Effect of low level laser therapy in acute low back pain with radiculo

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Akhil Mathew et al / Int. J. of Allied Med. Sci. and Clin. Research Vol-42 2016 216-225 216 IJAMSCR |Volume 4 | Issue 2 | April - June - 2016 www.ijamscr.com Research article Medical research Effect of low level laser therapy in acute low back pain with radiculopathy: A single blinded randomized control study Akhil Mathew 1 Dr. Dhanesh Kumar K U 2 Dr. Ajith S 3 and Subash Chandra Rai 4 1 Musculoskeletal and Sports Physiotherapy PG Nitte Institute of Physiotherapy Nitte University Mangalore Karnataka India. 2 Principal and Professor. Musculoskeletal and Sports Physiotherapy Nitte Institute of Physiotherapy Nitte University Mangalore Karnataka India. 3 Associate prof. Musculoskeletal and Sports Physiotherapy Nitte Institute of Physiotherapy Nitte University Mangalore Karnataka India. 4 Assistant prof. Musculoskeletal and Sports Physiotherapy Nitte Institute of Physiotherapy Nitte University Mangalore Karnataka India. Corresponding author: Dr. Dhanesh Kumar K U Email: dhaneshphysioyahoo.co.in ABSTRACT Background The lifetime prevalence of low back pain is reported as over 70 in industrialized countries. Peak prevalence occurs between ages 35 and 55. There is increasing evidence that inflammation in association with root compression is the main pathological factor of radiculopathy. LLLT can be advantageous because its therapeutic window for anti-inflammatory actions overlaps with its ability to promote tissue repair in a dose dependent manner. Objective The aim of the study was to compare the effectiveness of low level laser therapy and conventional therapy in acute low back pain with radiculopathy. Methodology Study proceeded after ethical clearance from the central ethical committee of Nitte University. The subjects diagnosed with acute low back pain with radiculopathy by an orthopaedician fulfilling the inclusion criteria will be included in the study. An informed written consent will be collected from all the subjects included in the study. A total of 100 patients will be included in the study and they will be randomly assigned into two groups using convenience sampling. One group will receive conventional therapy and the other group LLLT. Visual Analogue Scale Oswestry Low Back Pain Disability Questionnaire Modified Schober’s test will be measured pre and post following treatment for a duration of 5 days. Results Both groups have shown significant improvement but low level laser therapy group have shown more significant results p value 0.001 compared to control group managed with conventional therapy. ISSN:2347-6567 International Journal of Allied Medical Sciences and Clinical Research IJAMSCR

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Akhil Mathew et al / Int. J. of Allied Med. Sci. and Clin. Research Vol-42 2016 216-225 217 Conclusion Based on the above results we conclude that low level laser therapy is having a remarkable effect on pain control and tissue repair in acute back pain with radiculopathy. Further research in dosiometry and also with large sample seize is recommended. Keywords: Acute Low Back Pain Laser Radiculopathy. INTRODUCTION Low back pain with radiculopathy is defined as pain and discomfort localized below the costal margin and above the inferior gluteal folds with leg pain 1 . Acute low back pain is usually defined as the duration of an episode of low back pain persisting for less than 6 weeks 2 . Pain is a subjective experience and acute pain is a warning signal which expresses that body tissue is about to be injured. If injury actually occurs then a cascade of patho physiological events will take place in a well mapped simultaneous and chronological order 2 . Pain intensity is usually most prevalent in the inflammatory phase during the first hours and days after injury and in most cases pain decreases as the tissue re pair processes get under way. In peripheral nerve injury pain may occur from persisting mechanical pressure neurogenic inflammation or damage to the nerve structure leading to a state of persistent central sensitization within the central nervous system 34 . The lifetime prevalence of low back pain is reported as over 70 in industrialized countries one-year prevalence 15 to 45 adult incidence 5 per year. Peak prevalence occurs between ages 35 and 55 2 . Specific low back pain represents 15 of low back pain problems. About 50 of specific back pain is due to prolapsed intervertebral disc PID in which the nucleus pulposus herniates through a tear in the annulus fibrosis resulting in irritation of the adjacent nerve root and causing a typical radiculopathy pain. It is commonly seen in the age group of 15- 45 years of age. 3 Majority of the spinal disc herniation occurs in the lumbar region 95 in the L 4 -L 5 or L 5 -S 1 1 . The clinical phenomena in acute LBP are pain and neurological disorders that affect activities of daily living. The symptoms range from mild to severe that radiate into the regions served by the affected nerve root that are irritated or impinged by the herniated material. Other symptoms may include motor and sensory changes such as muscular weakness numbness paralysis paresthesia and altered reflexes 4 . There is expanding proof that aggravation in relationship with root pressure is the fundamental neurotic element of radiculopathy. Disturbance of the annulus fibrosis causes spilling of the core pulposus into the spinal channel which contains different aggravations to tissues including glycoproteins nitric oxide and phospholipase A2 which cause an incendiary reaction in and around the torment touchy nerve tissues 5 . Hazard variables most much of the time reported are substantial physical work regular bowing winding lifting pulling and pushing monotonous work static stances and vibrations. Psychosocial hazard variables incorporate anxiety trouble tension wretchedness intellectual brokenness torment conduct work disappointment and mental anxiety at work. Representing 75 to 85 of aggregate labourers non-appearance 2 . Two deliberate audits found that guidance to stay dynamic with or without different medicines diminished incapacity agony and discovered quicker rates prompting less time went through off work contrasted and bed rest. In a few rules back particular activities e.g. fortifying flexion expansion extending are considered not valuable amid the main weeks of a scene. Different rules express that low push oxygen consuming activities are a remedial alternative in intense low back pain 25 . LASER The expression "laser" started as an acronym for light intensification by invigorated outflow of radiation. Low-level laser treatment LLLT is a treatment procedure which utilizes a solitary wavelength light source. Laser has the accompanying qualities: collimation – it has little bar dissimilarity over separation union – the light waves are all in stage and monochromicity – it has a solitary or tight band of a specific wavelength of light. The radiated laser light is noted for its high level of spatial and worldly coherence. Laser radiation and monochromatic light might adjust cell and tissue capacity 6 .

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Akhil Mathew et al / Int. J. of Allied Med. Sci. and Clin. Research Vol-42 2016 216-225 218 To the extent discogenic back agony is concerned most orthopedic specialists use non- steroidal calming drugs and customary exercise based recuperation comprising of ultrasonic treatment footing treatment Tran’s cutaneous electrical treatment and short-wave treatment. These types of moderate treatment modalities speak to symptomatic treatment just without the biomodulation impacts offered by low-level lasers 78 . In spite of the fact that LLLT is presently used to treat a wide assortment of diseases. A not exactly ideal decision of parameters can bring about lessened viability of the treatment or even a negative restorative result 9 . Thus a large number of the distributed results on LLLT incorporate negative results just in view of an improper decision of light source and measurements. This decision is especially vital as there is an ideal measurement of light for a specific application and dosages higher or lower than this ideal quality might have no restorative impact. Indeed LLLT is described by a biphasic measurements reaction: lower dosages of light are frequently more advantageous than high doses 10 . CELLULAR AND TISSULAR MECHANISMS OF LLLT Local LLLT effects occurring in less than 24 hours after first irradiation. LLLT has an extensive variety of impacts at the atomic cell and tissue levels. The three fundamental components by which laser produce pain relieving impacts are accepted to be: animating endogenous opoids discharge lifting torment limits and adjusting the arrival of harmful go betweens for example bradykinin and histamine. Torment balance might likewise happen because of changes in nerve conduction speed and change in the limit for myelin creation 12 . LLLT backs off the transmission of agony signs through the autonomic sensory system manages serotonin and nor epinephrine and expansions the torment edge. Inside of the cell there is solid proof to propose that LLLT follows up on the mitochondria to build adenosine tri phosphate ATP creation adjustment of responsive oxygen species ROS and the affectation of interpretation elements. These interpretation variables cause protein union that triggers an expanded cell multiplication and movement balance in the levels of cytokines development elements and incendiary middle people and expanded tissue oxygenation 12 . LLLT is additionally utilized for irritation edema swelling and tissue mending. LLLT application is accepted to restrict the arrival of incendiary arbiters for example bradykinin and histamine diminishing the provocative reaction. Notwithstanding it has been unequivocally conjectured that a lessening in prostaglandin action amid the provocative procedure is the principle mitigating impact of laser incitement. Prostaglandins cause vasodilation at the site of aggravation encouraging invasion of incendiary cells to the encompassing tissue. Concentrates on have demonstrated that an abatement in prostaglandin movement because of laser incitement might advance healing. 1213 LLLT causes vasodilatation by setting off the unwinding of smooth muscle connected with endothelium which is very pertinent to the treatment of joint irritation. This vasodilatation expands the accessibility of oxygen to treated cells furthermore takes into account more noteworthy activity of safe cells into tissue. These two impacts add to quickened mending 14 . At the most fundamental level LLLT acts by prompting a photochemical response in the cell a procedure alluded to as biostimulation or photobiomodulation. At the point when a photon of light is consumed by a chromophore in the treated cells an electron in the chromophore can get to be energized and hop from a low-vitality circle to a higher-vitality circle. This put away vitality can Reduced PGE2 levels Reduced IL1 levels Reduced TNF levels Reduceplasminogen activator Redced neutrophil influx Reduced hemorrhagic formation Reduced COX- 2 expression Effects on inflammatory mediators Reduced cell aptosis improved micro circulation Reduced edema formation

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Akhil Mathew et al / Int. J. of Allied Med. Sci. and Clin. Research Vol-42 2016 216-225 219 then be utilized by the framework to perform different cell assignments. There are a few bits of proof that indicate a chromophore inside mitochondria being the underlying focus of LLLT. Radiation of tissue with light causes an expansion in mitochondrial items for example ATP NADH protein and RNA and additionally an equal growth in oxygen utilization and different in vitro tests have affirmed that cell breath is up regulated on treatment with LLLT 12 . Cytochrome c oxidase CCO is the pivotal chromophore in the cell reaction to LLLT. CCO is an extensive transmembrane protein complex comprising of two copper focuses and two heme iron focuses which is a segment of the respiratory electron transport chain. The electron transport chain passes high-vitality electrons from electron bearers through a progression of transmembrane buildings counting CCO to the last electron acceptor creating a proton angle that is utilized to deliver ATP. Consequently the utilization of light straightforwardly impacts ATP generation by influencing one of the transmembrane buildings in the chain: specifically LLLT results in expanded ATP creation and electron transport 1214. LLLT has prompted theory that CCO and NO discharge are connected by two conceivable pathways. It is conceivable that LLLT might bring about photodissociation of NO from CCO. Cell breath is down regulated by the creation of NO by mitochondrial NO synthase mtNOS a NOS isoform particular to mitochondria that ties to CCO and represses it. The NO uproots oxygen from CCO repressing cell breath and accordingly diminishing the creation of ATP. By separating NO from CCO LLLT keeps this procedure from occurring and results in expanded ATP creation 12 15 . The wavelengths of light utilized for LLLT fall into an "optical window" at red and NIR wavelengths 600–1070 nm. Wavelengths in the reach 600–700 nm are utilized to treat shallow tissue and more wavelengths in the extent 780–950 nm which infiltrate further are utilized to treat more profound situated tissues 12 . MATERIALS AND METHOD The objective of the study was to compare the effectiveness of laser therapy and conventional treatment in acute low back pain with radiculopathy. A sample seize of 100 patients were selected from Justice K. S Hegde Charitable Hospital Department of physiotherapy having acute back pain with radiculopathy. Patients who met the inclusion criteria were included in the study and were divided into 2 groups by computer generated random numbers. One group will receive conventional therapy and the other group LLLT. Hot pack will be given for both groups prior to treatment session for 10 minutes. Visual analogue scale VAS Oswestry back pain disability questionnaire OWQ and Schober’s test SCT to document pain disability and lumbar range of motion respectively will be measured pre and post following treatment for duration of 5 days. Laser unit of wavelength 905nmred frequency 5000HZ power output 100mW spot seize 1cm power density 20 mW/cm 2 energy density 3J and treatment time of 150 second in each points. Laser probe is held in contact with skin over local transforaminal region 2.5cm and 3.5 cm laterally of the of the involved nerve root and on distal level segment. Conservative group will be receiving TENS for 10 minutes. TENS- VectroStim bipolar 100 HZ 30mA. Inclusion Criteria Exclusion Criteria Age – 18 to 60 years Previous history of spinal surgery Sex – Male and Female Sub-acute and chronic LBP Patients with acute low back pain and radiculopathy diagnosed with or without the help of radiographs Formal therapeutic or medical intervention within the last three months eg: steroid injections Both single and multiple levels lumbar disc protrusion and prolapse Co-existing conditions like ankylosing spondylitis rheumatoid arthritis spinal stenosis VAS score more than 6 Spinal tumors or patients where secondary metastases was suspected

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Akhil Mathew et al / Int. J. of Allied Med. Sci. and Clin. Research Vol-42 2016 216-225 220 Figure 1: Intervention group receiving LASER therapy Figure 2: Control group receiving TENS. RESULTS Statistical analysis was performed with the SPSS Version. 21.0 programs. A .05 of probability was adopted as the level for statistical significance. Descriptive statistics of Age Gender was done by using Mean and Standard Deviation. Comparison within group A and B was done by using Paired t test. Between group comparison was done by Independent t test. Since the VAS score was following the normal distribution curve Wilcoxon Signed Rank Test was not performed. Instead comparison was done by independent t test. VAS OWQ SCT was evaluated in this study as outcome measures. A total number of 90 patients completed the study out of which each group contains 45 subjects. There were10 dropouts in this study who had taken discharge early. In group A intervention mean age was 40.98±10.04. Group Bcontrol mean value were43.38±9.73.. There is no difference in the age between the groups which means subjects are equally distributed according to age. In Paired sample statistics results of VAS test for pain had an initial mean value of control group was 1.96 ± .47 and that of intervention group was 3.96 ± .96.This data clearly shows that both the group having significant change in reduction of the pain after the treatment session. The result of OWQ test had an initial mean value of control group was 4.35±4.65 and that of intervention group was 9.97±3.73. Available data clearly shows that both the group is having significant change in reduction of the disability after the treatment session. Result of SCT test had an initial mean value of control group was Flexion0.81±0.63Extension 0.26±0.44and that of intervention group was Flexion 1.42±0.49 Extension 0.84±0.47. Available data clearly shows that both the group is having significant change in reduction of the lumbar range of motion after the treatment session. Table 2: shows the significance of p 0.05 0.001. In Independent sample statistics Pain difference PD at the end of 5 days of treatment shows differences in both group Control 1.96 ± .47 and Intervention 3.97 ± .96 and statistically stating that there is a difference existing between the group treatment p 0.001 hence LASER is effective in reducing acute pain than conservative treatment. Low back Disability difference OWD at the end of 5 days of treatment shows differences in both group control group 4.35±4.65 and that of intervention group was 9.97±3.73 and statistically stating that there is a difference existing between the group treatment p 0.001 hence LASER is effective in reducing pain and disability than conservative treatment. Schobers test difference STD at the end of 5 days of treatment shows differences in both group control group was Flexion0.81±0.63 Extension 0.26±0.44 and that of intervention group was Flexion 1.42±0.49 Extension 0.84±0.47 statistically stating that there is a difference existing between the group treatment p 0.001 hence LASER is effective in improving lumbar flexibility than conservative treatment.

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Akhil Mathew et al / Int. J. of Allied Med. Sci. and Clin. Research Vol-42 2016 216-225 221 Table 1: Descriptive statistics of the subjects Table 2: Paired t test within group comparison Group Variables PAIRED DIFFERENCES t value Sig.2-tailed Mean ± SD 95 Confidence Interval of the Difference Lower Upper ContrControl VAS pre -post 1.95 ± 0.47 1.81 2.09 27.64 .001 OWQ pre - post 4.35 ± 4.65 2.95 5.77 6.27 .001 SCT Flex pre- post 0.81 ± 0.63 1.00 0.62 8.59 .001 SCT Ext pre-post 0.26 ± 0.44 0.40 0.13 4.00 .001 I Intervention VAS pre - post 3.97 ± 0.96 3.68 4.26 27.65 .001 OWQ pre - post 9.97 ± 3.73 8.85 11.10 17.90 .001 SCT Flex pre- post 1.42 ± 0.49 1.57 1.27 19.10 .001 SCT Ext pre-post 0.84 ± 0.47 0.98 0.70 11.93 .001 Group Mean Std. Deviation Control Age 43.38 9.733 VAS pre 7.60 .751 VAS post 5.64 .645 OWQ pre 32.18 6.840 OWQ post 27.82 6.936 SCT pre Flexion 3.09 1.104 SCT pre Extension 2.24 .679 SCT post Flexion 3.900 .8367 SCT post Extension 2.51 .626 Intervention Sex 1.33 .477 Age 40.98 10.042 VAS pre 7.89 .859 VAS post 3.91 .557 OWQ pre 33.42 5.061 OWQ post 23.44 3.461 SCT pre Flexion 2.78 .765 SCT pre Extension 1.93 .688 SCT post Flexion 4.200 .7261 SCT post Extension 2.78 .420

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Akhil Mathew et al / Int. J. of Allied Med. Sci. and Clin. Research Vol-42 2016 216-225 222 Table 3: Independent t test between group comparisons DISCUSSION Although low back pain is prevalent and is having a very high chance of chronicity and recurrence there is lack of evidence on effective treatment in acute phase patients. The requirement for an effective and optimal treatment is emphasized by the fact that optimal treatment in acute phase will reduce the prevalence and prevent the chronicity and recurrence 5 . In clinical practice a broad spectrum of therapy approaches is being used ranging from pharmacological physical agents to exercise and manual therapy practice. Various types of physical agents are not sufficiently supported. The general recommendation is that further studies are required or it can be used to manage patients for whom no improvement has been achieved by previous treatments 16 . This study included patients with severe pain VAS≥6 and moderate to minimal disability during V Variable Differences t-test for Equality of Means Mean ± SD t Sig.2- tailed 95 Confidence Interval of the Difference Lower Upper PD CONTROL 1.96 ± .47 - 12.614 .001 -2.34082 -1.70363 INTERVENTION 3.97 ± .96 OWD CONTROL 4.35 ± 4.65 -6.315 .001 -7.39144 -3.85301 INTERVENTION 9.97 ± 3.73 SFD CONTROL 0.81 ± .63 -5.083 .001 -.85005 -.37218 INTERVENTION 1.42 ± .49 STD CONTROL 0.26 ± .44 -5.944 .001 -.77097 -.38459 INTERVENTION 0.84 ± .47 0 2 4 6 8 10 12 VAS OWQ SCT flxn SCT extn control intrvntn Independent t test between group comparison

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Akhil Mathew et al / Int. J. of Allied Med. Sci. and Clin. Research Vol-42 2016 216-225 223 daily activities on screening associated with acute radiculopathy and disc herniation. Results show statistically significant improvement in all groups with better result for all parameters measured in group Aintervention group with other group p value 0.001. The analysis of parameters with more specified clinical meaning has shown significant differences between Group A and Group B with better reduction in pain intensity and disability. The main problems in comparing the results of this study with others are the differences in the included patients and applied parameters. Metaanalysis by Yousefi-Nooraie and colleagues considered nonspecific LBP and there were no consistent conclusions 4 . Many other clinical studies have used LLLT for nonspecific chronic LBP however a group of patients with nonspecific chronic LBP is very heterogenic and the reasons of their pain caused not only by pathological changes in the spinal and paraspinal structures but also by complex neurophysiologic and psychosomatic and psychosocial mechanisms 4 . Hypothetically the biological actions of LLLT are multiple the reduction of inflammation is the primary effect with consecutive improvement in neurophysiologic features of the affected nerve. The direct effect on nerve which accelerates recovery of the conduction block changes in endorphin level the results of clinical and experimental study has shown that the anti- inflammatory effects are more significant 16 . Various studies have documented changes in biochemical markers of inflammation distribution of inflammatory cells and the reduction in formation edema hemorrhage and necrosis after local LASER beams ranging from 660-905nm 5 . Comparison with anti-inflammatory drugs like Meloxicam and Indomethacin has shown similar anti-inflammatory effects. The direct action or effect of LLLT on neural structures that are damaged by compression or inflammation should be considered as an important additional effect. This additional effect is beneficial in acute lesions of neural structures such as acute lumbar radiculopathy. A less than optimal choice of parameters can result in reduced effectiveness of treatment or even a negative therapeutic outcome. As a result many of the published results on LLLT include negative results simply because of an on appropriate choice of light source and dosage. LLLT is characterized by a biphasic dose response: lower doses of light are more beneficial than high doses 5 . Evidence from this study suggests only the short term effects of LASER. Further studies could include patients randomized by levels of baseline disability and duration of symptoms. Studies which state the long term effect of LLLT should be emphasized. Further studies should evaluate many factors such as psychosocial aspect and dosiometry that may reflect on treatment response and recovery. The complete substitution of anti- inflammatory drugs by LLLT in patients that are at high risk should also be targeted in future studies. CONCLUSION Treatment of acute low back pain with radiculopathy at 905-nm LLLT of a dose of 3J/point proposed as an additional therapy in acute care setup has shown better short term improvement in pain disability and quality of life compared with patients treated with conventional physiotherapy TENS.No side effects were noticed for LLLT throughout the study period. Hence LLLT is a viable option to treat acute radicular pain and there by arresting the promotion towards chronicity. LLLT reduces pain and disability in acute state and delay or prevents progression. REFERENCES 1. Djavid G Mehrdad R Ghasemi M Hasan-Zadeh H Sotoodeh-Manesh A Pouryaghoub G. In chronic low back pain low level laser therapy combined with exercise is more beneficial than exercise alone in the long term: a randomised trial. Australian Journal of Physiotherapy. 2007 533:155-160. 2. Van Tulder M Becker A Bekkering T Breen A Gil Del Real M Hutchinson a et al. Chapter 3 European guidelines for the management of acute nonspecific low back pain in primary care. European Spine Journal. 2006 15S2:s169-s191.

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Akhil Mathew et al / Int. J. of Allied Med. Sci. and Clin. Research Vol-42 2016 216-225 225 24. Patel V Wasserman R Imani F. Interventional Therapies for Chronic Low Back Pain: A Focused Review Efficacy and Outcomes. Anesthesiology and Pain Medicine. 2015 54. 25. Gross A. Low Level Laser Therapy LLLT for Neck Pain: A Systematic Review and Meta-Regression. The Open Orthopedics Journal. 2013 71:396-419. How to cite this article: Akhil Mathew Dr. Dhanesh Kumar K U Dr. Ajith S and Subash Chandra Rai. Effect of low level laser therapy in acute low back pain with radiculopathy: a single blinded randomized control study. Int J of Allied Med Sci and Clin Res 2016 42: 216-225. Source of Support: Nil. Conflict of Interest: None declared.