1. Daniel Woodward, SPT
East Tennessee State University, Year II
Healing Hands Physical Therapy Clinic
LOW LEVEL LASER THERAPY (LLLT)
AN ALTERNATIVE INTERVENTION FOR SHOULDER IMPINGEMENT

2. OVERVIEW
• Introduction to Laser Therapy
• Case Study
• Research Findings
• Clinical Implications

3. 1. What is a Laser?
a) Light Amplification by Stimulated Emission of
Radiation
b) Device that generates intense beam of coherent,
monochromatic, and collimated light by
stimulated emission of photons from excited
atoms or molecules
c) Light Amplifier: If radiation produced is within
the visible range (400nm – 750 nm)
d) Radiation (laser) Amplifier: If the radiation
produced is within the infrared range (750 nm –
1mm)
2. Laser Requirements
a) Energy Source (power supply)
b) Population Inversion
c) Amplifying Medium (solid, gas, or liquid)
d) Resonating Cavity (mirrors)
• A 100% reflecting mirror
• A selective filter mirror
LASER INTRODUCTION7,8,10

4. 1. Endre Mester
a) Hungarian Physician
b) Father of Laser Therapy
2. 1967 Experiments with mice
a) Could laser be used to treat
cancerous tumors?
b) Used low power ruby laser (694 nm)
b) Laser treatments did NOT kill tumor
cells
c) Laser treatments DID enhance
healing of incisions and hair growth
d) First to observe photobiostimulation
HISTORY OF LASER THERAPY7

5. 1. What is LLLT?
a) Application of light (low power laser or
LED) to pathological tissue to promote
healing, reduce inflammation, and
relieve pain.
2. Terraquant Solo Portable Cold Laser
a) Laser Type: "Cold Laser"
• No thermal effect
b) Class 1M
• Has the power of a Class IV laser
c) Battery powered handheld device
• 18 hours on one charge
d) Frequency Modes: 5 Hz, 50Hz, Variable
e) Semiconductor Laser
• Amplifying Medium = Gallium
Arsenide
LOW LEVEL LASER THERAPY (LLLT)7,14

6. 1. 1 Super Pulsed Laser Diode
a) Power = 15 W
b) Wavelength = 905 nm
c) Very low duty cycle (100-200 ns)
• Relatively low average power output
d) Deep Focused Penetration (4-5")
2. 4 Infrared LED's
a) Power = 60 mW
b) Wavelength = 875 nm
c) Pulsed Duty Cycle: 50%
d) Medium and Broad Penetration
3. 4 Red LED's
a) Power = 7.5 mW
b) Wavelength = 660 nm
c) Pulsed Duty Cycle: 50%
d) Shallow and Broad Penetration
4. Static Magnetic Field
a) Facilitates circulation and healing
MULTI-RADIANCE TECHNOLOGY3,7
Optimal Parameters/Dosage
• Highly debatable and complex
• Depends on Treatment Tissue (Depth/Type)
• Dosage (J), Power/Energy Density (joules/cm2),
Frequency (Hz) and Wavelength (nm) are all
important parameters
• Greater Wavelength = Deeper Penetration
• TQ Solo Treatment Parameters Preset (1-4
joules/cm2) except for pulse frequency
• WALT Dose Recommendations

7. 1. FDA approved for
temporary relief of:
a) Minor muscle and joint pain
b) Arthritis and muscle spasm
c) Joint stiffness
d) Promoting relaxation of
muscle tissue
e) Temporarily increasing local
blood circulation
2. Other musculoskeletal
applications:
a) Chronic and Acute Pain
b) Reduces Inflammation
c) Tendinopathies
d) Epicondylitis
e) Back Pain
f) Fibromyalgia
g) Wound Healing
h) Bone Healing (Dental)
i) Carpal Tunnel Syndrome
INTRODUCTIONBENEFITS OF LLLT7,8,10

8. 7. Stimulates long term production of NO
8. Decreases the formation of bradikynin,
histamine, and acetylcholine
9. Stimulates production of endorphins
1. Increases ATP synthesis
2. Stimulates cell growth
3. Increases cell metabolism
4. Improves cell regeneration
5. Invokes an anti-inflammatory
response
6. Promotes edema reduction
7. Reduces fibrous tissue formation
8. Stimulates nerve function
9. Reduces the production of
substance P
PHOTOBIOSTIMULATION BENEFITS8

9. 1. Irradiation over the eyes
2. Pregnancy (over the pregnant uterus)
3. Cancers (over the tumor site)
4. Patients with Hemorrhage
5. Directly over Thyroid Gland
6. History of Epilepsy
7. Directly over Pediatric Joint Epiphysis
• There are no known permanent or
serious side effects from laser therapy
LOW LEVEL LASER THERAPYCONTRAINDICATIONS8

10. 1. Locate Treatment Area
• Tender Points
• Use of Pain-Relieving Guide
2. Turn on TQ Solo
3. Select Frequency (5 Hz, 50 Hz, or Variable Frequency)
4. Press "Start" and place laser device over treatment
area
5. Treatment Duration: 5 minutes
Modes of Operation
HOW IT WORKSHOW TO ADMINISTER LASER
Program / Mode 1 2 3
Pulse Frequency 5 Hz 50 Hz 1000 to 3000 Hz
Time 5 Minutes 5 Minutes 5 Minutes
Systemic Effect Tissue Repair / Healing Anti-inflammatory Acute Pain Treatment
Depth Of Penetration Deepest Medium Superficial

11. TREATMENT TECHNIQUES

12. Patient Description
1. 51 year old WF
2. Height: 5' 7'' Weight: 210 lbs.
3. (R) Shoulder pain began 3 weeks
before evaluation
4. Pain progressively worsened
Mechanism of Injury
Too embarrassed to tell but mentioned that it
involved the arm being twisted behind her
back….
Medical History
1. GERD, IBS, Restless Leg Syndrome,
Panic Attacks, and Depression
2. Normal mental/cognitive function
Medical Diagnosis
1. (R) Shoulder Pain
2. (R) Shoulder Rotator Cuff Syndrome
PT Diagnosis
1. Severe (R) shoulder pain with UE
activity
2. Increased inflammation
3. Severe decrease in AROM/PROM
4. Decrease in muscle and functional
strength
CASE DESCRIPTIONCASE DESCRIPTION

13. CASE DESCRIPTION
Current Level of Function
1. Pain Free (R) Shoulder @ rest
• ↑ to severe pain with UE activity
2. Palpation tenderness over anterior/lateral aspect of (R)
shoulder
3. Moderate-severe difficulty with ADL's
4. Avoids reaching above 90 degrees
5. Pain worse with reaching behind back
• "Increased difficulty undoing bra"
6. Unable to sleep on (R) Side
Special Tests:
1. Empty Can Test: Positive
2. Hawkins Kennedy Test: Positive
3. Subscapularis Lift Off Test: Positive
Patient Goals
1. "I just want my (R) Shoulder to be pain free"
CASE DESCRIPTION

14. OUTCOME MEASURES
Motion Initial ROM
Flexion 160
Abduction 150
Extension 40
External Rotation 50
Internal Rotation 50
Range of Motion
Strength
Pain RatingUE Quick Dash6
• 11 item, self reported questionnaire
• Measures physical function and
symptoms of UE musculoskeletal
disorders
• Strong reliability/validity and high
response rate (a = 0.94)(r-values = 0.7-
0.8 correlating to VAS)
• Scoring: Out of 100 (higher score =
greater disability
Initial Quick Dash Score = 52/100
At Rest = 0 / 10
With Movement = 10 / 10
Description: Sharp
Unable to test secondary to pain
* Pain during and at the end of available ROM

15. Low Level Laser Therapy
1. Irradiated tender point over lateral
aspect of (R) Shoulder
• 2 x / week
2. Frequency: 5 Hz
3. Duration: 5 minutes
4. Technique: Contact
Other Modalities
1. Hot Pack – 15 minutes (Warm-up)
2. Cold pack – 15 minutes (Cool-down)
Stretch Exercises
1. Pulley Exercises (Flex/Abd)
2. Doorway Stretch
3. IR stretching
4. Shoulder Flex/Ext (Cane)
5. Wall Circles (Small → Big)
6. PROM (patient in supine)
Strengthening Exercises
1. Thera-band scapular squeeze
2. Thera-band (Flex, Ext, IR, ER)
3. Submaximal Isometrics
4. Shoulder Shrugs
APPLICATION OF TREATMENT

16. RATIONALE FOR LLLT
Patient Demonstrated Classic RC Impingement Symptoms
• Specifically in the Supraspinatus muscle tendon
Treatable Symptoms with LLLT:
1. Pain
2. Inflammation
3. Decreased ROM
4. Decreased Strength
LLLT Promotes:
1. Cell proliferation
2. Healing of damaged tissue

17. Low Level Laser Therapy
• Treatment parameters remained
the same throughout her
rehabilitation
Exercise
• Increased frequency, resistance,
and duration of various shoulder
stretching and strengthening
exercises
PROGRESSION OF INTERVENTIONS
Treatment over tender point on lateral
aspect of shoulder

18. Treatment Procedure
"Sometimes I can sense a
slight tingling in the treatment
area, but other times I don't
feel a thing"
Benefits of Treatment
"I feel like the laser treatments
are helping, but I am not sure
if it is because of the laser
therapy, the exercises, or the
other modalities (heat/cold)"
PATIENT'S PERCEPTION OF LLLT
Does Laser
Therapy Work
for you?

19. MEASUREMENT COMPARISON
Motion Initial ROM Final ROM
Flexion 160 170
Abduction 150 160
Extension 40 50
External Rotation 50 74
Internal Rotation 50 60
Pain Rating Initial Rating Final Rating
At Rest 0/10 0/10
With Movement 10/10 3/10
Strength Initial Score Final Score
Flexion Not tested 4+/5
Abduction Not tested 4/5
Extension Not tested 4+/5
External Rotation Not tested 5/5
Internal Rotation Not tested 5/5
Initial Quick Dash Score Final Quick Dash Score
52/100 15/100
Range of Motion Strength
Pain Rating
UE Quick Dash Score
Evaluation Date: 4/30/13 Final Treatment Date: 6/13/13 Worked with patient for 6 visits

20. Laser vs. Ultrasound in the Treatment of
Supraspinatus Tendinosis: RCT
• 36 subjects with supraspinatus tendinosis
• Laser Group, Ultrasound Group, Control
Group (advice only)
• Laser Dose = 30 j/cm2, 50 mW 820 nm
(infrared) laser probe, 5000 Hz frequency
• Duration: 90 seconds on 2 locations; 3 x
week x 3 weeks
• Locations:
• 1) Anterior shoulder (point of max
tenderness)
• 2) On tendon just below the acromion
with subjects hand placed behind
back
• Conclusion: Laser reduces pain, disability,
and tenderness more than US and
significantly more than advice alone in the
treatment of supraspinatus tendinosis
SAUNDERS, 2003
Muscle Force Change in Pain
Pain Diary
Improvements
Force Required to
Produce Tenderness

21. Results
• Statistically significant improvements
in pain severity and shoulder ROM in
both groups
Group 1 (LLLT + Exercise)
• More significant pain reduction
(VAS scores)
• More significant improvement for
all active/passive movements
Conclusion
• LLLT + Exercise Therapy was more
effective than exercise therapy alone
in the improvement of pain and active
and passive ROM in patients with sub-
acromial syndrome.
ABRISHAM ET AL. 2011
Efficacy of LLLT + Exercise on Subacromial
Syndrome

22. OTHER RESEARCH
Other Supporting Research not involving Rotator Cuff 9,15,18
1. LLLT + Eccentric Exercise = Accelerated Recovery for Chronic Achilles Tendinopathy
(Pain VAS, ↓ Morning Stiffness, ↓ Palpation Tenderness, ↓ Crepitation, and ↑ active
Dorsiflexion
2. LLLT = Significant ↑grip strength, ↑ pinch strength, and significant ↓ in overall diameter
of tendon sheaths in patients with de Quervains Tenosynovitis
3. LLLT = Significant ↑ mechanical pain threshold and VAS in patients with lateral
epicondylitis
Opposing Research regarding LLLT 2,11,17
1. Vecchio et al; 1993 – Active Laser vs. Dummy Laser = Both Groups improved but no
significant difference between groups
2. Mulcahy et al. 1995 – Showed no differences between LLLT group and placebo group for
pain VAS and verbal pain score "Elaborate Placebo"
3. Dogan et al. 2010 – LLLT + Exercise + Cold Pack showed no difference when compared
to Placebo Laser in patients with subacromial impingement

23. CLINICAL IMPLICATIONS15
• Low level laser therapy may be a beneficial modality to utilize for improving pain
and function in individuals with shoulder impingement symptoms as well as
various other musculoskeletal conditions
• No research specifically on the TQ Solo Portable Cold Laser
• The true impact that LLLT had on the patient is unknown as there were many
other forms of treatment which she was receiving
Literature Conflict:
• 25 trials (22 were RCT's)
• 12 trials reported positive effects of LLLT
• 13 trials reported no effects or inconclusive
results for LLLT
• Therefore, the efficacy of this modality is still
under much debate

24. High Level Laser Therapy (HLLT)
• 70 participants with SAIS symptoms
• HLLT vs. US
• VAS, CMS, and SST scores
• Laser Specifications:
• Neodymium-yttrium aluminum garnet
laser
• Peak Power = 1 Kw (1000 Watts)
• Wavelength = 1064 nm
• Pulsating waveform (5000 W/cm2)
• 10 treatment sessions (10 minutes/session)
over 2 weeks
Treatment Phases
• Initial Phase: Fast manual
scanning over upper trap, deltoid,
and pectoralis minor
• Intermediate Phase: Static
treatment over trigger points
• Final Phase: Slow manual
scanning in same areas treated in
initial phase
Results
• HLLT = greater reduction in pain
• HLLT = greater improvement in
articular movement, functionality, and
muscle strength
ALTERNATIVE INTERVENTION FOR SAIS11
HLLT

25. FUTURE RESEARCH SUGGESTIONS
1. Most Effective Treatment Parameters?
• Laser wavelength (nm), power (W), power density (W/cm2), dose (J/cm2), type of pulsing,
pulse frequency (Hz), pulse duty cycle, and treatment intervals
• Several of these parameters are missing in the research or have been inaccurately
recorded
• Premature conclusions should not be made about the negative results obtained while
using LLLT
• Further research is needed to determine the most effective parameters
2. Application Procedures?
• Tissue saturation (Contact vs. Scanning)
• Trigger points
• Acupuncture points
• Tender Points
3. Larger Scale Clinical Trials with Long Term Outcomes
Future Research
(Probe vs. no probe)

26. REFERENCES
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therapy with exercise on subacromial syndrome: a randomised, double-blind, controlled trial. Clinical rheumatology.
2011;30(10):1341–6. Available at: http://www.ncbi.nlm.nih.gov/pubmed/21538218. Accessed June 1, 2013.
2. Dogan SK, Ay S, Evcik D. The effectiveness of low laser therapy in subacromial impingement syndrome: a randomized
placebo controlled double-blind prospective study. Clinics. 2010;65(10):1019–1022. Available at:
http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1807-59322010001000016&lng=en&nrm=iso&tlng=en. Accessed
August 1, 2013.
3. Effective Treatment Strategies for Low-Level Laser Therapy. Advance for Physical Therapy and Rehab Medicine. 2012.
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4. Eslamian F, Shakouri SK, Ghojazadeh M, Nobari OE, Eftekharsadat B. Effects of low-level laser therapy in combination with
physiotherapy in the management of rotator cuff tendinitis. Lasers in medical science. 2012;27(5):951–8. Available at:
http://www.ncbi.nlm.nih.gov/pubmed/22052627. Accessed July 12, 2013.
5. Gedevanishvili G. What is Laser Therapy and Does it Really Work? The American Chiropractor. 2012. Available at:
http://www.theamericanchiropractor.com/articles-alternative-therapies/8514-what-is-laser-therapy-and-does-it-really-
work.html. Accessed August 1, 2013.
6. Gummesson C, Ward MM, Atroshi I. The shortened disabilities of the arm, shoulder and hand questionnaire (QuickDASH):
validity and reliability based on responses within the full-length DASH. BMC musculoskeletal disorders. 2006;7:44. Available
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August 1, 2013.
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27. REFERENCES
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