and BASDAI. After 8 weeks of treatment, all treatment is dependent from severity, the localization, the
the above-mentioned parameters showed significant im- manifestation, and the degree of progress of AS [1, 2].
provement in comparison with placebo laser with passive Anti-inflammatory medications such as indomethacin,
stretching. These differences remained unchanged in the diclofenac, novel more COX-2-selective agents, cortico-
follow-up period only for the pain perception, while in the steroids, and biological therapy with agents directed
other outcomes, although remained changed, the differ- against tumor necrosis factor-alpha (TNF-a), seem to have
ences between the two groups were not statistically an effect in the pain perception and in the other symptoms
significant. of AS patients. However, these biological agents have
A serious symptom of inflammation in AS patients is various side effects and its clinical use is questioned and
pain which is produced by pro inflammatory cytokines. For limited [48].
exam- ple, interleukin-6, increases the sensitization of thin LLLT is the modality used in rehabilitation departments
myelinat- ed A delta fibers and unmyelinated C fibers to decrease inflammation and pain. It is believed that LLLT
innervating the joint [46]. Additionally, tumor necrosis acts similarly as the effects of nonsteroidal anti-
factor-alpha (TNF-a), and interleukin-1beta (IL-1β), inflammatory ste- roids and drugs. Laser light enhances the
contribute to pain hypersensi- tivity [47]. blood concentration of B-endorphins, reduces the level of
Thus, the treatment options are the suppression of the prostaglandin E2, and inhibits the release cyclo-oxygenase.
in- flammatory mediators, that are increased in the Also, it modulates nerve transmission [16–20, 49].
diseased
Lasers Med Sci

Table 4 Results of analysis

comparing outcomes Outcome variable Median (IQR) for each group Median Difference p value p value†
between treatment and Between Groups (95 % CI)
control groups Treatment Control

Tragus to wall distance

4 weeks 3.1 (11.5) 5.1 (5.1) −2.0 (−3.1, −1.0) <0.01 <0.01
8 weeks 2.8 (2.3) 5.9 (4.1) −3.1 (−4.5, −1.4) <0.01 <0.01
8 weeks follow-up 5.1 (3.0) 5.5 (3.9) 0.5 (−2.2, 1.3) 0.45 0.36
BASDAI
4 weeks 24.8 (7.9) 28.3 (11.9) −3.6 (−9.4, 0.1) 0.07 0.25
8 weeks 21.3 (9.3) 26.6 (10.0) −5.4 (−9.1, 1.8) <0.01 0.02
8 weeks follow-up 22.1 (8.3) 25.1 (4.9) −3.0 (−6.0, 0.6) 0.07 0.14
†
p values from generalized mixed model analysis
α
Range of scores = 0–50; higher scores represent higher levels of disability

However, the exact mechanisms by which LLLT Kingsley et al. [63], and Yousefi-Nooraie et al. [64] in the
alleviates pain is not fully understood. It is believed that reviews.
laser irradiation causes a series of reactions in biological However, in spite of the above-mentioned positive LLL
tissues. Increase in NO, which is beneficial in the healing effects, Chou and Huffman supported that LLLT may not
process since its in- crease at the inflammation site, would be beneficial for spondyloarthritides [65].
improve the local in- flammation [50, 51]. With regards to AS, only one study by Aydin et al. [66]
LLLT causes an increase in the metabolism of cells such was found. The authors studied the effects of GaAlAs, λ =
as a release of growth factors, upregulation of ATP, 810 nm, 30 mW in the treatment of patients with AS. They
cytokine reactions, an increase in reactive oxygen species measured pain, functional status, and disease activity in 37
(ROS) and therefore cell proliferation [52]. (19 experi- mental and 18 control) patients with AS. In the
AS is reported to affect cervical, thoracic, and lumbar skin contact method used in 10 sessions, they delivered 1.2
spine. Typically, osteoarthritis of spine zygapophyseal J per point on the L3 to S1 supra spinous ligaments and
joints manifests inflammation, pain, and restricted move- sacroiliac joints bilaterally. These investigators did not find
ments. The distance between skin and lateral aspect of significant differ- ences in the measurement parameters
joint surface is for cervical spine about 3 cm, while for between the placebo and control groups.
the lumbar spine 7 cm. Laser 820 nm of our study param- The negative results of the above-mentioned study were
eters can penetrate several centimeters at these joints and mainly due to different lasers being used and differences in
can decrease inflammation and consequent the pain inten- the treatment parameters. We hypothesized that the patients
sity [53]. with AS would show better results in all BASMI, BASFI,
Bad posture, that characterizes AS patients, cause and BASDAI and VAS scores, if along with the laser
fatigue and increases the oxidative stress in the erector treatment passive stretching was applied at the same time.
spine muscles. Muscle fatigue is the precursor of muscle The finding that LLLT, together with passive stretching,
pain because the ischemia impairs microcirculation. Laser reduced significantly the five symptoms of BASDAI
with light doses, which is used for inflammatory purposes, (fatigue, morning stiffness, tenderness, and spinal or joint
can delay the in- flammation process and preserve the pain), at the end of the intervention and remained slightly
physiology of spine curves by decreasing the oxidative improved in the follow-up, indicates that this protocol
stress and muscle fatigue [54–56]. plays an important role in the treatment of AS patients.
Several studies investigated the efficacy of different The results also showed an increase in physical
phys- ical therapy modalities such as LLLT and exercise in functions as presented by BASFI. It seems that this
patients suffering from spondyloarthritides reporting improvement is due to the reduction in pain intensity
positive and neg- ative effects. during daily activities that was caused by LLLT.
For example, Konstantinovic et al. [57], Jovicic et al. Also, the results demonstrated an increase in mobility,
[58], Djavid et al., [59], Fiore et al. [60], and Ay [61] functional capacity, and activity, reported by the modified
investigated the effects of 904-nm low-level laser with Schöber test, tragus to wall distance, lumbar side flexion,
different doses and energy density in patients suffering cer- vical rotation, and intermalleolar distance.
from acute or chronic low back pain or back pain with Literature search revealed that the effect of
radiculopathy and reported good effects. Similar were the physiotherapy with exercise as main component was
conclusions of Fulop et al. [62], mostly investigated, in
 Lasers Med Sci

the treatment of AS. Therefore, the results of the present energy delivering per point, per treatment session, and the
study are most comparable with these studies. total session energy [78–80].
For example Kjeken et al. [67], Aytekin et al. [68], Altan Several steps to avoid these methodological errors were
et al. [69], Strumse et al. [70], Rosu et al. [71], and taken. AS patients were recruited from a large rural region.
Rodriguez- Lozano et al. [72] studied the effects of It is believed that our subjects are representative, as a
different exercise types such as home-based exercise, homog- enous population lives in Peloponnese prefecture.
Pilates, McKenzie and Heckscher training and Out of 65 patients initially enrolled, 24 completed the
physiotherapy. These authors mea- sured the same experimental pro- tocol; It is thought that this number is
parameters of the present study. They showed a significant high if taking in account that the prevalence of AS is low
improvement in the fatigue, morning stiffness, tenderness, and patients are hard to find. The laser intensity and
and spinal or joint pain (BASDAI); in mobility, functional duration of every session were stan- dardized and
capacity, and activity (BASMI); and in physical function quantified, and ensured that the patients follow- ed strictly
(BASFI) and pain which remained after the follow- up to the intervention. Finally, an 8-week follow-up period
periods. was included, that is generally acceptable by patients in
Besides the aforementioned studies, the current clinical studies, since it is not ethical to leave the placebo
literature showed many reviews that further strengthened laser group, without treatment for a long time (more than 8
the view that physical therapy has positive effects in weeks). This length of time can usually be tolerated by
patients suffering from AS (Elvan and Khan [73], patients with- out undue distress, compared to longer time
Passalent [74], Dagfinrud et al. [75], Giannoti et al. [76]). [35, 77]. Another significant advantage of this study was
It was decided that the present study would include the specific spine point, which is either trigger, motor, or
passive stretching exercises in order to strength the acupuncture points for irradiation were used. Simons, et al.
interaction be- tween the group and time effect. The [81] confirmed the characteristics of relationship of the
stretching program per- formed satisfactorily in the specific points that are the following: tenderness to
treatment sessions, because this maneuver accelerates palpation in the presence of segmen- tally related
collagen realignment [23, 77]. Passive stretching activate pathology, decrease resistance to electricity, in- creased
the stress/relaxation phenomenon and im- prove function resistance to pressure (hardness, firmness, muscle guarding
of the erector spine muscles [35]. It is believed that or spasm), anatomically situated, near, or over su- perficial
because of inflammation, free nerve endings of the area are nerve fibers and blood vessels, contain fibrositic
irritated and produce pain, which does not allow the AS components, give rise to referred pain on pressure, exists
patient to use the spine in concrete motions. Passive an- atomically at similar locations, and represent or are
stretching can improve and realign the collagen fibers in located at dense groupings of sensory end organs, on or
muscles, fascia, ligaments, and in the other soft tissues of just below the skin surface.
the spine [28]. At the end of the present investigation, our Τhe patients of our study who received LLLT were
protocol was offered to all of the AS patients. All accepted improved with regards to pain, but there was no signifi-
and all improved. Twelve treatments were sufficient to cant difference in comparison with the placebo laser sub-
elicit a significant change. Further improvement was jects in other parameters, supporting the view that the
achieved in pain during follow-up period by continuing the laser treatment has analgesic effects. The analgesia pro-
passive stretching exercises, all pa- tients being kept on vided by laser treatment allows other therapeutic proce-
treatment for at least 8 more weeks. It is not known if this dures such as passive stretching to be performed more
continued improvement also would have occurred if comfortably. Decreasing the pain intensity will gain the
passive stretching exercises been stopped after the end of confidence of the patient and facilitate spine muscles re-
the active laser treatment. Most patients stated that could laxation, which is essential for the process of recovery
be more active during daily activities without pain. and pain improvement [16–20].

Validity and reliability of the study

Unfortunately, studies of low-level laser application have Conclusion

been prone to several methodological errors. These include
the fol- lowing: (a) a diversity of subjects with respect to In conclusion, the present investigation showed that a
the parame- ters being measured; (b) too few subjects; (c) combi- nation of a Ga-Al-As CW 820 nm 60 mW, 4.5/cm2,
lack of blind- ness; (d) no monitoring of the laser along with passive stretching is more effective than
parameters according to WALT guidelines; (e) no follow- placebo laser and passive stretching in the decrease of pain
up period; (i) no focus on a possible dose–response in patients with AS. The repetition of the present
relationship between the laser treat- ment and changes in investigation is necessary with more patients, in order to
the profile of the target parameters; (f) uses different pulse strengthen the view of the effectiveness of the proposed
repetition rates, although in vivo and vitro studies showed protocol.
no effects; and (g) do not indicate exactly the
Lasers Med Sci

Acknowledgments We would like to thank all the subjects for the

exercises in the treatment of recreational athletes with chronic
enthusiastic contribution and patience during this project. We are also
Achilles tendinopathy. Am J Sports Med 36(5):881–887
thankful to Dr. P. Baltopoulos (Associate Professor of Department of
Sports Sciences, University of Athens) for his comments; Dr. D. 17. Stergioulas A (2007) Effects of low level laser and plyometric
Sotiropoulos (director of Panarkadikon Orthopedic Clinic) for ex- ercises in the treatment of lateral epicondylitis. Photomed
patients referred to the lab; Director of the Lab Health and Fitness Laser Surg 25:132–191
Management Dr. A. Tripolitsioti for her assistance in subjects 18. Stergioulas A (2004) Low-level laser treatment can reduce
randomization; Physical therapist L. Papadolias for patients edema in second degree ankle sprains. Laser Med Sci Surg
evaluation; and Physical therapists D. Kokkinis and and A. Tyflidis 21(2):125–128
for their help during the study protocol. 19. Stasinopoulos D, Stasinopoulos I, Manias P, Stasinopoulou K
(2008) Comparing the effects of exercise program and low-level
laser therapy with exercise program and polarized
polychromatic non-coherent light (bioptron light) on the
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