Original Article

Comparison of high-intensity laser therapy and combination of

transcutaneous nerve stimulation and ultrasound treatment
in patients with chronic lumbar radiculopathy:
A randomized single-blind study
Emine Kolu1, Raikan Buyukavci2, Semra Akturk3,
Fatma Eren4, Yuksel Ersoy5
ABSTRACT
Objective: To compare the effects of high-intensity laser therapy (HILT) and a combination of transcutaneous
nerve stimulation (TENS) with ultrasound (US) therapy on pain and functionality in patients with chronic
lumbar radiculopathy.
Methods: This prospective randomized comparative study was conducted in Department of physical
medicine and rehabilitation, Turgut Ozal Medicine Center, Malatya, Turkey from April 2016 to September
2016. A total of 54 patients with chronic lumbar radiculopathy were enrolled in this study. The patients
were randomly divided into two groups: Group 1 (n:27) received 10 sessions of a combination of hot pack,
TENS, US and exercise, and Group 2 (n:27) received hot pack, HILT and exercise. The outcomes measured
were low back with unilateral leg pain level measured by visual analog scale (VAS) and functionality
measured with the Oswestry Disability Index (ODI) at the end of the therapy and four weeks later. p-value
less than 0.05 considered statistically significant.
Results: In two groups, VAS (low back with unilateral leg pain) and ODI scores showed significant changes.
At the end of the 2 weeks intervention, participants in Group-1 showed a significantly greater decrease in
pain than participants in Group-2. Statistically significant differences in pain variation and functionality
(VAS and ODI) were observed four weeks after treatment sessions for participants in the TENS+US therapy
group compared with participants in the HILT group.
Conclusion: HILT and TENS+US combined with exercise were effective treatment modalities in decreasing
the VAS and ODI scores. TENS+US combined with exercises were more effective than HILT combined with
exercise.
KEYWORDS: High intensity laser therapy, Lumbar radiculopathy, transcutaneous nerve stimulation,
Ultrasound.
doi: https://doi.org/10.12669/pjms.343.14345
How to cite this:
Kolu E, Buyukavci R, Akturk S, Eren F, Ersoy Y. Comparison of high-intensity laser therapy and combination of transcutaneous nerve
stimulation and ultrasound treatment in patients with chronic lumbar radiculopathy: A randomized single-blind study. Pak J Med
Sci. 2018;34(3):530-534. doi: https://doi.org/10.12669/pjms.343.14345
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0),
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Correspondence:
INTRODUCTION
Raikan Buyukavci, MD. Low back pain is one of the most common musculo-
Assistant Professor, skeletal system pains that cause loss of work power
Department of Physical Medicine and Rehabilitation,
Inönu University, Faculty of Medicine, and negatively affects quality of life. The prevalence
Malatya, Turkey. of low back pain, observed in every culture and
E-mail: rsoydemir@yahoo.com ethnic group, is reported as nearly 84%.1 The rate of
* Received for Publication: December 8, 2017 chronic back pain is about 10%.2
* Revision Received: May 11, 2018 Discogenic low back pain, whether accompanied
* Revision Accepted: May 14, 2018 by radicular symptoms or not, is one of the common

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 Emine Kolu et al.

causes of low back pain.3 There are a variety of METHODS

conservative treatment methods for low back
This prospective single-blind randomized
pain, led by lumbar radicular symptoms. There is
study included patients, visiting the Department
a wide spectrum of conservative treatment options
of Physical Medicine and Rehabilitation, Turgut
including patient education, behavioral therapies,
Ozal Medicine Center, Malatya, Turkey from three
back school, exercise, and physical therapy
3 months low back with unilateral leg pain and
modalities such as traction, superficial heaters,
clinical signs of radicular lesion in dermatomal
deep heaters (short wave diathermy, ultrasound
distribution and/or myotomal muscle weakness
etc.), transcutaneous electrical nerve stimulation
and/or diminished reflexes in lower limbs. Lumbar
(TENS), and laser.4
spinal root pressure was detected by MRI.
Laser is a pain-free and non-invasive treatment
The local hospital ethics committee approved the
modality.5 It is used in many acute and chronic
study. Patients agreeing to participate in the study
painful conditions. HILT therapy is a type of Nd
provided an informed consent form. Exclusion
YAG laser with 1064 nm wavelength. Light with
criteria for the study were previous history of spinal
slow chromofors and low level is absorbed and
surgery, sequestrated disk hernia on MRI, steroid
deep tissues are affected without radiation. High
injection and/or physical therapy for the lumbar
intensity lasers may affect deeper tissue as they
region within the last four weeks, inflammatory
have shorter emission time and longer emission
rheumatic disease, cardiac pacemaker, continuing
intervals compared to low intensity lasers.6 In recent
or previous malignancy history and pregnancy.
times, the use of high intensity laser for physical
Patients included in the study were randomly
therapy has been shown to significantly reduce divided into two groups. The patients in Group
pain with a variety of causes.7,8 The anti-edematous, 1 had a total of 10 sessions of hot pack, TENS and
anti-inflammatory and analgesic effect of Nd YAG ultrasound treatment applied over two weeks for
laser for patients with pain has been determined by five days each week. Patients had hot pack applied
studies.9 Though there is no universal consensus to the lumbar paravertebral area for 20 minutes,
to clearly explain the effect mechanism of laser, it along with TENS application in conventional
is accepted as having three effects; photothermal, mode for 20 minutes at 70 Hz frequency and 100
photochemical and photomechanic.10,11 microsecond wave length. Later again in the lumbar
In the literature there is no consensus on the paravertebral region, patients had therapeutic
application duration, pulse power, energy dose ultrasound treatment of 1.3 watt/cm2 power, 1
and frequency to be used for laser treatment of mHz frequency applied with a US device (BTL4825S
patients. There are a few studies to date on the Kombi Topline) for 10 minutes continuously.
effects of HILT therapy on cervical radiculopathy, The second group had high intensity laser device
frozen shoulder, lateral epicondylitis, carpal tunnel (BTL 6000) used after 20 minutes hot pack application
syndrome, myofascial pain syndrome, low back for five days per week over two weeks for a total
pain, gonarthrosis, post-mastectomy and lumbar of 10 sessions of high intensity laser treatment. The
discopathy pain.7,8,12,13 device was set to 25 Hz frequency, 10 watt power
There are studies in the literature showing the with 12 j/cm2 dosage to the lumbar region over 25
efficacy of physical therapy modalities and HILT in cm2 area for four minutes biostimulation mode,
patients with chronic low back pain.14-16 However, followed by continuous mode for 6 minutes with 7
in patients with chronic lomber radiculopathy, the watt power and 120 j/cm2 dosage.
literature is limited in terms of HILT treatment. In addition, an isometric lumbar exercise
In this study we aimed to compare TENS and program was initiated by the same physiotherapist
Ultrasound combination, commonly used in to be performed with five repetitions in each set
routine practice, with the new non-invasive (modified straightening and pelvic tilt exercises) in
treatment method of HILT in terms of effects on Groups-1 and 2 during the therapy duration. The
pain and functionality for patients with chronic repetitions of both sets were increased up to ten,
lumbar radiculopathy. At the same time, we aimed provided that this did not increase the patient’s
to suggest an appropriate and effective treatment pain.
proposal for patients with chronic lomber Assessment of pain: The patients were assessed
radiculopathy for HILT, which is one of the new with the visual analog scale (VAS) for low back
treatment options. with unilateral leg pain at rest, when moving and at

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 Chronic Lumbar Radiculopathy

night. Accordingly on a 10 cm line, the 0 point was

accepted as no pain while the 10 point was accepted
as maximum pain. Patients were asked to indicate
the severity of low back pain on this line. Later the
distance between the 0 point and the marked point
was measured with a ruler.
Oswestry Disability Index: This comprises 10
questions assessing pain, personal care, lifting,
walking, sitting, standing, sleeping, social life,
travel and degree of pain variation, with each
scored from 0 to 5. Maximum points are 50 and total
score is multiplied by two to provide a percentage
result. The evaluation is made with the formula:
point/total score (50) x 100 = %. This form used
to assess treatment results and compare different
treatments in chronic low back pain patients and
Turkish validity and reliability has been proven.17
The pateints were assessed by the same blinded
doctor before treatment, after treatment and four
weeks later for pain with VAS and for functional
state with ODI. Flow diagram of the study has been
given Fig.1.
Statistical Analysis: It was calculated that a total
of 54 individuals should be taken, with at least 27
subjects from each group when α = 0.05 and 1-β =
0.80 were taken in the power analysis performed.
For statistical analysis of research data, SPSS for
Windows version 17.0 software was used. Data
related to quantitative variables are given as
arithmetic mean ± standard deviation (sd) and min-
Fig.1: Flow diagram of the study.
max, while data related to qualitative variables are
given as number (n) and percentage (%). The one- (HP+HILT) consisted of 27 patients with mean age
way ANOVA test was used for comparisons of the 53.40±10.57 years. The female/male distribution
parametric continuous data. The Kruskal-Wallis test was 20/7 in Group-1 and 16/11 in Group 2, while
was used for the nonparametric continuous data. A BMI was 26.9±3.65 kg/m2 in Group-1 and 26.7±3.65
repeated measures ANOVA was used to analyze the kg/m2 in Group 2. There was no difference between
changes in variables. Significant differences were the two groups in terms of age and BMI (p>0.05).
determined by Bonferroni post hoc tests. A value of In terms of pain duration, there was no difference
p<0.05 was accepted as statistically significant. between the two groups (Group-1: 3.66±2.89 years,
RESULTS Group 2: 5.18±5.13 years, p>0.05) (Table-I).
The VAS and ODI scores were similar in the two
A total of 54 patients participated in this study. groups before treatment (p>0.05) (Table-II). The
Group 1 (HP+TENS+US) consisted of 27 patients comparison of parameters in Group-1 and Group-2
with mean age 50.14±15.55, while Group 2 before treatment and at the end of therapy revealed

Table-I: Patients demographic datas.

Group 1 (n=27) HP+TENS+US Group 2 (n=27) HP+HILT P value
Mean±SD Min-Max Mean±SD Min-Max
Age (year) 50.14±12.55 19-64 53.40±10.57 22-65 0.363
BMI (kg/m2) 26.9±3.65 17-33 26.7±3.65 21-34 0.878
Duration of illness (age) 3.66±2.89 0.5-20 5.18±5.13 0.5-15 0.530
BMI: Body Mass Index.

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 Emine Kolu et al.

Table-II: Baseline VAS scores and Oswestry mechanisms of action, including its ability to slow
Disability Index score for two groups. the transmission of the pain stimulus and to increase
Before Treatment Group 1 Group 2 P value the production of morphine-mimetic substances in
HP+TENS+US HP+HILT the body.6 In addition, it may have a direct effect
Resting VAS score 4.33±1.79 4.29±1.75 0.965 on nerve structures, which could increase the
Moving VAS score 8±0.78 7.78±1.06 0.554 speed of recovery from conduction block or inhibit
Night VAS score 3.25±1.43 3.29±1.26 0.783 Aδ- and C-fiber transmission.19 The treatment also
ODI score 68.51±14.18 70.22±12.63 0.735 increases blood flow, vascular permeability, and
VAS: Visuel analog scale, ODI: Oswestry Disability Index cell metabolism.20
score. P value: p value obtaining by which comparing A recent study by Choi et al. randomly divided
statistcally scores of the scales among the groups before patients with chronic low back pain into two
treatment. groups. One group received conservative treatment
(HP+TENS+US), while the other group received
significant difference changes in VAS and ODI
10 minutes of HILT with 1378 mJ/ cm2 to the L1-
scores (p<0.05).
S1 region three times per week after conservative
Assessment of the two groups at the end of
treatment for four weeks. The response to treatment
treatment and 1 month after treatment found that the
was assessed with VAS and ODI scores before
moving VAS score and ODI score were statistically
treatment and after treatment and they concluded
significantly lower in Group 1 (HP+TENS+US)
that the addition of HILT treatment to conservative
(p<0.05) (Table-III).
treatment was more effective on pain and function
DISCUSSION for chronic low back pain patients. However, the
low number of patients in the groups and the lack
In this present study, patients with chronic lumbar of assessment of long term efficacy of treatment
radiculopathy in the high intensity laser treatment were given as limitations of the study.21
(HILT) and ultrasound (US) with transcutaneous A study by Fiore et al. compared the efficacy
nerve stimulation (TENS) combination groups were of high intensity laser treatment and ultrasound
compared in terms of VAS scores and Oswestry for patients with low back pain.22 Each group had
Disability Index (ODI) score. In the two groups, VAS and ODI scores assessed after 15 sessions of
VAS and ODI scores showed significant changes. treatment. There was significant amelioration of the
However, patients receiving TENS+US treatment VAS and ODI scores in both groups at the end of
had a greater reduction in VAS scores and ODI treatment. When the laser group is compared with
score at the end of treatment and 1 month later the ultrasound group, it appeared the laser group
compared to the HILT group. had significant superiority for VAS and ODI scores.
In recent years, high intensity laser treatment has Another study by Boyraz et al. assessed the pain and
been used for a wide range of painful conditions. quality of life with lumbar disc herniation patients
The efficacy of the pulsed Nd:YAG laser has been receiving three different therapeutic methods of
proven in the treatment of many musculoskeletal HILT, US and medical treatment. All three forms of
diseases and it is believed to have anti-inflammatory, treatment were effective; however they concluded
anti-edema, analgesic, and reparative effects.18 HILT and US treatment were effective in the long
The analgesic effect of HILT is based on different term.23

Table-III: Changes in VAS scores and Oswestry Disability Index score in the
two groups at the and of the treatment and 1 month later after therapy.
Group 1 Group 2
Pre treatment Post treatment 1.month Pre treatment Post treatment 1.month P1 value P2 value
RestingVAS score 4.33±1.79 2.66±1.30 2.70±1.40 4.29±1.75 2.90±1.19 2.85±1.16 0.283 0.486
Moving VAS score 8±0.78 4.33±1.27 4.22±1.05 7.78±1.06 5.18±1.38 5.29±1.51 0.027* 0.011*
Night VAS score 3.25±1.43 2.25±1.16 2.25±1.22 3.29±1.26 2.66±1.17 2.81±1.24 0.198 0.091
ODI score 68.5±14.1 42.5±12.8 45.1±13.0 70.2±12.6 51.4±12.6 54.5±14.6 0.014* 0.014*
VAS: Visuel analog scale, ODI: Oswestry Disability Index score.
P1: p value obtaining by which comparing statistcally scores of the scales among the groups after treatment.
P2: p value obtaining by which comparing statistcally scores of the scales among the groups 1 month later after treatment.
* p<0.05 for the Kruskal Wallis test.

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 Chronic Lumbar Radiculopathy

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