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Low-Level Laser Therapy for Fibromyalgia: A Systematic Review and Meta-Analysis

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Background: Fibromyalgia is a chronic disorder characterized by widespread pain and tenderness. Low-level laser therapy (LLLT), an emerging nonpharmacological treatment, has been used for relieving musculoskeletal or neuropathic pain. Objective: The objective of this review and meta-analysis was to determine the efficacy of LLLT on patients with fibromyalgia. Study design: This study involved systematic review and quantitative meta-analysis of published randomized controlled trials (RCTs). Setting: This study examined all RCTs evaluating the effect of LLLT on fibromyalgia. Methods: We performed a systematic review and meta-analysis of RCTs evaluating the effect of LLLT on patients with fibromyalgia. PubMed, EMBASE, and the Cochrane Library were searched for articles published before August 2018. RCTs meeting our selection criteria were included. The methodological quality of the RCTs was evaluated according to the Cochrane risk-for-bias method. Review Manager version 5.3 was used to perform the meta-analysis. The primary outcomes were the total scores on the Fibromyalgia Impact Questionnaire (FIQ), pain severity, and number of tender points. The secondary outcomes were changes in fatigue, stiffness, anxiety, and depression. Standardized mean difference (SMD), 95% confidence intervals (CI), and P values were calculated for outcome analysis. Results: We identified 9 RCTs that included 325 fibromyalgia patients undergoing LLLT or placebo laser treatment with or without an exercise program. The meta-analysis showed that patients receiving LLLT demonstrated significantly greater improvement in their FIQ scores (SMD: 1.16; 95% CI, 0.64-1.69), pain severity (SMD: 1.18; 95% CI, 0.82-1.54), number of tender points (SMD: 1.01; 95% CI, 0.49-1.52), fatigue (SMD: 1.4; 95% CI, 0.96-1.84), stiffness (SMD: 0.92; 95% CI, 0.36-1.48), depression (SMD: 1.46; 95% CI, 0.93-2.00), and anxiety (SMD: 1.46; 95% CI, 0.45-2.47) than those receiving placebo laser. Furthermore, when compared with the standardized exercise program alone, LLLT plus the standardized exercise program provided no extra advantage in the relief of symptoms. On the other hand, the results of the only RCT using combined LLLT/LED phototherapy showed significant improvement in most outcomes except for depression when compared to placebo. When compared with pure exercise therapy, combined LLLT/LED phototherapy plus exercise therapy had additional benefits in reducing the severity of pain, number of tender points, and fatigue. Limitations: There were some limitations in this review, mostly because of the low-to-middle methodological quality of the selected studies; for example, there was no clear allocation process and only patients were blinded in most studies. In addition, one study used per-protocol analysis with a 20% loss to follow-up. On the other hand, the differences in laser types, energy sources, exposure times, and associated medication status in these studies may have resulted in some heterogeneity. Conclusions: Our results provided the most up-to-date and relevant evidence regarding the effects of LLLT in fibromyalgia. LLLT is an effective, safe, and well-tolerated treatment for fibromyalgia. Key words: Low-level laser therapy, fibromyalgia, meta-analysis, FIQ, pain, tender points,exercise.
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Background: Fibromyalgia is a chronic disorder characterized by widespread pain and tenderness.
Low-level laser therapy (LLLT), an emerging nonpharmacological treatment, has been used for
relieving musculoskeletal or neuropathic pain.
Objective: The objective of this review and meta-analysis was to determine the efficacy of LLLT
on patients with fibromyalgia.
Study Design: This study involved systematic review and quantitative meta-analysis of published
randomized controlled trials (RCTs).
Setting: This study examined all RCTs evaluating the effect of LLLT on fibromyalgia.
Methods: We performed a systematic review and meta-analysis of RCTs evaluating the effect of
LLLT on patients with fibromyalgia. PubMed, EMBASE, and the Cochrane Library were searched
for articles published before August 2018. RCTs meeting our selection criteria were included. The
methodological quality of the RCTs was evaluated according to the Cochrane risk-for-bias method.
Review Manager version 5.3 was used to perform the meta-analysis. The primary outcomes were
the total scores on the Fibromyalgia Impact Questionnaire (FIQ), pain severity, and number of
tender points. The secondary outcomes were changes in fatigue, stiffness, anxiety, and depression.
Standardized mean difference (SMD), 95% confidence intervals (CI), and P values were calculated
for outcome analysis.
Results: We identified 9 RCTs that included 325 fibromyalgia patients undergoing LLLT or
placebo laser treatment with or without an exercise program. The meta-analysis showed that
patients receiving LLLT demonstrated significantly greater improvement in their FIQ scores (SMD:
1.16; 95% CI, 0.64-1.69), pain severity (SMD: 1.18; 95% CI, 0.82-1.54), number of tender
points (SMD: 1.01; 95% CI, 0.49-1.52), fatigue (SMD: 1.4; 95% CI, 0.96-1.84), stiffness (SMD:
0.92; 95% CI, 0.36-1.48), depression (SMD: 1.46; 95% CI, 0.93-2.00), and anxiety (SMD: 1.46;
95% CI, 0.45-2.47) than those receiving placebo laser. Furthermore, when compared with the
standardized exercise program alone, LLLT plus the standardized exercise program provided no
extra advantage in the relief of symptoms. On the other hand, the results of the only RCT using
combined LLLT/LED phototherapy showed significant improvement in most outcomes except for
depression when compared to placebo. When compared with pure exercise therapy, combined
LLLT/LED phototherapy plus exercise therapy had additional benefits in reducing the severity of
pain, number of tender points, and fatigue.
Limitations: There were some limitations in this review, mostly because of the low-to-middle
methodological quality of the selected studies; for example, there was no clear allocation process
and only patients were blinded in most studies. In addition, one study used per-protocol analysis
with a 20% loss to follow-up. On the other hand, the differences in laser types, energy sources,
exposure times, and associated medication status in these studies may have resulted in some
heterogeneity.
Conclusions: Our results provided the most up-to-date and relevant evidence regarding
the effects of LLLT in fibromyalgia. LLLT is an effective, safe, and well-tolerated treatment for
fibromyalgia.
Key words: Low-level laser therapy, fibromyalgia, meta-analysis, FIQ, pain, tender points,
exercise
Pain Physician 2019: 22:241-254
Systematic Review
Low-Level Laser Therapy for Fibromyalgia: A
Systematic Review and Meta-Analysis
From: 1School of Medicine,
Taipei Medical University,
Taipei, Taiwan; 2Institute of
Epidemiology and Preventive
Medicine, College of Public
Health, National Taiwan
University; 3Cochrane Taiwan,
Taipei Medical University, Taipei,
Taiwan; 4Center for Evidence-
Based Health Care, Taipei
Medical University - Shuang Ho
Hospital, New Taipei City, Taiwan;
5Division of General Surgery,
Department of Surgery, School of
Medicine, College of Medicine,
Taipei Medical University, Taipei,
Taiwan; 6Division of General
Surgery, Department of Surgery,
Shuang Ho Hospital, Taipei
Medical University, New Taipei
City, Taiwan; 7Department of
Neurology, Shuang Ho Hospital,
Taipei Medical University, New
Taipei City, Taiwan; 8Department
of Neurology, School of
Medicine, College of Medicine,
Taipei Medical University,
Taipei, Taiwan; 9Department of
Neurology, Taipei Neuroscience
Institute, Taipei Medical
University, Taipei, Taiwan
Address Correspondence:
Yi-Chun Kuan, MD
Department of Neurology, Taipei
Medical University-Shuang Ho
Hospital, 291 Zhongzheng Rd,
Zhonghe District, New Taipei
City, 23561, Taiwan
E-mail: yckuang2@gmail.com
Disclaimer: Shu-Wei Yeh and
Chien-Hsiung Hong contributed
equally to this study. There
was no external funding in the
preparation of this manuscript.
Conflict of interest: Each author
certifies that he or she, or a
member of his or her immediate
family, has no commercial
association (i.e., consultancies,
stock ownership, equity interest,
patent/licensing arrangements,
etc.) that might pose a conflict of
interest in connection with the
submitted manuscript.
Manuscript received: 09-27-2018
Revised manuscript received:
10-06-2018
Accepted for publication:
11-05-2018
Free full manuscript:
www.painphysicianjournal.com
Shu-Wei Yeh, MD1, Chien-Hsiung Hong, MD1, Ming-Chieh Shih, MD2, Ka-Wai Tam, MD, PhD3-6,
Yao-Hsien Huang, MD4,7,8, and Yi-Chun Kuan, MD2-4,7-9
www.painphysicianjournal.com
Pain Physician 2019; 22:241-254 • ISSN 1533-3159
Pain Physician: May/June 2019: 22:241-254
242 www.painphysicianjournal.com
ing the use of LLLT in fibromyalgia. On the other hand,
since exercise therapies or physical therapies have been
proven to be beneficial to patients with fibromyalgia,
we also used meta-analysis to compare the effective-
ness of a standardized exercise program plus LLLT with
a standardized exercise program alone.
Methods
Selection Criteria
We reviewed RCTs evaluating the efficacy of LLLT
for fibromyalgia. We included trials that (a) compared
the results of LLLT and placebo laser therapy in patients
with fibromyalgia; (b) described the inclusion and ex-
clusion criteria for patient selection; and (c) reported
power, wavelength, and laser exposure duration. We
excluded trials that used a class IV laser because laser
class ≤ IIIB is considered therapeutic, whereas a class IV
laser causes tissue destruction. Furthermore, trials with
laser treatment focusing only on one joint or a specific
region of the body were excluded.
Search Strategy and Study Selection
We searched PubMed, EMBASE, and the Cochrane
Library for studies on fibromyalgia. The following MeSH
terms and Boolean operator were used: fibromyalgia
AND (laser OR low-level laser OR photobiomodulation
OR phototherapy). The “Related Articles” option in
PubMed was used to broaden the search. We applied no
language restrictions. The final search was performed
in August 2018. We selected studies on the basis of
the titles and abstracts meeting the selection criteria.
The systematic review described here was accepted by
PROSPERO, the online international prospective regis-
ter of systematic reviews of the National Institute for
Health Research (CRD42017079531).
Data Extraction
Two authors (SWY and CHH) independently se-
lected RCTs and extracted the relevant details: number,
age, and gender of participants; inclusion and exclusion
criteria; laser strategies; and outcome parameters. The
individually-recorded information of both reviewers
was compared, and a third reviewer (YCK) resolved any
discrepancies.
Methodological Quality Appraisal
The 3 aforementioned reviewers independently
evaluated the methodological quality of the RCTs ac-
cording to the Cochrane risk-for-bias method (12).
Fibromyalgia is a chronic disorder characterized
by widespread pain and tenderness. Patients
with fibromyalgia often suffer from fatigue,
sleep disturbance, and memory problems (1).
Neurological complaints such as paresthesia, blurred
vision, numbness, and weakness are also commonly
seen (1,2). Its estimated prevalence is 2.1% to 5.3%
in the general population, with women experiencing
more severe symptoms. This syndrome typically occurs
in middle-aged adults, but it can develop in any age
group, including childhood, adolescence, as well as
in the elderly (1). Although the cause of fibromyalgia
is uncertain, central nervous system sensitization is
considered to be its major pathogenesis. External factors
such as infection, trauma, and stress may precipitate
it (1,2). No curative treatment for fibromyalgia is
available thus far. A combination of pharmacological
and nonpharmacological treatments is generally
recommended for adequate symptom relief (1). The US
Food and Drug Administration approved duloxetine
(Cymbalta), milnacipran (Savella), and pregabalin
(Lyrica) for treating fibromyalgia. Duloxetine and
milnacipran help control pain levels by changing
some of the brain neurotransmitters (serotonin and
norepinephrine), whereas pregabalin blocks the
overactivated neurons involved in pain transmission.
Physical exercise and cognitive behavior therapy are the
nonpharmacological options with stronger evidence
of efficacy in fibromyalgia (3,4). Other interventional
approaches with lower levels of evidence include
occipital nerve stimulation, lidocaine infusion, and
hyperbaric oxygen therapy (4).
Low-level laser therapy (LLLT) is an emerging,
noninvasive alternative treatment with some efficacy
in relieving musculoskeletal or neuropathic pain and
improving the quality of life (5-10). The mechanism
is believed to involve photochemical reactions, which
alter cell membrane permeability, increase messenger
RNA buildup, and lead to cell proliferation. The light
emitted during LLLT reacts with cytochrome c oxidase, a
respiratory enzyme in mitochondria, and increases ade-
nosine triphosphate (ATP) production and reduces reac-
tive oxygen species levels; this helps reduce cell inflam-
mation and death (11). Some randomized controlled
trials (RCTs) have investigated the efficacy of LLLT for
fibromyalgia. However, the results have been inconsis-
tent, with small sample sizes. Therefore, we conducted
a comprehensive systematic review and meta-analysis
of the effectiveness of LLLT in fibromyalgia, aiming to
contribute to evidence-based decision-making regard-
www.painphysicianjournal.com 243
Low-Level Laser Therapy for Fibromyalgia: A Systematic Review and Meta-Analysis
Several domains were evaluated: allocation generation
and concealment; blinding of patients, personnel, and
outcome assessor; incomplete outcome data (intention-
to-treat or per-protocol); and loss to follow-up rate.
Outcome Assessment
To logically and clearly perform the meta-analysis,
the outcome assessment comprised 2 sections. One sec-
tion pooled data from RCTs comparing LLLT with pla-
cebo to evaluate the benefits of LLLT. The other section
pooled data from RCTs comparing LLLT plus standard-
ized exercise with standardized exercise alone in order
to investigate whether applying the additional laser to
exercise therapies provides more benefits than exercise
alone.
In each section, we evaluated 3 primary outcomes,
namely improvement in the total Fibromyalgia Impact
Questionnaire [FIQ] scores (13), severity of pain, and
number of tender points; and 4 secondary outcomes,
namely improvement in fatigue, stiffness, anxiety, and
depression. The improvement in pain severity was as-
sessed by extracting the score of the subitem “pain”
from FIQ (0-10), using a 5-point Likert scale (0 = none,
1= mild, 2 = moderate, 3 = severe, and 4 = extreme), or
by using a visual analog scale (VAS) in cm. As for the
definition of tender points, points that were reported
by patients as being painful were regarded as tender
points; additional tender points were more rigorously
defined if patients felt pain at pressure less than or equal
to 2.6 kgf/cm2 while subject to an increasing pressure of
0.1 kgf/s via placement of an apparatus perpendicular
to the point to be evaluated (14). Improvements in fa-
tigue, stiffness, anxiety, and depression were assessed
using the subitem score of “fatigue” on the FIQ (0-10)
or on the Likert scoring system for grading, “stiffness”
on the FIQ and “morning stiffness” on the Likert scoring
system, “anxiety” on the FIQ, and “depression” on the
FIQ, respectively. In some cases, depression was assessed
by a psychiatrist according to the Hamilton Depression
Rating Scale (HDRS) (15,16), DSM-IV criteria (17), or the
Beck Depression Inventory (18).
Statistical Analysis
We used RevMan 5.3 (The Nordic Cochrane Center
for The Cochrane Collaboration, Copenhagen, Denmark)
to perform the meta-analysis of the RCTs according to
the PRISMA (Preferred Reporting Items for Systematic
Reviews and Meta-Analysis) guidelines (19). The stan-
dardized mean difference (SMD) was calculated as the
effect size for continuous outcomes. The accuracy of the
result was reported as a 95% confidence interval (CI). P
< 0.05 was considered significant. When necessary, the
means and standard deviations of pretreatment-post-
treatment changes were estimated according to the
reported pretreatment and posttreatment data (20).
Due to possible heterogeneity between each study, the
DerSimonian and Laird random-effects model was used
for calculating a pooled estimate of the mean differ-
ence (21). The I-square test was performed to assess the
heterogeneity among these trials.
Results
Study Selection and Characteristics of
Included Studies
Figure 1 illustrates a flowchart of the study se-
lection process. We initially identified 305 potential
trials but excluded 105 duplicates and 97 ineligible
articles after screening their titles and abstracts. Sub-
sequently, 103 additional reports were excluded as
follows: 55 were on different topics, 14 used different
comparisons, 14 were review articles, 6 were systematic
reviews, 3 were protocols, 1 was a cohort study, and
1 was a case study. Finally, the remaining 9 RCTs were
further analyzed.
The characteristics of these eligible studies (14,22-
29) are summarized in Table 1. These 9 RCTs were pub-
lished between 2002 and 2018, with sample sizes of 20
to 80 patients. The mean participant age ranged from
29 to 52 years; however, an earlier trial in 2002 by Gür
et al (29) did not offer any information on age. Most
RCTs only included women, except that the trial by Gür
et al (28) enrolled some male patients and the trial by
Ruaro et al (24) enrolled one man in the placebo group.
All patients had been diagnosed with fibromyalgia.
For patient diagnosis, 6 RCTs (14,22,24,27-29) used the
American College of Rheumatology’s diagnostic criteria
(30), one (23) used the American Rheumatology Society’s
criteria, and the diagnostic criteria were not mentioned
in 2 RCTs (25,26). Patients continued their usual pharma-
cological therapy in one RCT (22), whereas 3 RCTs did
not mention whether the patients were taking medica-
tion concurrently (24-26), some of the patients in one
RCT continued their regular medication for fibromyalgia
(14), and the remaining 4 claimed that no patients took
analgesic, anti-inflammatory medications or central ner-
vous system drugs during the study period.
Regarding laser parameters, 6 RCTs (23,24,26-29)
used GaAlAs or Ga-AS laser, one (25) used Girlase, one
RCT employed a 9-diode cluster device containing mul-
Pain Physician: May/June 2019: 22:241-254
244 www.painphysicianjournal.com
Fig. 1. Flow chart of the process of study selection.
tiple light sources (LLLT and light-emitting diode [LED])
(22), and the latest RCT used a DMC® Photon Laser III de-
vice (14). Therefore, we performed a subgroup analysis
to differentiate the efficacy of monowavelength LLLT
vs an LLLT/LED combination. Laser wavelength ranged
from 640 to 950 nm and power from approximately
0.9 to 1000 MW. The follow-up period of the 8 RCTs
ranged from 2 to 10 weeks; one RCT further followed
for 6 months. Five studies (24,25,27-29) involving 173
patients evaluated the effectiveness of LLLT by com-
paring with placebo laser. Three RCTs compared LLLT
plus stretching exercise with stretching exercise alone
(14,23,26). One RCT designated patients into 4 groups:
control group, phototherapy group, stretching and
aerobic exercise training group, and phototherapy plus
stretching and aerobic exercise training group (22).
Study Quality
As shown in Table 2, the methodological quality of
9 RCTs was assessed (14,22-29). Five RCTs (14,22,24,28,29)
reported acceptable methods of randomization, but
none described allocation concealment methods. Eight
RCTs (14,22-25,27-29) reported patient blinding by ap-
plying placebo or sham laser treatment; the remaining
RCT (26) did not provide any relevant blinding informa-
tion. Three RCTs by Armagan et al (27), da Silva et al
(22) and Germano (14) blinded outcome assessors; da
Silva et al also blinded the phototherapy programmer.
Eight RCTs used an intention-to-treat analysis without
loss to follow-up. However, 20% of the patients with-
drew from one RCT (26) without reporting the reason,
so per-protocol analysis was used for that study. One
RCT reported higher variability of emitted power and
energy dose of laser (26).
Comparison of LLLT and Placebo LLLT
Primary Outcome (FIQ Score, Pain, and Number of
Tender Points)
The meta-analysis showed significant improve-
ment in FIQ score after monowavelength LLLT than
that after placebo laser treatment (pooled SMD: 1.16;
95% CI, 0.64-1.69; I2 = 47%; Fig. 2). The severity of pain
was also significantly reduced in the monowavelength
LLLT group (pooled SMD: 1.18; 95% CI, 0.82-1.54, I2 =
0%; Fig. 3) compared with the placebo groups. A sig-
nificant decrease in the number of tender points after
monowavelength LLLT was also noted (SMD: 1.01; 95%
Table 1. Characteristics of the selected RCTs.
Study Inclusion
Criteria
No. of
Patients Age (yrs) Intervention Outcomes
Germano
(14), 2018
(Brazil)
Diagnosed with
FM by ACR
criteria
I: 11 (0%)
C: 11 (0%)
I: 39.73 ± 5.25
C: 40.36 ± 7.24
I: functional exercise program (40 to 60 min/
session) associated with active phototherapy
(808 nm, 100 mW, continuous, 4 J, and 142.85
J/cm2 on 17 tender points immediately after
exercise, 40 s/site 3 times/wk) x 8 wks
C: functional exercise program (40 to
60 min/session) associated with placebo
phototherapy (3 times/wk) x 8 wks
FIQ, VAS, no. of tender
points, Beck Depression
Inventory, pain
threshold, functional
performance, muscle
performance (flexibility,
strength)
da Silva (22),
2018 (Brazil)
Diagnosed as
FM by ACR
criteria on FIQ
for > 5 yrs, ≥ 35
y/o women
I: 20 (0% a)
C1: 20 (0%)
C2: 20 (0%)
C3: 20 (0%)
Overall:
40 ± 2
I: Phototherapy (a cluster with 9 diodes-1
super-pulsed infrared 905 nm, 4 LED of 640
nm, 4 LED of 875 nm, 39.3 J & 5 min/point x
10 sites) x 10 wks
C1: Placebo phototherapy x 10 wks
C2: Phototherapy + exerciseb x 10 wks
C3: Placebo phototherapy + exerciseb x 10 wks
FIQ, VAS, fatigue, body
stiffness, no. of tender
points, depression,
anxiety, SF-36;
(10 wks)e
Vayvay
(23), 2016
(Turkey)
Diagnosed with
FM by ARS
criteria, ≥18
y/o, continuous
chronic pain ≥
6 mos
I: 15 (0%)
C1: 15 (0%)
C2: 15 (0%)c
I: 36.4 ± 8.3
C1: 38 ± 8.4
C2: 38 ± 9.9 c
I: Ga-AS Laser (850 nm; 40 mW; 2 J/cm2; 50-
60 Hz, 3 min/painful point on back and head)
+ exercise x 3 wks
C1: Placebo laser + exercised x 3 wks
C2: Kinesiotape on the back for 3 wks +
exercised x 3 wks
FIQ, VAS, SF-36, Beck
Depression Inventory
Anxiety Level (3 wks)
Ruaro (24),
2014 (Brazil)
Diagnosed with
FM by ACR
criteria
I: 10 (0%)
C: 10 (10%)
I: 39.4 (34-45)
C: 43.4 (33-55)
I: GaAlAs laser (670 nm, 20 mW, 4 J/cm2 on
18 tender points, 3 times/wk) x 4 wks
C: Placebo laser x 4 wks
FIQ, McGill Pain
Questionnaire, VAS (4
wks)
Fernández
(25), 2011
(Spain)
Diagnosis of FM
for 3-10 yrs, 36-
61 y/o woman
I: 16 (0%)
C: 15 (0%)
I: 51.6 ± 6.18
C: 52.4 ± 5.88
I: Girlase E1.1010 (905 + 10 nm, 0.70 mJ/
drive, 1000 mW boost of the drives, pulsed, 1
min/frequency x 6 on 7 points) x 8 wks
C: Placebo laser x 8 wks
CRD (FIQ), Generalized
pain, fatigue (8 wks)
Matsutani
(26), 2007
(Brazil)
Diagnosed as
FM for 25-60
y/o, exclude
neoplasia
I: 10 (0%)
C: 10 (0%)
I: 44 (28-60)
C: 45 (31-57)
I: GaAlAs laser (830 nm, 3 J/m2, average 30
mW, continuous) + exercised 1 h BIW x 5 wks
C: Placebo laser + exercised 1 h BIW x 5 wks
FIQ, VAS, SF-36 (5 wks)
Amargan
(27), 2006
(Turkey)
Diagnosed with
FM by ACR
criteria
I: 16 (10%)
C: 16 (0%)
I: 38.9 ± 4.9
C: 37.6 ± 5.9
I: GaAlAs laser (830 nm, 50 mW, continuous,
1 min & 2 J/tender point), 5 days/wk x 2 wks
C: Placebo laser 5 days/wk x 2 wks
FIQ, no. of tender
points, morning
stiffness, VSGI
(2 wks)
Gür (28),
2002
(Turkey)
Diagnosed with
FM by ACR
criteria; exclude
major clinical
conditions other
than FM
I: 25 (20%)
C1: 25 (24%)
C2: 25 (16%)c
I: 30.4 ± 6.9
C1: 28.5 ± 6.3
C2: 30.1 ± 8.7c
I: Ga-As laser (904 nm, average 11.2 mW,
2 J/cm2, 2.8 kHz) 3 min/tender point every
afternoon x 2 wks (except weekend)
C1: Placebo laser x 2 wks
C2: Amitriptyline 10 mg at bedtime x 8 wksc
FIQ, depression (HDRS,
DSM-IV), pain, no.
of tender points,
morning stiffness, sleep
disturbance, fatigue (2
wks/6 mos)
Gür (29),
2002 (earlier
published)
(Turkey)
Diagnosed with
FM by ACR
criteria; exclude
major clinical
conditions other
than FM
I: 20 (0%)
C: 20 (0%)
Not mentioned I: Ga-As laser (904 nm, average 11.2 mW,
2 J/cm2, 2.8 kHz) 3 min/tender point every
afternoon x 2 wks (except weekends)
C: Placebo laser x 2 wks
Pain, morning stiffness,
no. of tender points,
sleep disturbance,
fatigue (2 wks)
Abbreviations: ACR, American College of Rheumatology; ARS, American Rheumatology Society; C, Control group; CRD, Cuaderno de re-
cogida de datos; FIQ, Fibromyalgia Impact Questionnaire; FM, Fibromyalgia; HDRS, Hamilton Depression Rating Scale; I, Intervention group;
LED, light-emitting diode; SF-36, 36-item Short-Form Health Survey; VAS, Visual Analog Scale of pain; VSGI, global improvement as reported
on a verbal scale. Age was presented as mean ± SD or mean (range). a (): % men; b stretching and aerobic exercise; c not included for our analy-
sis; d stretching; e (): duration of outcome follow-up
www.painphysicianjournal.com 245
Low-Level Laser Therapy for Fibromyalgia: A Systematic Review and Meta-Analysis
Table 2. Methodological quality assessment of the selected RCTs.
Study Allocation
Generation
Allocation
Concealment Blinding Data
Analysis
Loss to
Follow-up
Patient
Gender Other Relevant Remarks
Germano
(14), 2018
Adequate Unclear Patients,
evaluators
ITT 0% Only women Some patients continued regular
medications for fibromyalgia in
2 groups
da Silva (22),
2018
Adequate Unclear Patients,
phototherapy
programmer,
and outcome
assessor
ITT 0% Only women Age distribution not reported;
unknown pharmacological
therapy for fibromyalgia in 2
groups
Vayvay (23),
2016
Unclear Unclear Patients ITT 0% Only women -
Ruaro (24),
2014
Adequate Unclear Patients ITT 0% Only women,
with one man
in the placebo
group
Unknown pharmacological
therapy for fibromyalgia in 2
groups
Fernández
(25), 2011
Unclear Unclear Patients ITT 0% Only women Unknown pharmacological
therapy for fibromyalgia in 2
groups
Matsutani
(26), 2007
Unclear Unclear Unclear PP 20% Only women Unclear reasons for, and
unknown distribution of, loss
of follow-up; may have high
variability of emitted power
and energy dose; unknown
pharmacological therapy for
fibromyalgia in 2 groups
Armagan
(27), 2006
Unclear Unclear Patients and
evaluators
ITT 0% Only women -
Gür (28),
2002
Adequate Unclear Patients ITT 0% - -
Gür (29),
2002 (earlier
published)
Adequate Unclear Patients ITT 0% Only women Age distribution not reported
Abbreviations: ITT, intention to treat; PP, per-protocol; RCT, randomized controlled trial.
Pain Physician: May/June 2019: 22:241-254
246 www.painphysicianjournal.com
Fig. 2. Forest plot of changes in FIQ score after LLLT or placebo laser treatment.
Fig. 3. Forest plot of changes in pain severity after LLLT or placebo laser treatment.
Fig. 4. Forest plot of changes in number of tender points after LLLT or placebo laser treatment.
www.painphysicianjournal.com 247
Low-Level Laser Therapy for Fibromyalgia: A Systematic Review and Meta-Analysis
CI, 0.49-1.52; I2 = 49%; Fig. 4). As for the combined LLLT/
LED phototherapy, the only RCT evaluating efficacy
showed significant improvement in FIQ, pain, and num-
ber of tender points compared with the placebo group.
The effect of combined LLLT/LED phototherapy on pain
relief and reduction in the number of tender points
seemed to be more obvious than monowavelength
LLLT (Figs. 3 and 4).
Secondary Outcomes (Fatigue, Stiffness,
Depression, and Anxiety)
In the monowavelength LLLT group, our analysis
showed significant improvements in the severity of
fatigue (pooled SMD: 1.4; 95% CI, 0.96-1.8), stiffness
(pooled SMD: 0.92, 95% CI: 0.36-1.48), depression
(pooled SMD: 1.46, 95% CI: 0.93-2.00), and anxiety
(pooled SMD: 1.46, 95% CI, 0.45-2.47). On the other
hand, the only one RCT evaluating the efficacy of the
combined LLLT/LED phototherapy demonstrated signif-
icant improvement in the severity of fatigue, stiffness,
and anxiety, but not depression, when compared with
those in the placebo laser group.
Comparison of LLLT Plus Exercise and Placebo
Laser Treatment Plus Exercise
Three RCTs evaluated the efficacy of monowave-
length LLLT with exercise (14,23,26). There was no
significant difference between the monowavelength
Pain Physician: May/June 2019: 22:241-254
248 www.painphysicianjournal.com
Fig. 5. Forest plot of changes in severity of fatigue after LLLT or placebo laser treatment.
Fig. 6. Forest plot of changes in severity of stiffness difference after LLLT or placebo laser treatment.
Fig. 7. Forest plot of changes in severity of depression after LLLT or placebo laser treatment.
Fig. 9. Forest plot of changes in FIQ scores between LLLT with exercise and exercise alone.
www.painphysicianjournal.com 249
Low-Level Laser Therapy for Fibromyalgia: A Systematic Review and Meta-Analysis
Fig. 8. Forest plot of changes in severity of anxiety after LLLT or placebo laser treatment.
LLLT plus standardized exercise program and exercise
program alone in the primary outcomes of FIQ score
(pooled SMD: 0.34; 95% CI, -0.17 to 0.85; I² = 14%; Fig.
9), pain (pooled SMD: 0.46; 95% CI, -0.10 to 1.01; I² =
0%; Fig. 10) and number of tender points (pooled SMD:
0.59; 95% CI, -0.26 to 1.45; Fig. 11) and secondary out-
comes of fatigue, stiffness, anxiety, or depression (SMD:
-0.16; 95% CI, -1.04 to 0.72; SMD: 0.08; 95% CI, -0.79 to
0.96; SMD: 0.09; 95% CI, -0.80 to 0.98; I² = 70%; SMD:
-0.38; 95% CI, 1.27-0.50, respectively; Figs. 12-15).
Compared with standardized exercise alone, LLLT/
LED combination phototherapy plus exercise program,
as reported in only one RCT, provided significant ad-
ditional benefit in relieving the primary outcome
of the severity of pain and number of tender points
(SMD: 5.20; 95% CI, 3.85-6.55 and SMD: 7.02; 95% CI,
5.29-8.76, respectively) and the secondary outcome of
fatigue (SMD: 1.35; 95% CI, 0.65-2.04), but it not de-
crease in FIQ score, severity of stiffness, or psychiatric
symptoms (Figs. 9-15) (22).
Side Effects
Four RCTs (22,24,27,29) reported no side effects
of LLLT in patients with fibromyalgia, consistent with
previous studies (6,10,31). However, the remaining RCTs
did not report on side effects (14,23,25,26,28).
discussion
LLLT has been introduced as a noninvasive, thera-
peutic intervention for pain in several musculoskeletal
disorders. Some mechanisms, such as increased nocicep-
tive threshold, endorphin production, and downstream
Pain Physician: May/June 2019: 22:241-254
250 www.painphysicianjournal.com
Fig. 12. Forest plot of changes in severity of fatigue between LLLT with exercise and exercise alone.
Fig. 11. Forest plot of changes in number of tender points between LLLT with exercise and exercise alone.
Fig. 10. Forest plot of changes in severity of pain between LLLT with exercise and exercise alone.
www.painphysicianjournal.com 251
Low-Level Laser Therapy for Fibromyalgia: A Systematic Review and Meta-Analysis
Fig. 13. Forest plot of stiffness between laser with physical activity and physical activity only.
Fig. 14. Forest plot of depression between laser with physical activity and physical activity only.
Fig. 15. Forest plot of anxiety between laser with physical activity and physical activity only.
Pain Physician: May/June 2019: 22:241-254
252 www.painphysicianjournal.com
opioid receptors, have been postulated to explain the
analgesic effect of phototherapy (32). Other hypoth-
eses include anti-inflammation due to a decrease in
prostaglandin-2 and cyclooxygenase-2 levels (28,32),
proliferation and neovascularization of connective tis-
sue cells (33,34), and increase in blood flow and promo-
tion of healing by increase in the levels of nitric oxide,
a powerful vasodilator (32). A recent systematic review
and meta-analysis of 18 studies suggested that LLLT
effectively reduces pain in adult patients with musculo-
skeletal disorders; however, patients with fibromyalgia
were not included in this meta-analysis (7). Further-
more, studies have indicated the beneficial role of LLLT/
LED combination in the treatment of nonspecific knee
pain (35) as well as masseter and temporalis muscle
pain in women with temporomandibular disorder (36).
Pain is the main symptom in patients with fibromy-
algia. Some RCTs have investigated the effect of LLLT
on fibromyalgia, but by using small sample sizes. Our
study is the first systematic review and meta-analysis
including 9 RCTs involving 325 patients to specifically
evaluate the efficacy of LLLT in fibromyalgia. Our
results demonstrated that LLLT provided significant
improvement in FIQ score, pain severity, number of ten-
der points, fatigue, stiffness, depression, and anxiety
compared to placebo. However, when compared with
pure exercise therapy, LLLT with exercise therapy did
not show more benefits. On the other hand, the single
RCT using LLLT/LED showed significant improvement in
the above-mentioned outcomes, except for depression,
when compared to placebo. When compared with pa-
tients with fibromyalgia who received exercise therapy,
combined LLLT/LED phototherapy and exercise therapy
had additional benefits in reducing the severity of pain,
number of tender points, and fatigue.
However, this review still has some limitations,
mostly because of the low-to-middle methodological
quality of the selected studies (Table 2). First, most stud-
ies did not report the allocation process clearly and only
blinded the patients; neither phototherapy program-
mer nor outcome assessor were blinded. Considering
that nearly all outcomes were subjective parameters,
the above shortcomings may introduce allocation bias,
performance bias, and detection bias. Second, one
study used per-protocol analysis because of a 20% loss
to follow-up without reporting the reasons for, or the
distribution of, the loss to follow-up (26); this may have
introduced attrition bias. Third, although LLLT was used
in all trials, the differences in laser types, energy sourc-
es, and exposure times used in the studies may have
resulted in some heterogeneity. Fourth, although pa-
tients with fibromyalgia did not take associated medi-
cations in most RCTs, patients in one trial maintained
their usual pharmacological therapies (22), another
trial included some patients continuing their regular
medications (14), and the other 3 RCTs did not men-
tion whether the participants were under concurrent
medication (24-26); therefore, we could not clarify the
separate roles of medication or phototherapy in fibro-
myalgia. Finally, long-term follow-up up to 6 months
was only conducted in one RCT (27).
In spite of the limitations, our study is the largest
systematic review and meta-analysis to evaluate the
efficacy of LLLT in patients with fibromyalgia, and it
has provided the most relevant available evidence on
LLLT for fibromyalgia. In conclusion, our data indicate
that LLLT is an emerging, noninvasive, well-tolerated
treatment for fibromyalgia to relieve discomfort, par-
ticularly in patients who do not exercise regularly.
Acknowledgments
We are grateful to Mariana Moreira da Silva and
all her coworkers for providing us with the raw data
of their original study “Randomized, blinded, con-
trolled trial on the effectiveness of photobiomodula-
tion therapy and exercise training in the fibromyalgia
treatment.” This enriched the content of our meta-
analysis and enhanced the power of evidence of LLLT.
This manuscript was edited by Wallace Academic
Editing.
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Low-Level Laser Therapy for Fibromyalgia: A Systematic Review and Meta-Analysis
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... Fibromyalgia (FM) is a common clinical syndrome characterized by diffuse pain and tender points throughout the body, head, and neck. Diagnostic examinations and tests and no radiographic or pathological findings allow the detection of this pathology with accuracy [7].FM is considered a central nociception modulation syndrome, also known as central pain sensitization, related strictly to chronic pain [1,2,9].FM is a rheumatological disease with a prevalence of 2.5% of the general Brazilian population (15% in medical practice), characterized by generalized muscle pain in addition to generating fatigue, changes in sleep, memory and mood [3,1,2,10]. Symptoms may arise after atraumatic event such as surgical procedure, physical trauma, infection, or even some significant psychological tension. ...
... We emphasize the main characteristics of this pathology and therefore we believe multidisciplinary knowledge is necessary for its diagnosis and treatment [5]. The following are the main characteristics of FM: fatigue, sleep disturbances [10] , rigidity [9], paresthesia, headache, weakness, symptoms similar to those of Raynaud's syndrome, depression, anxiety, mood disturbance, cognitive difficulties [10], brain fog, subjective joint swelling (without true synovitis), abdominal pain, chest wall pain, irritable bowel syndrome, Temporomandibular Disorder (TMD), pelvic pain, interstitial cystitis/painful bladder syndrome, multiple chemical sensitivities, palpitations, vulvodynia, dysmenorrhea, sexual dysfunction, weight fluctuations, night sweats, orthostatic intolerance, and chronic fatigue syndrome. LASER is the abbreviation for Light Amplification by Stimulated Emission of Radiation. ...
... We emphasize the main characteristics of this pathology and therefore we believe multidisciplinary knowledge is necessary for its diagnosis and treatment [5]. The following are the main characteristics of FM: fatigue, sleep disturbances [10] , rigidity [9], paresthesia, headache, weakness, symptoms similar to those of Raynaud's syndrome, depression, anxiety, mood disturbance, cognitive difficulties [10], brain fog, subjective joint swelling (without true synovitis), abdominal pain, chest wall pain, irritable bowel syndrome, Temporomandibular Disorder (TMD), pelvic pain, interstitial cystitis/painful bladder syndrome, multiple chemical sensitivities, palpitations, vulvodynia, dysmenorrhea, sexual dysfunction, weight fluctuations, night sweats, orthostatic intolerance, and chronic fatigue syndrome. LASER is the abbreviation for Light Amplification by Stimulated Emission of Radiation. ...
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... A emissão de fótons com cores e comprimento de ondas é sincronizada em fases, tempo e foco de emissão, o que caracteriza sua monocromaticidade, coerência e colimação. Esses fatores permitem que a intensidade dos fótons seja direcionada em áreas menores, o que favorece Sampaio et al a absorção adequada do comprimento da onda, a exemplo dos tecidos biológicos, cujos potenciais de absorção são diferentes 31,32 . ...
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Introdução: Terapias biomoduladoras como o Ultrassom Microfocado, a Fotobiomodulação LASER e LED e a Radiofrequência tem sido cada vez mais utilizadas para tratamento de disfunções íntimas em mulheres. Objetivo: Compilar evidências científicas acerca dos principais efeitos decorrentes do uso de terapias não-invasivas para o manejo de disfunções íntimas em mulheres, assim como documentar seus protocolos de tratamento descritos na literatura. Metodologia: Trata-se de uma revisão integrativa da literatura, cuja busca por artigos científicos foi realizada nas bases de dados, por meio de descritores da biblioteca virtual em saúde (DeCS), a saber, Laserterapia Vaginal E Fotobiomodulação, Laserterapia Vaginal E Radiofrequência, Ultrassom Microfocado, com seus correspondentes na língua inglesa. Foram incluídos estudos que abordaram as terapias estéticas não-invasivas para o tratamento de disfunções íntimas, publicados no período de 2014 a 2024 disponibilizados integralmente para leitura. Resultados: o Ultrassom Microfocado tem sido indicado para o tratamento de disfunções diversas da região íntima, promovendo respostas no índice de saúde vulvar. A fotobiomodulação LASER e/ou LED tem sido apontada como uma terapia inovadora para tratar síndromes geniturinárias. Estudos sobre o uso do sistema de Radiofrequência têm relatado resultados promissores, com a adoção de diferentes protocolos para o tratamento das disfunções íntimas. Conclusão: A literatura aponta para o possível potencial de ação benéfico das terapias não-invasivas citadas no manejo de disfunções na região íntima, no entanto, constatou-se que sua aplicabilidade clínica e acessibilidade ainda são limitadas.
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Fibromyalgia is a prevalent chronic condition marked by widespread pain, fatigue, and other debilitating symptoms. This guideline provides evidence‐based recommendations for nonpharmacological treatments, developed by a multidisciplinary expert group, including specialists in rheumatology, rehabilitation, pain management, traditional Chinese medicine (TCM), and evidence‐based medicine. The guideline follows the RIGHT checklist and is registered with the International Practice Guideline Registry Platform. The literature review incorporates systematic reviews, meta‐analyses, and randomized controlled trials (RCTs) up to March 2023, focusing on the effects of nonpharmacological interventions on pain intensity, fatigue, sleep quality, mood, and quality of life. A total of 57 studies were included, with findings supporting acupuncture and health education as core therapies. These interventions significantly reduce pain, alleviate fatigue, and improve sleep quality, and are strongly recommended based on moderate‐quality evidence. Additionally, aerobic exercise and resistance training are recommended for their proven effectiveness in reducing pain, enhancing physical function, and providing long‐term benefits. Emerging therapies, such as transcranial magnetic stimulation (TMS) and nutritional supplements, show promise but require further research due to low‐certainty evidence.
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Background Fibromyalgia is a chronic condition characterised by widespread musculoskeletal pain. Sleep problems are reported by 92% of people living with fibromyalgia. Objectives To evaluate the effectiveness and safety of interventions for the management of fibromyalgia-related sleep problems; explore the experiences of people with fibromyalgia-related sleep problems and examine the content of patient-reported outcome measures for ‘sleep quality’. Methods We conducted: (1) a network meta-analysis of randomised controlled trials to compare the effectiveness of pharmacological and non-pharmacological interventions; (2) a systematic thematic synthesis of qualitative evidence; (3) a content analysis of existing patient-reported outcome measures validated in people with fibromyalgia. Major electronic databases were searched in November 2021. Results One hundred and sixty-eight studies were included in the effectiveness synthesis. The network meta-analysis assessing sleep quality included 35 treatment categories from 65 studies (8247 participants). Most studies were at high overall risk of bias. There is some evidence that compared with placebo or sham treatments, some forms of exercise [i.e. land-based aerobic exercise training in combination with flexibility training (standardised mean difference −4.69, credible interval −8.14 to −1.28) and aquatic-based aerobic exercise training (standardised mean difference −2.63, credible interval −4.74 to −0.58)] may improve sleep. There is also a suggestion that land-based strengthening exercise, psychological and behavioural therapies with a focus on sleep, electrotherapy, weight loss, dental splints, antipsychotics and tricyclics may have a modest effect on sleep, but credible intervals are wide. For other interventions, there is no clear evidence of beneficial effects on sleep. Our certainty of current evidence was predominantly low to very low. The thematic synthesis highlighted the bidirectional relationship between sleep and pain. Twenty-one sleep domains were identified across five patient-reported outcome measures. The domain most frequently identified was sleep maintenance. The Pittsburgh Sleep Quality Index was the most comprehensive tool (15 domains), followed by the Medical Outcomes Study Sleep Scale (11 domains). Limitations Quantitative studies varied considerably in terms of characteristics of interventions, control treatments and type of outcome measures. In the network, most interventions were compared with placebo, sham treatment or usual care and not with another active treatment. In general, studies were small, unblinded and of short duration (median 12 weeks). For the qualitative synthesis and patient-reported outcome measures analysis, it is unclear whether study participants are adequately representative of the wider population of fibromyalgia patients due to poor reporting of demographic data. Conclusions Some forms of exercise may be effective for managing sleep problems in people with fibromyalgia. However, heterogeneity, imprecision and low quality of the current evidence base preclude any firm conclusions. Qualitative data indicate that poor sleep is a common, profoundly disabling problem for people with fibromyalgia that negatively affects their other symptoms (e.g. pain), health and well-being. While we found heterogeneity among the item content of the patient-reported outcome measures, all capture constructs associated with sleep quality and, conceptually, are similar enough to be combined in a synthesis. Future work High-quality research is needed to investigate which interventions are more likely to be effective for treating fibromyalgia-related sleep problems. Future studies must be designed in collaboration with fibromyalgia patients and include an appropriate comparator treatment. Pre-registration of study protocols is essential. Study registration This study is registered as PROSPERO CRD42021296922. Funding This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: NIHR132999) and is published in full in Health Technology Assessment ; Vol. 29, No. 20. See the NIHR Funding and Awards website for further award information.
Chapter
This chapter reviews non-pharmacologic treatments within the categories of integrative medicine, psychological interventions, external devices, and manual treatments. These treatments are discussed in detail and evidence is reviewed for which musculoskeletal conditions these treatments may be utilized for.
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Background and Objective Fibromyalgia is a condition characterised by disabling levels of pain of varying intensity. Aerobic exercise may play a role in reducing pain in these patients. The aim of this review is to assess the dose of aerobic exercise needed, based on the frequency, intensity, type, time, volume and progression (FITT‐VP) model, to obtain clinically relevant reductions in pain. Databases and Data Treatment A systematic review and meta‐analysis of randomised clinical trials was conducted in the Web of Science (WoS), PEDro, PubMed and Scopus databases, the search having been conducted between July and October of 2023. Risk of bias was assessed with the Cochrane Risk of Bias assessment tool 2. Results Seventeen studies were included. The risk of bias varied, with six studies showing low risk; five, some concerns; and six, high risk. Aerobic exercise interventions were analysed using the FITT‐VP model. Frequency ranged from 1 to 10 times per week, intensity varied from light to vigorous, and the types of exercise included music‐based exercise, interval training, pool‐based exercise, stationary cycling, swimming and walking. The intervention durations ranged from 3 to 24 weeks, with session lengths ranging from 10 to 45 min. Most of the studies presented significant differences, favouring aerobic exercise (MD −0.49; CI [−0.90, −0.08; p = 0.02]), with moderate to low heterogeneity in subgroup analyses. Conclusions The study findings underscore the efficacy of aerobic exercise in alleviating pain among fibromyalgia patients, advocating for tailored exercise dosing to optimise adherence and outcomes. Significance Statement Individuals with fibromyalgia should engage in aerobic exercises two to three times weekly, for twenty‐five to forty minutes in each session, aiming for more than a hundred minutes per week. They should start at low intensity, gradually increasing to higher intensities over six to twelve weeks, for optimal pain management. Exercise types should be selected in collaboration with the patient and based on personal preferences and accessibility, such as walking, and swimming, to ensure long‐term adherence to the regimen.
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This meta-analysis investigated therapeautic effects of laser therapies in patients with Bell’s palsy (BP). The authors performed the literature search in the PubMed, Embase, and Cochrane Library databases using the following search terms: (facial paralysis OR Bell’s palsy OR facial palsy OR idiopathic facial paralysis) AND (laser OR low-level laser OR photobiomodulation OR phototherapy). Relevant studies published before October 29th 2024 were identified. Randomized trials comparing the outcomes of laser therapies with other interventions, including electrical stimulation and control or usual care in patients with BP were included. The mean difference (MD) was determined as the effect size for continuous outcomes, and outcome accuracy was determined using 95% confidence intervals (CIs). Twelve studies were included, with a total of 597 patients. Nine studies were further included in the quantitative analysis. Our meta-analysis revealed that laser therapy significantly improved disease severity (House-Brackmann facial paralysis scale) (MD = −1.51, 95% CI = −2.43 to −0.59), facial asymmetry (Sunnybrook facial grading system) (MD = 20.63, 95% CI = 10.33 to 30.94), and facial function and disability (Facial disability index) (MD = 17.91, 95% CI = 5.60 to 30.22) when compared with control care in adult patients. Moreover, laser therapy significantly improved facial severity (MD = 21.05, 95% CI = 16.77 to 25.33) when compared with electrical stimulation. In addition, no adverse effects of laser therapy were reported. Laser therapy has favorable effects on disease severity, facial asymmetry, and facial function and disability for patients with BP.
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This study aims to investigate the effects of low-level laser therapy (LLLT) combined to a functional exercise program on treatment of FM. A double-blind and placebo-controlled randomized clinical trial composed of 22 women divided into two groups: placebo group (functional exercise program associated with placebo phototherapy n = 11) and laser group (same exercise program associated with active phototherapy; n = 11). Each session lasted from 40 to 60 min and was performed three times a week for 8 weeks. Phototherapy (808 nm, 100 mW, 4 J, and 142.85 J/cm² per point) was bilaterally applied to different points of the quadriceps (8), hamstrings (6), and triceps sural muscles (3) immediately after each exercise session. Pre- and post-intervention evaluations regarding pain (sites, intensity, and threshold), functional performance (balance, functional tests), muscle performance (flexibility and isokinetic variables), depression, and quality of life were conducted. A reduction in pain and improvement in functional and muscular performance, depression, and quality of life were observed in both groups (p < 0.05); however, with no significant differences between them (p > 0.05). In conclusion, the benefic effects of functional exercise were not improved by combination with LLLT.
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This study evaluated the role of the phototherapy and exercise training (EXT) as well as the combined treatment in general symptoms, pain, and quality of life in women suffering from fibromyalgia (FM). A total of 160 women were enrolled and measures were carried out in two sets: it was sought to identify the acute effect for a single phototherapy and EXT session (Set 1); long-term effect (10 weeks) of the interventions (Set 2). Phototherapy irradiation was performed at 11 locations in their bodies, employing a cluster with nine diodes (one super-pulsed infrared 905 nm, four light-emitting diodes [LEDs] of 640 nm, and four LEDs of 875 nm, 39.3 J per location). Algometry and VAS instrument were applied to evaluate pain. The FM symptoms were evaluated with Fibromyalgia Impact Questionnaire (FIQ) and Research Diagnostic Criteria (RDC) instruments. Quality of life was assessed through SF-36 survey. Set 1: pain threshold was improved with the phototherapy, and EXT improved the pain threshold for temporomandibular joint (right and left body side) and occipital site (right body side). Set 2: there was improved pain threshold in several tender points with the phototherapy and EXT. There was an overlap of therapies to reduce the tender point numbers, anxiety, depression, fatigue, sleep, and difficulty sleeping on FIQ/RDC scores. Moreover, quality of life was improved with both therapies. The phototherapy and EXT improved the pain threshold in FM women. A more substantial effect was noticed for the combined therapy, in which pain relief was accomplished by improving VAS and FIQ scores as well as quality of life.
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Objectives To assess the effectiveness of low-level laser therapy (LLLT) in reducing orthodontic pain after the application of orthodontic force (OF). Methods A systematic search was conducted in the MEDLINE, EMBASE, Scopus, Cochrane Library, Web of Science, and EBSCOhost databases. The study included randomized clinical trials (RCT) which analysed the effectiveness of LLLT in reducing orthodontic pain assessed at 24 and 72 hrs after the application of OF. The risk of bias of the eligible trials was assessed using the Cochrane Collaboration's risk of bias tool. Standard mean difference was calculated and pooled by meta-analysis using random effect models. Results Of 467 identified articles, 20 RCT were finally included. In the risk of bias assessments, 13 studies presented a high risk, 5 an unclear risk, and 2 a low risk. The meta-analysis showed that in patients treated with laser versus placebo there was a difference in favour of LLLT in spontaneous pain 24 and 72 hrs after the installation of light archwires and spontaneous pain and chewing pain 24 and 72 hrs after the installation of elastomeric separators. Conclusions LLLT proved to be effective in promoting a reduction in spontaneous and chewing pain after the application of OF; however, the poor quality of the evidence requires these results to be treated with caution.
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Introduction: Low-level laser therapy (LLLT) was introduced as an alternative non-invasive treatment for osteoarthritis, but its effectiveness is still controversial. The main objective of this article was to determine the safety and efficacy of LLLT in patients with knee osteoarthritis (KOA). Methods: In order to gather evidence, main medical databases as well as relevant websites were browsed without time limit. We searched with appropriate keywords and strategies. After quality assessment of studies, study data were extracted by two reviewers. Standard mean difference proposed through inverse variance was used in the meta-analysis using the random-effects model. Twelve values were used for the evaluation of heterogeneity. Results: A total of 823 studies, 14 randomized controlled trials (RCTs) were selected after final review. There was a significant difference between LLLT and placebo in pain at rest (P = 0.02), pain at activity (P = 0.01), total pain (P = 0.03), WOMAC function (P = 0.01), WOMAC stiffness (P = 0.02) and WOMAC total (P < 0.0001) in favor of the LLLT. There was no significant difference between LLLT and Placebo in WOMAC pain (P = 0.09) and range of motion (P = 0.1). Conclusion: In spite of some positive findings, this meta-analysis lacked data on how LLLT effectiveness is affected with important factors: wavelength, energy density, treatment duration, numbers of sessions the treatment, severity of KOA and site of application.
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Introduction: This meta-analysis investigated the effectiveness of low-level laser therapy (LLLT) on pain in adult patients with musculoskeletal disorders. Evidence acquisition: A systematic literature search was conducted in the Medline and PEDro databases. Two researchers independently screened titles and abstracts of the retrieved studies for eligibility. Quality assessment of the eligible studies was conducted using the PEDro rating scale. Studies that scored ≥ 4 were included. A random-effects model was used for this meta-analysis. Subgroup meta-analyses were conducted to evaluate the influence of the adherence of the applied LLLT to the World Association of Laser Therapy (WALT) guidelines, the anatomical site under investigation and the study design on the overall weighted mean effect size. Meta regression was used to assess the possible influence of the study quality on the individual study effect sizes. Evidence synthesis: Eighteen studies allowing for 21 head-to-head comparisons (totaling n=1462 participants) were included. The pooled raw mean difference (D) in pain between LLLT and the control groups was -0.85 [95%CI: -1.22 to -0.48]. There was high (I² = 85.6%) and significant between study heterogeneity (Cochran's Q = 139.2; df = 20; p < 0.001). The subgroup meta-analysis of the comparisons not following the WALT guidelines revealed a D = -0.68 [95%CI: -1.09 to -0.27]. In this group, heterogeneity decreased to I² = 72.6% (Q = 51.2; df = 14; p < 0.001). In the WALT subgroup D equaled -1.52 [95%CI: -2.34 to -0.70]. this between groups difference was clinically relevant although statistically not significant (Q = 3.24; df = 1; p = 0.072). Conclusions: This meta-analysis presents evidence that LLLT is an effective treatment modality to reduce pain in adult patients with musculoskeletal disorders. Adherence to WALT dosage recommendations seems to enhance treatment effectiveness.
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Neuropathic pain can be defined as pain initiated or caused by a primary lesion or dysfunction in the central or peripheral nervous system. The low level laser therapy (LLLT) has gained great prominence as a treatment in this type of pain; however, the application parameters are still controversial in the literature. This study aimed to review the literature on the use of LLLT in neuropathic pain with the goal of establishing a “therapeutic window” for the effective use of this treatment. We analyzed 14 articles, 10 in experimental animals and 4 in humans. The results are presented in three tables, the first being for comparison of the studies' application parameters, the second showing the average and median parameters experimental studies and third showing the clinical studies embodiment. The experimental studies revealed better results for LLLT and infrared laser powers above 70 mW. Clinical studies are inconclusive as to the application parameters, due to the discrepancy; however all demonstrate the effectiveness of LLLT. According to the data presented, it was concluded that LLLT has positive effects on the control of analgesia for neuropathic pain, but further studies with high scientific rigor are needed in order to define treatment protocols that optimize the action LLLT in neuropathic pain.
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To compare the in vitro effectiveness of Low-Level Laser Therapy (LLLT) and Low Intensity Pulsed Ultrasound (LIPUS) on bony cells and related stem cells. In this study, we aim to systematically review the published scientific literature which explores the use of LLLT and LIPUS to biostimulate the activity or the proliferation of bony cells or stem cells in vitro. We searched the database PubMed for LLLT or LIPUS, with/without bone, osteoblast, osteocyte, stem cells, the human osteosarcoma cell line (MG63), bone-forming cells, and cell culture (or in vitro). These studies were subdivided into categories exploring the effect of LLLT or LIPUS on bony cells, stem cells, and other related cells. 75 articles were found between 1987 and 2016; these included: 50 full paper articles on LLLT and 25 full papers on LIPUS. These articles met the eligibility criteria and were included in our review. A detailed and concise description of the LLLT and the LIPUS protocols and their individual effects on bony cells or stem cells and their results are presented in five tables. Based on the main results and the conclusions of the reviewed articles in the current work, both, LLLT and LIPUS, apply a biostimulatory effect on osteoblasts, osteocytes, and enhance osteoblast proliferation and differentiation on different bony cell lines used in in vitro studies, and therefore, these may be useful tools for bone regeneration therapy. Moreover, in consideration of future cell therapy protocols, both, LLLT and LIPUS (especially LLLT), enhnce a significant increase in the initial number of SCs before differentiation, thus increasing the number of differentiated cells for tissue engineering, regenerative medicine, and healing. Further studies are necessary to determine the LLLT or the LIPUS parameters, which are optimal for biostimsulating bony cells and SCs for bone healing and regenerative medicine.