Comparison of two different electrotherapy methods in low back pain treatment

Abstract

OBJECTIVE:

To investigate the efficacy of High Intensity Laser Therapy (HILT) and Transcutaneous Electrical Nerve Stimulation (TENS) in low back pain (LBP).

METHODS:

Forty patients aged between 18 to 60 were included in this study. The patients were randomized into two groups as TENS (Group I) and HILT (Group II). The severity of pain was measured by Visual Analog Scale (VAS), and the range of motion (ROM) of the joint was measured by goniometer. The Oswestry Disability Questionnaire (ODQ) was used to assess the effect of LBP on daily living activities, and the Beck Depression Inventory (BDI) was used to assess depression. All patients were taken into physical therapy program for 5 days a week for a total of 20 sessions. Patients in Group I received ultrasound, hot pack and HILT, while the patients in Group II received ultrasound, hot pack and TENS.

RESULTS:

In the comparison of post-treatment improvements, among all parameters only VAS score had a significant difference in favor of Group I.

CONCLUSIONS:

The study demonstrated that HILT is more effective than TENS in terms of pain reduction and that HILT can be used as an alternative to TENS.

Keywords

Low back pain electrotherapy HILT TENS

1. Introduction

Low back pain (LBP) is a significant issue of health. This term is described as pain which is felt between the twelfth rib and gluteal area with and without lower limb pain by patients. LBP is a common malady experienced by as many as one-quarter of the adult population, and the vast majority will experience LBP at some point in their lives [2, 3, 4].

Intervertebral discs include a gelatinous core, the nucleus pulposus, with a surrounding tough ring, the annulus fibrosis. A rise in the internal pressure of the disc generates stretch forces on the annulus that may cause the annulus to tear. The nucleus then herniates through the annular tear into the spinal canal, where it may compress nerve roots. Lumbar disc herniation is a common cause of LBP and radiculopathy [5, 6, 7].

Most of the patients with disc herniation benefit from conservative treatment. Medical treatment is also important in the herniation. In patients with no significant changes in pain with medical treatment, physical therapy modalities are applied and an exercise program is added. Different exercise approaches, electrotherapy modalities, thermotherapy, manual treatments, medical therapy and LBP education program are the most common methods used in the treatment of chronic LBP [8, 9, 10].

Recently, High Intensity Laser Therapy (HILT) was introduced to the field of physical therapy as part of non-invasive interventions for treating musculoskeletal disorders [11]. It is noninvasive and painless and may be administered for treatment of different clinical condition. The reduction of pain after laser treatment can be attributed to its potential to reduce inflammation, increase microcirculation, and stimulate immunological processes and nerve regeneration [12].

Nevertheless, the effectiveness of the HILT is still not completely known, due to the lack of study done. Therefore, the aim of this study was to investigate the effectiveness of the application of HILT and TENS in patients with LBP due to lumbar disc hernia.

2. Methods

2.1 Subjects

The current study was performed at the Kolan International Hospital, Physical Medicine and Rehabilitation Department. The study was approved by the Ethics Committee, Istanbul Medipol University with decision no. 309. Subjects with a diagnosis of lumbar disk herniation participated in the study. Volunteer participants were informed about the study and they all completed an informed consent form. Inclusion criteria were: Literate and fully co-operative individuals who voluntarily agreed to participate in the study, without cognitive and mental problems and self-expressing. Exclusion criteria were: Those with a psychological disorder, cancer, dementia, inflammatory rheumatic disease, polyneuropathy, vasculitis, dermatological disease, neovascular skin diseases, burnt and sensory, peripheral vascular disease, spinal cord injury psychosis and neurological disease, using heart pills and being pregnant, malignant state, blood coagulation disorder, spinal curvature and active infection. The sample size was calculated using the Raosoft sample size program with a minimally significant clinical change score of the ODQ [13].

Forty patients with lumbar disk herniation (indistinguishable disc extrusion, protrusion, and sequestration) were randomly assigned into two groups in this prospective designed randomized controlled trial. Group I ( $n=$ 20, aged $=$ 39.35 $\pm$ 12.61 years) was treated with HILT, ultrasound, hot pack and exercise. Group II ( $n=$ 20, aged $=$ 41.60 $\pm$ 11.05 years) received ultrasound, hot pack, TENS and exercise; with the aim of investigating the effectiveness of HILT, comparatively. Patients were treated 5 times a week, for 20 sessions. Patients were evaluated before and after the physiotherapy program by another physiotherapist blinded to the groups.

2.2 Outcome measures

Outcome measures included demographic data, pain, range of motion, disability and state of depression. Demographics like name, surname, age, gender, height, weight, occupation, address and telephone number were recorded. All cases participating in the study were evaluated before treatment and 4 weeks after treatment.

2.2.1 Pain

Pain was evaluated by using Visual Analog Scale (VAS, 0–10 cm; 0 means no pain, 10 means severe pain). Patients’ and physician’s global assessments were also measured with VAS.

2.2.2 Range of motion

Spine ROM was assessed clinically in coronal, sagittal and axial motion planes. Extension, flexion, right and left lateral flexion angles were measured with the aid of a goniometer.

2.2.3 Back functional activity

The Oswestry Disability Questionnaire (ODQ) is one of the oldest self-report questionnaires for measuring functional outcomes in patients with low back pain and remains widely used. The ODQ was developed as a clinical assessment tool that would provide an estimate of disability expressed as a percentage score. Ten sections or items assess pain, personal care, lifting, walking, sitting, standing, sleeping, sex life, social life and travelling. Each item is scaled from 0 to 5. The rating is: “Patient Score $=$ (Patient’s score/Possible maximum score) $\times$ 100”. A score of 0% means minimal disability, and a score of 100% means bed addiction [14].

2.2.4 State of depression

The Beck Depression Inventory (BDI) is a 21-item self-reporting questionnaire for evaluating the severity of depression in normal and psychiatric populations. The minimum score is 0 and maximum score is 63. In those diagnosed with depression, scores of 0–13 indicate minimal depression, 14–19 (mild depression), 20–28 (moderate depression) and 29–63 (severe depression) [15].

2.3 Treatment protocols

2.3.1 HILT group (Group I)

The most important clinical effects of HILT are analgesia and bio stimulation. The analgesic effect is produced by high power pulsed applications, which create inside the body photomechanical waves that reach the subcutaneous pain receptors, stimulate the A fibers and close the gate for pain transition. The bio stimulation effect is the ability to bio stimulate cell growth and cell repair [16]. Based on this information, we also aimed to determine the analgesic effect of HILT in our study. Physical therapy was applied to the lumbar paravertebral area when the patient was in the supine position, 5 days a week for 4 weeks, 1 session a day, 20 sessions in total. HILT; The BTL 6000 was applied with a frequency of 25 Hz, a power density of 10 J/cm ${}^{2}$ and an area of 25 cm ${}^{2}$ for 1 minute and 40 seconds with a total energy of 250 J for 25 minutes. 1064 nm wavelength. Because the laser beam is directly harmful to the eyes, the user and the patient wear protective goggles.

2.3.2 TENS group (Group II)

Many researchers have investigated the effectiveness of TENS for treating chronic low back pain. However, most studies have not found statistically meaningful results, in comparison with placebo groups [17]. Therefore, in order to determine the effectiveness of TENS, physical therapy was applied to the lumbar paravertebral area when the patient was in the supine position, 5 days a week for 4 weeks, 1 session a day, 20 sessions in total. Conventional TENS 80 Hz frequency was used as an analgesic current with 180 ms current duration and 4 electrodes for 20 minutes. The current intensity was adjusted to the patient’s tolerance and the current intensity was increased with the decrease of the current flow in the patient.

2.3.3 Exercise

Lumbar stabilization exercises provide strength/resistance and coordination/stabilization approaches. The primary goals being to retrain the optimal control and coordination of the trunk muscles to maintain the dynamic stability of the spine, and to overload the trunk muscles to increase strength and endurance [1]. Therefore, we applied core stabilization and stretching exercises in our study.

All groups received hot-pack therapy for 20 min. Ultrasound used as deep heater was applied ultrasonically using Sono Puls model device for 4 minutes at 1 Mhz and 1.5 Watt/cm ${}^{2}$ as a conductive material.

2.4 Statistical analysis

In order to analyze the data of the study, the Statistical Package for Social Statistics (SPSS) version 20.0 (SPSS Inc., Chicago, IL, USA) was used. In all analyses, $p<$ 0.05 (two-way) value was considered statistically significant. In the data analysis of the study, it was determined by the Shapiro-Wilk test whether the data groups were normal for the selection of appropriate advanced statistical analyses. According to the results of this test, it was deduced that the distribution of some data was not normal because the value of p determined in two directions was 0.05. Non-parametric tests were used for this. The variables included in the study were VAS, ODQ, BDI, ROM, demographic characteristics (age, gender, occupation, etc.), and changes in these scores were assessed by the Independent Samples t-Test and compared with the Wilcoxon Signed-Rank Test. The pre-treatment and post-treatment values of the patients in both groups included in the study were compared with the Mann-Whitney U test.

3. Results

A total number of 40 patients with LBP participated in this study. Table 1 shows the mean and standard deviation values of sex, age, height, body weight and occupation of the subjects participating in the study.

Table 1
Demographic features of the patients

	Group I	Group II	$p$
Sex (Female/Male)	8/12	11/9	0.264
Age (Average)	39.35 $\pm$ 12.61	41.60 $\pm$ 11.05	0.495
Height (cm)	171.50 $\pm$ 6.53	169.00 $\pm$ 5.85	0.254
Weight (kg)	72.85 $\pm$ 8.00	72.40 $\pm$ 9.62	0.185
Occupation
Self-employment, $n$ (%)	14 (70)	12 (60)
Officer, $n$ (%)	3 (15)	1 (5)
Housewife, $n$ (%)	3 (15)	7 (35)

$n$ : Number of people, cm: Centimeter, kg: Kilogram.

There was no significant difference between the groups in VAS, ODQ, BDI, flexion and extension scores of all patients who were evaluated before treatment ( $p>$ 0.05). There was a significant difference in right and left lateral flexion scores ( $p<$ 0.05). There was a significant difference in sleeping, social life and travel scores of all patients evaluated before treatment ( $p<$ 0.05). There was no significant difference in pain severity, personal care, lifting, walking, sitting, standing, pain grading scores ( $P>$ 0.05). Comparison of pretreatment scores of the groups is shown in Table 2.

Table 2

VAS, ODQ, BDI, flexion, extension, lateral flexion and ODQ scores values before therapy

	Group I		Group II		$p$
	X $\pm$ SD		X $\pm$ SD
VAS	6.10	$\pm$ 2.38	7.10	$\pm$ 1.65	0.131
ODQ	42.10	$\pm$ 14.10	32.70	$\pm$ 17.60	0.070
Flex	66.79	$\pm$ 11.18	68.07	$\pm$ 15.15	0.764
Ext	14.99	$\pm$ 6.96	13.11	$\pm$ 5.53	0.352
Lat flex (R)	28.32	$\pm$ 6.28	22.74	$\pm$ 7.48	0.015
Lat flex (L)	28.82	$\pm$ 6.75	23.32	$\pm$ 7.21	0.017
Severity of pain	2.65	$\pm$ 1.38	2.60	$\pm$ 1.56	0.916
Personal care	1.55	$\pm$ 1.09	1.30	$\pm$ 1.21	0.500
Load lifting	2.55	$\pm$ 1.09	2.10	$\pm$ 0.96	0.177
Walking	1.75	$\pm$ 1.16	1.55	$\pm$ 1.05	0.572
Sitting	1.95	$\pm$ 1.19	1.50	$\pm$ 1.00	0.203
Standing	2.30	$\pm$ 1.34	1.70	$\pm$ 0.86	0.101
Sleeping	1.55	$\pm$ 1.23	0.65	$\pm$ 1.03	0.017
Social life	2.30	$\pm$ 1.41	1.20	$\pm$ 1.10	0.009
Travel	2.05	$\pm$ 1.09	1.10	$\pm$ 1.02	0.007
Pain grading	2.40	$\pm$ 1.35	2.70	$\pm$ 1.12	0.451
BDI	8.75	$\pm$ 8.47	5.20	$\pm$ 4.87	0.113

SD: Standard deviation, VAS: Visual Analog Scale, ODQ: Oswestry Disability Questionnaire, BDI: Beck Depression Inventory, Flex: Flexion, Ext: Extension, Lat flex: Lateral flexion, R: Right, L: Left.

There was statistically significant difference between VAS and ODQ values after treatment in both groups ( $p<$ 0.05). BDI scores were significantly higher in Group II after treatment ( $p<$ 0.05). There was no significant difference in Group I ( $p>$ 0.05). There was statistically significant difference between both groups after treatment in flexion, extension, right/ left lateral flexion scores ( $p<$ 0.05). When VAS, ODQ, BDI, flexion, extension, left/right lateral flexion change differences were compared between the groups, only VAS values were statistically significant in favor of Group I ( $p=$ 0.031).

There was a significant difference in personal care scores in Group II ( $p<$ 0.05), but no significant difference was found in Group I ( $p>$ 0.05). There was a statistically significant difference in the severity of pain, lifting, walking, sitting, standing, sleeping, social life, travel and pain grading scores in both groups ( $p<$ 0.05). There was no statistically significant difference between the groups when compared in terms of pain intensity, personal care, lifting, walking, sitting, standing, sleeping, social life, travel and changing gradation of pain ( $p>$ 0.05). Pre-treatment and post-treatment comparisons of the scores of the participants are shown in Table 3.

Table 3

Intragroup analysis of VAS, ODQ, flexion, extension, lateral flexion and BDI

	Group I			Group II			Both groups
	Pre-tre	Post-tre	$p$	Pre-tre	Post-tre	$p$	$p$
	X $\pm$ SD	X $\pm$ SD		X $\pm$ SD	X $\pm$ SD
VAS	7.10 $\pm$ 1.65	1.85 $\pm$ 1.38	0.000	6.10 $\pm$ 2.38	1.95 $\pm$ 1.39	0.000	0.031*
ODQ	42.10 $\pm$ 14.10	22.45 $\pm$ 11.78	0.000	32.70 $\pm$ 17.60	13.80 $\pm$ 10.44	0.000	0.673
Flex	66.10 $\pm$ 11.18	73.98 $\pm$ 8.34	0.000	68.07 $\pm$ 15.15	77.73 $\pm$ 11.11	0.000	0.238
Ext	14.99 $\pm$ 6.96	17.98 $\pm$ 6.09	0.000	13.11 $\pm$ 5.53	15.98 $\pm$ 5.84	0.001	0.886
Lat flex (R)	28.32 $\pm$ 6.28	31.65 $\pm$ 6.13	0.000	22.74 $\pm$ 7.48	28.46 $\pm$ 7.19	0.000	0.106
Lat flex (L)	28.82 $\pm$ 6.75	31.40 $\pm$ 5.80	0.006	23.32 $\pm$ 7.21	28.73 $\pm$ 7.53	0.001	0.089
Severity of pain	2.65 $\pm$ 1.38	0.90 $\pm$ 1.07	0.000	2.60 $\pm$ 1.56	0.55 $\pm$ 0.82	0.000	0.387
Personal care	1.55 $\pm$ 1.09	1.05 $\pm$ 1.23	0.126	1.30 $\pm$ 1.21	0.70 $\pm$ 0.65	0.007	0.788
Load lifting	2.55 $\pm$ 1.09	1.55 $\pm$ 0.99	0.000	2.10 $\pm$ 0.96	0.95 $\pm$ 0.60	0.000	0.671
Walking	1.75 $\pm$ 1.16	0.80 $\pm$ 0.76	0.001	1.55 $\pm$ 1.05	0.95 $\pm$ 0.88	0.000	0.203
Sitting	1.95 $\pm$ 1.19	1.25 $\pm$ 0.78	0.000	1.50 $\pm$ 1.00	0.80 $\pm$ 0.61	0.001	1.000
Standing	2.30 $\pm$ 1.34	1.70 $\pm$ 0.86	0.042	1.70 $\pm$ 0.86	0.90 $\pm$ 0.78	0.001	0.508
Sleeping	1.55 $\pm$ 1.23	0.60 $\pm$ 0.68	0.001	0.65 $\pm$ 1.03	0.10 $\pm$ 0.30	0.012	0.225
Social life	2.30 $\pm$ 1.41	1.15 $\pm$ 0.98	0.000	1.20 $\pm$ 1.10	0.75 $\pm$ 0.91	0.004	0.200
Travel	2.05 $\pm$ 1.09	1.35 $\pm$ 1.08	0.001	1.10 $\pm$ 1.02	0.60 $\pm$ 0.59	0.004	0.402
Pain grading	2.40 $\pm$ 1.35	0.95 $\pm$ 0.82	0.000	2.70 $\pm$ 1.12	0.55 $\pm$ 0.68	0.000	0.600
BDI	8.75 $\pm$ 8.47	7.00 $\pm$ 6.43	0.173*	5.20 $\pm$ 4.87	3.95 $\pm$ 3.76	0.005	0.761

Pre-tre: Pre-treatment, Post-tre: Post-treatment, SD: Standard deviation, VAS: Visual Analog Scale, ODQ: Oswestry Disability Questionnaire, BDI: Beck Depression Inventory, Flex: Flexion, Ext: Extension, Lat flex: Lateral flexion, R: Right, L: Left.

4. Discussion

To determine the HILT activity in the treatment of lumbar disc herniation, we formed two groups as Group I and Group II, and compared the effectiveness of two different physical therapy programs. VAS, ODQ, BDI, flexion, extension, right and left lateral flexion measurements were performed before and after the treatment in order to test the efficacy of the treatments.

The association between the factors age, sex, height, weight, physical activity level, posture, lumbar level, body side, and presence of low back pain is discussed [18]. Our study is similar to the literature.

Fiore et al. compared short term effects of ultrasound and HILT in patients with LBP. Participants were randomly assigned to two groups. Both groups showed an improvement of mean VAS and ODQ scores, but the HILT group showed a statistically significant reduction of mean VAS and ODQ scores with respect to the US group at the end of the treatment [19]. Gocevska et al. compared the long-term effects of ultrasound and HILT in patients with LBP. This study has shown that patients with chronic low back pain treated with a high-intensity laser significantly reduced low back pain, reduced disability and improved range of motion and this positive effect maintained for three months [20]. Kolu et al. compared 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. HILT and TENS+US combined with exercise were effective treatment modalities in decreasing the VAS and ODQ scores [21]. Considering last studies, HILT therapy can be good alternative physical therapy agent for the patients with lumbar disc herniation. The results of this study are similar to those of our study.

Zati et al. compared the efficacy of TENS, HILT and NSAID in their studies. Patients were assessed 4 times before treatment, 15-45-180 days after treatment. In the short-term; each treatment gave similar results to accepted treatments. However, with respect to long-term outcomes, the results of HILT have better clinical effects than other treatments [22]. In our study, we compared HILT and TENS similarly. HILT was found to be more advantageous in terms of shorter applicability and easier applicability and pain reduction than TENS.

Rapday et al. aimed to evaluate the benefits and hazards of the HILT and the epidural block with chronic LBP in their study. The pain decrease in the HILT group was significantly higher than in the epidural group [23]. In patients with LBP, noninvasive approaches such as HILT or TENS may be preferred primarily instead of invasive procedures as in our study.

In a systematic review, the effectiveness of high intensity laser therapy (HILT) on pain and function in patients with spinal disorder was evaluated. HILT has been recognized as a complementary method for reducing pain and improving function in patients with spinal disorders. In order to determine the efficacy of HILT for spinal disorders, higher quality studies for standardization of irradiation parameters and treatment protocol are needed [24]. In our study, HILT was found to be significant in reducing pain compared to TENS. Positive effects can be increased by treatment protocols to be determined.

Huang et al. investigated the efficacy of low intensity laser in patients with chronic LBP. It has been found that the laser has significantly reduced VAS significantly more than the placebo laser treatment. However, no significant difference was found between the two groups in terms of changes in ODQ parameters and goniometric measurements (flexion, extension, right and left lateral flexion) [25]. In our study, we obtained similar results using HILT. Studies that can be done to compare HILT with low-intensity laser therapy will guide our ideas.

Previous studies support the use of laser therapy for relief of both acute and chronic pain associated with chronic arthritis, tendonitis, carpal tunnel syndrome, fibromyalgia, knee injuries, and shoulder pain [26, 27].

Kim et al. investigated short-term effects of HILT on frozen shoulder. Patients with frozen shoulder were randomly divided into 2 groups: a HILT group and a placebo group. The HILT group had a lower pain VAS score at 3 weeks and 8 weeks, however, no statistically significant difference in the pain VAS was observed between the two groups at the final follow-up (12 weeks). No statistical difference in the ROM and the satisfaction VAS was observed between the 2 groups at serial follow-ups [28].

Alayat et al. reported that the combination of HILT and exercise increased cervical ROM, functional activity and reduced pain after 6 weeks of treatment with chronic neck pain [12]. In patients with cervical spondylosis, a study was performed that examine the effect of HILT and traction. In the long-term follow-up, positive therapeutic effects were maintained by the HILT method [29].

According to the results of the study by Casale et al., pain and electrophysiological parameters were improved with combined HILT according to TENS in symptomatic carpal tunnel syndrome [30]. In a study in Egypt, patients suffering from cubital tunnels, it has been determined that high density laser causes ulnar nerve conduction velocity and decreased pain [31].

White et al. examined the treatment of drug-resistant fibromyalgia symptoms using HILT at a case-based review. The patient received a series of treatments with a HILT device at a wavelength of 1275 nm administered at both the paraspinous region and tender points in the shoulder and hip regions. This treatment produced a dramatic reduction in her overall pain, improved quality of sleep, and increased her level of physical activity for 4–10 days after these treatment sessions [32].

In the study by Kim et al., HILT is considered an effective non-surgical intervention for reducing pain in patients with knee osteoarthritis and helping them to perform daily activities [33]. In the study by Thabet et al., HILT was found to be effective in reducing pain in primary dysmenorrhea treatment [34]. In another study, it was concluded that in men with osteopenia or osteoporosis, HILT combined with exercise was more effective than exercise [35].

As a different study, Lee et al. aimed to develop a theragnostic optical system by combining HILT with a near-infrared spectroscopy (NIRS) that not only relieves muscle spasms but also monitors muscle conditions such as oxygen saturation and deoxygenation. The transitory HILT effect was evaluated from patients experiencing spasticity after stroke. The results showed the proportionate relationship between manual muscle testing grades and the HILT effect on hemiplegic patients. The developed system proved to be useful for the simultaneous assessment and treatment of spasticity [36].

Jeong et al. reported that waist stabilization exercises increased mobility and stability of the sacroiliac joint, therefore it increases pelvic and back movements [37].

In a review study, Neto et al. reported that stabilization exercises are as effective as manual treatment in reducing pain and disability and should be encouraged as part of musculoskeletal rehabilitation for low back pain [38]. In the treatment of low back pain, electrotherapy and exercise therapy are an integral whole. Stabilization and stretching exercises are emphasized in most of the studies. Therefore, these exercises were included in our study.

This study has several limitations. First, our study contains a period of 4 weeks. Long-term follow-up will give us more understandable results about HILT. Second, it would be more appropriate to evaluate the patients by classifying them as chronic and acute LBP.

Finally, there is a difference in the doses and durations applied in the studies carried out on this subject. In order to determine the effectiveness of the HILT and to determine the dose to be administered, more patients, more patient participation, and controlled work are needed.

5. Conclusion

The HILT’s mechanism of analgesia was investigated in this study. In patients with LBP due to lumbar disc herniation, HILT instead of TENS was applied. According to the findings, the VAS scores seem to be superior in the HILT group in comparison to the TENS group. Further investigations regarding the mechanism(s) of laser action should be performed in future.

Footnotes

Conflict of interest

None to report.

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Comparison of two different electrotherapy methods in low back pain treatment

Abstract

OBJECTIVE:

METHODS:

RESULTS:

CONCLUSIONS:

Keywords

1. Introduction

2. Methods

2.1 Subjects

2.2 Outcome measures

2.2.1 Pain

2.2.2 Range of motion

2.2.3 Back functional activity

2.2.4 State of depression

2.3 Treatment protocols

2.3.1 HILT group (Group I)

2.3.2 TENS group (Group II)

2.3.3 Exercise

2.4 Statistical analysis

3. Results

Table 1 Demographic features of the patients

5. Conclusion

Footnotes

Conflict of interest

References

Table 1
Demographic features of the patients