Hindawi

BioMed Research International

Volume 2022, Article ID 4133883, 8 pages
https://doi.org/10.1155/2022/4133883

Research Article
Effectiveness of High Power Laser Therapy on Pain and Isokinetic
Peak Torque in Athletes with Proximal Hamstring Tendinopathy:
A Randomized Trial

Sachin Verma,1 Vandana Esht,1 Aksh Chahal,1 Gaurav Kapoor,2 Sorabh Sharma,3
Ahmad H. Alghadir,4 Masood Khan ,4 Faizan Z. Kashoo ,5 and Mohammad A. Shaphe 6

1
Maharishi Markandeshwar Institute of Physiotherapy and Rehabilitation (Deemed to be University), Mullana, Ambala,
Haryana 133207, India
2
Chitkara School of Health Sciences, Chitkara University, Punjab, India
3
KYNA Physiotherapy, Patiala, Punjab, India
4
Department of Rehabilitation Sciences, College of Applied Medical Sciences, King Saud University, Riyadh 11433, Saudi Arabia
5
Department of Physical Therapy and Health Rehabilitation, College of Applied Medical Sciences, Majmaah University, Majmaah,
11952, Saudi Arabia
6
Department of Physical Therapy, College of Applied Medical Science, Jazan University, Jazan, 45142, Saudi Arabia

Correspondence should be addressed to Masood Khan; masoodkhan31@rediffmail.com

Received 27 January 2022; Revised 12 April 2022; Accepted 20 April 2022; Published 20 May 2022

Academic Editor: Mario Bernardo-Filho

Copyright © 2022 Sachin Verma et al. This is an open access article distributed under the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Athletes such as long-distance runners, sprinters, hockey, and/or football players may have proximal hamstring tendinopathy
(PHT). Laser therapy has been shown to be effective in tendinopathies. High power laser therapy (HPLT) is used for the
treatment of several musculoskeletal conditions; however, its efficacy on PHT has not been investigated. This study is aimed at
examining the effects of HPLT on pain and isokinetic peak torque (IPT) in athletes with PHT. The two-arm comparative
pretest-posttest experimental design was used with random allocation of 36 athletes aged 18-35 years into two groups
(experimental and conventional group). The experimental group included the application of HPLT for 3 weeks. The
conventional group included treatment with a conventional physiotherapy program including ultrasound therapy, moist heat
pack, and home exercises for a total of 3 weeks. Pain and IPT of the hamstring muscle were measured before and after the
application of the intervention. Pain score decreased, and IPT increased significantly (p < 0:05) after application of HPLT, by
61.26% and 13.18%, respectively. In the conventional group, a significant difference (p < 0:05) was observed in pain scores
only, which decreased by 41.14%. No significant difference (p > 0:05) was observed in IPT in the conventional group. When
HPLT was compared with conventional physiotherapy, a significant difference was found in pain scores only. HPLT for 3
weeks was found to be effective in improving pain in athletes with PHT. However, no significant difference was found between
HPLT and conventional physiotherapy (US, moist heat, and home exercises) in improving the IPT of the hamstring muscle.

1. Introduction long periods, excessive static stretching, squatting, lunging, or

changing the direction of running [2–4]. These activities com-
Proximal hamstring tendinopathy (PHT) is tendinopathy of the pressively load the hamstring tendon at its proximal attach-
semimembranosus and/or biceps femoris/semitendinosus com- ment. The main symptom of PHT is deep localized pain in
plex [1]. This condition is common among middle and long- the lower gluteal region near the ischial tuberosity, which may
distance runners, athletes who perform more sagittal plane or may not radiate to the posterior thigh [5]. This pain often
activities (e.g. sprinters), and individuals including nonathletes, worsens during or after sitting, squatting, lunging, or running
who routinely perform activities like leaning forward, sitting for [4]. This condition may be present unilaterally or bilaterally [4].
2 BioMed Research International

Surgery is indicated for recalcitrant cases, and most cases 2.2. Participants
are treated conservatively. Physical therapy treatment of
PHT focuses on activity modification, effective tendon load- 2.2.1. Sample Size Calculation. Before conducting the study,
ing including eccentric training, addressing contributing the sample size was calculated using the software G∗Power
biomechanical deficiencies, and electrotherapy including 3.1.9.4. The pain score data from the study of Elsodany
laser therapy. Two types of laser therapy are used as a part et al. [21], who used high intensity laser therapy on patients
of physical therapy management: low power laser therapy with rotator cuff tendinopathy, was used to calculate the
(LPLT) which has an output power of less than 0.5 watts effect size. Based on α = 0:05, power ð1‐βÞ = 0:95, and effect
and high power laser therapy (HPLT) which has an output size d = 3:89, the minimum sample size was calculated to be
power of 0.5 watts or greater. 5 (including 12% drop out) in each group. Therefore, due to
Previous studies have shown the efficacy of laser therapy the availability of patients, a total of 36 participants aged 18-
in the treatment of tendinopathy. The study by Stergioulas 35 years were recruited in the present study (Table 1)
et al. [6] showed that LPLT when added to an eccentric exer- (Figure 1).
cises regimen speeds up clinical recovery in patients with
chronic Achilles tendinopathy. HPLT produces more pow- 2.2.2. Inclusion and Exclusion Criteria. The selected partici-
erful beams (power > 0:5 watts) and has longer laser emis- pants were diagnosed with PHT by a consultant physiother-
sion intervals and shorter laser emission time in apist. They were athletes, who took part in national level
comparison to LPLT; thus, the deeper areas can be irradiated competitive track and field events more than once, with sub-
in a short time with HPLT [7, 8]. HPLT also creates heat on acute onset of the buttock or posterior thigh pain for less
the skin surface due to its higher power density. than a year, tenderness in the ischial tuberosity, tightness
A recent systematic review by Taradaj et al. indicated the deep of the hamstring muscle, deeper hip flexion such as
effectiveness of HPLT in decreasing musculoskeletal pain [9]. squatting or sitting for long periods, repeated knee exten-
Other studies also showed that HPLT affects the repair of dia- sion, and resisted knee flexion increased their pain. Other
betic foot ulcer trauma [10], gonitis [11], shoulder pain [8], differential diagnoses like radiation due to lumbosacral radi-
chronic low back pain [12, 13], chronic neck pain [14], and culopathy, piriformis syndrome, or ischiofemoral impinge-
pain in the knee osteoarthritis [15, 16]. HPLT can also ment were ruled out by an expert physiotherapist.
remove exudates through increased metabolism and blood Participants who had a recent history of trauma to the pos-
circulation, thus helping in the quick absorption of edema terior thigh, a musculoskeletal disorder or deformity of the
[8]. Few physiological changes occur in tissues as a result of ipsilateral lower extremity, lumbar prolapsed intervertebral
HPLT which do not occur in the case of a conventional phys- disc, history of or currently taking pain medications, cardio-
iotherapy program for tendinopathy including ultrasound vascular diseases, malignant tumor in the lower extremity,
therapy, moist heat pack, and eccentric hamstring exercises. phlebitis, blood disorders, or tattoo over or around the area
HPLT radiation causes slow and small light absorption by of treatment were excluded from the study because these
the chromophores. The absorption by chromophores occurs conditions will affect the application of laser therapy or exer-
with diffuse light in all directions, not with concentrated cise of hamstring muscles. The repeated movement of the
light, which is called the scattering phenomenon. This leads lumbar spine, sacroiliac joint provocation tests, SLR, and
to the phenomenon of tissue stimulation (photobiology slump test did not aggravate their pain.
effects) and an increase in the mitochondrial oxidative reac-
tion and DNA, RNA, or adenosine triphosphate production
(photochemistry effects) [17]. 2.2.3. Randomization of Participants and Blinding. The
To the best of our knowledge, no study has compared selected participants were randomly assigned to an experi-
the effects of HPLT with conventional physiotherapy pro- mental and a conventional group using the lottery method
grams in athletes suffering from PHT. Therefore, this study and http://randomization.com/ website with 18 participants
is aimed at assessing the effects of HPLT on pain and isoki- in each group. The participants and outcome assessor were
netic peak torque (IPT) of hamstring muscle in PHT kept blind to the allocation.
patients. We hypothesized that HPLT is effective in reducing
pain and improving the IPT of hamstring muscle in compar- 2.2.4. Setting, Ethical Statement, Clinical Trial Registration,
ison to conventional physiotherapy program in patients with and Informed Consent. The study was carried out in the clin-
PHT. In the present study, the conventional physiotherapy ical setting of the University. The present study conformed
program included ultrasound therapy [18], moist heat pack to the “The Code of Ethics of the World Medical Association
[19], and eccentric hamstring exercises [20]. (Declaration of Helsinki)” and was approved by the ethical
committee of the Institutional Review Board (file ID: RRC-
2021-07; date of approval: 9 March 2021). This study had
2. Materials and Methods been retrospectively registered on Protocol Registration
and Results System (PRS) clinicaltrials.gov (ID:
2.1. Study Design. We used a two-arm parallel pretest- NCT05100394) on 31st October 2021. The risks and benefits
posttest experimental research design with random of the study were discussed with each participant before the
allocation of subjects into two groups (experimental and start of the study, and informed consent was obtained from
conventional group). all participants involved in the study.
BioMed Research International 3

Table 1: Demographic data, baseline, and postintervention values of outcome variables in both groups (n = 18 each group), Shapiro-Wilk
test, and independent t-test p values for baseline values.

Experimental group Conventional group Shapiro-Wilk p value Independent t-test p values

Mean ± SD Mean ± SD
Age (years) 22:61 ± 1:68 22:39 ± 1:81
Height (cm) 162:83 ± 9:85 162:22 ± 7:47
Weight (kg) 58:78 ± 4:91 59:44 ± 3:95
BMI (kg/m2) 22:30 ± 2:58 22:70 ± 2:38
Pre_NPRS (points) 6:17 ± 1:42 6:61 ± 0:97 0.004∗ 0.283
Pre_IPT (Nm) 251:17 ± 78:00 236:89 ± 40:34 0.254 0.495
Post_NPRS (points) 2:39 ± 1:03 3:89 ± 0:96
Post_IPT (Nm) 284:28 ± 109:23 240:44 ± 44:03
∗
Significant. SD: standard deviation; BMI: body mass index; NPRS: numeric pain rating scale; IPT: isokinetic peak torque.

CONSORT 2010 flow diagram

Enrollment

Assessed for eligibility (n = 47)

Excluded (n = 7)
Not meeting inclusion criteria (n = 5)
Declined to participate (n = 2)
Other reasons (n = 0)

Randomized (n = 40)

Allocation

Allocated to intervention (n = 20) Allocated to intervention (n = 20)

Received allocated intervention (n = 20) Received allocated intervention (n = 20)
Did not receive allocated intervention (n = 0) Did not receive allocated intervention (n = 0)

Follow-Up
Lost to follow-up (n = 0) Lost to follow-up (n = 0)
Discontinued intervention (Did not complete 3- Discontinued intervention (Did not complete 3-
week intervention) (n = 2) week intervention) (n = 2)

Analysis
Analysed (n = 18) Analysed (n = 18)
Excluded from analysis (n = 0) Excluded from analysis (n = 0)

Figure 1: Consolidated Standards of Reporting Trials (CONSORT) flow chart of the study showing the recruitment of participants.
4 BioMed Research International

2.3. Outcome Measures. The following are the outcome was applied in continuous mode for a total of 6
measures: minutes. HPLT was administered 3 days a week for
a total of 3 weeks [30].
(i) Isokinetic peak torque of the hamstring muscle,
assessed using an isokinetic dynamometer (ii) Conventional group: conventional physiotherapy
treatment was administered that included ultra-
(ii) Pain, assessed using the NPRS (Numeric Pain Rating sound therapy (continuous mode, 1 MHz, 2 W/cm2
Scale) score for 5 minutes) in the area of the ischial tuberosity,
moist heat packs (10 minutes) [31] over the ipsilat-
2.4. Instrumentation. The following are the instruments eral buttock and posterior thigh region, and home
used: exercises. The US and moist heat pack were applied
in the prone position. Home exercises included Nor-
(i) LASER equipment (LiteCure, USA) [22] dic hamstring exercise (eccentric hamstring contrac-
(ii) Isokinetic dynamometer (Easy Tech Biomed, India) tions) [1]—2 sets of 5 repetitions. At home,
[23] participants were asked to stabilize their feet either
under furniture/immovable objects or ask someone
(iii) Ultrasound therapy equipment (Physiocare, India) to hold their feet firmly. Then, they have to slowly
[24] lower their body from a vertical position towards
(iv) Moist heat pack [25] the ground while maintaining a straight line from
knees to head. Participants were allowed to use their
2.5. Study Protocol. The study consisted of three phases: hands to catch themselves if they cannot control the
body movement from their knees. This treatment
2.5.1. Preintervention Assessment. Baseline NPRS (Numeric regimen was also administered 3 days a week for a
Pain Rating Scale) and IPT of hamstring muscle were mea- total of 3 weeks [5].
sured before the start of the intervention. (i) The Numeric
Pain Rating Scale (NPRS) is a subjective measure in which 2.5.3. Postintervention Assessment. After completion of the
participants are asked to rate their pain on a scale of 0–10, intervention, the NPRS score and IPT of the hamstring mus-
where 0 represents “no pain” and 10 represents “worst pain cle were again measured similarly to the preintervention
imaginable” [26, 27]. The participants were asked to rate assessment.
their pain on the NPRS scale. (ii) In the IPT of hamstring
muscle, participants were asked to sit on the isokinetic dyna- 2.6. Data Analysis. The baseline values of NPRS and IPT
mometer chair. Shoulders, chest, and hips were strapped to were compared between both groups using the independent
prevent unnecessary movements. The cuff of the dynamom- sample t-test, which revealed no significant difference
eter arm was attached near the ankle of the ipsilateral side. (p < 0:05); therefore, both groups were comparable for both
The back seat of the dynamometer was tilted 75-85° back- variables. The Shapiro-Wilk normality test was performed to
ward. The angle on the dynamometer was set from 0° (full assess the normal distribution of the baseline NPRS and IPT
knee extension) to 90° knee flexion, and the speed was values. The Shapiro-Wilk test revealed that the distribution
selected at 90°/s. Before taking the readings for baseline mea- of baseline NPRS values was not normal (p < 0:05); there-
surement, each participant was asked to practice the move- fore, for further with-in and between-group comparison,
ment thrice with submaximal effort. The participants were nonparametric tests were used. Wilcoxon’s signed-rank test
then asked to bend the knee with maximum effort. A total and Mann–Whitney U test were performed for within and
of three measurements were taken, and the highest reading between-group comparison, respectively. The confidence
was used for data analysis [28]. interval was set at 95%; p < 0:05 was considered significant
(Table 2).
2.5.2. Intervention

(i) Experimental group: the participants were made to 3. Results and Discussion
lie prone, and the area around the ischial tuberosity 3.1. Within-Group (Wilcoxon’s Signed Rank Test) Analysis
was uncovered. Participants were asked to remove
the excess hairs if present. HPLT was administered 3.1.1. For the Experimental Group. There was a significant
as monotherapy, in the area of ischial tuberosity difference (p < 0:05) in both variables (NPRS scores and
where the hamstring tendons originate. The follow- IPT values) after the application of the intervention. NPRS
ing parameters were used in laser equipment: aver- scores decreased by 61.26%, and IPT increased by 13.18%
age output power: 5 watts, dosage: 50 joules/cm2, after HPLT.
laser wavelength: 980/810 nm, total treatment area:
6 cm × 6 cm = 36 cm2 , and total energy: 50 × 36 = 3.1.2. For the Conventional Group. There was a significant
1800 joules. Depending upon the total area to be difference (p < 0:05) in the NPRS scores after application
treated and average output power and the total of intervention; however, for IPT there was no significant
energy to be delivered, the total treatment time was difference (p > 0:05). NPRS scores decreased by 41.14%,
calculated to be 6 minutes [29]. Therefore, HPLT and IPT increased marginally by 1.49%.
BioMed Research International 5

Table 2: Within-group (Wilcoxon’s signed-rank test) and between-group (Mann–Whitney U test) comparisons of outcome variables.

Within-group, p values Between-group, p values

Experimental group Conventional group
Post_NPRS–Pre_NPRS ≤0.001∗ ≤0.001∗ Post_NPRS ≤0.001∗
Post_IPT–Pre_IPT 0.028∗ 0.662 Post_IPT 0.113
∗
Significant. NPRS: numeric pain rating scale; IPT: isokinetic peak torque.

3.2. Between-Group (Mann–Whitney U Test) Analysis 44]. This mode of application inhibits nociceptive stimula-
tion and produces low heat. If a continuous mode is used,
3.2.1. For Post_NPRS Scores. There was a significant differ- then photochemical and photothermic effects are produced
ence (p ≤ 0:001) in post_NPRS scores between both groups. in deeper tissues. These effects increase vascular permeabil-
ity, blood flow, and cell metabolism which result in the
3.2.2. For Post_IPT Values. There were no significant differ- washing out of cytokines that justifies pain reduction [45].
ences (p = 0:131) for post_IPT values between the two In our study, HPLT resulted in improvement in IPT of
groups. the hamstring muscle. Not many studies have examined
The results of the present study revealed that HPLT is the effects of HPLT on muscle strength. A study by Santa-
effective in improving pain scores and hamstring IPT in ath- mato et al. reported improved muscle strength of shoulder
letes with PHT; however, compared to the conventional joints affected with subacromial impingement syndrome
group (US, moist heat, and home exercises), a significant dif- after application of HPLT [8]. Some studies have reported
ference was found only in NPRS scores. With the application no significant improvements in muscle performance with
of HPLT, NPRS scores decreased and IPT increased. Con- LPLT when combined with physical exercises [46, 47]. How-
ventional physiotherapy (US, moist heat, and home exer- ever, several other studies have reported improved muscle
cises), treatment also decreased NPRS scores; however, IPT performance and reduced fatigue as a result of LPLT
remained unchanged. HPLT was more effective in reducing [47–49]. Lopes-Martins et al. reported that muscle damage
pain than the conventional physiotherapy program. With and fatigue caused by tetanic contractions in the rat model
conventional physiotherapy treatment, no improvement in are seemed to be reduced by LPLT [50]. In the present study,
IPT was observed, perhaps because patients performed an increase in IPT after the application of HPLT may be due
eccentric Nordic hamstring exercises, which may have put to reduced pain intensity. When pain intensity is reduced,
a strain on the hamstring tendons and prevented the muscle then participants will be able to exert more force on the
from being unloaded. hamstring muscle.
In earlier studies, laser therapy was found to be effective In the present study, laser therapy was used as a mono-
in relieving pain associated with several conditions such as therapy because its clinical benefits were reported when used
knee injuries, shoulder pain, fibromyalgia, chronic arthritis, alone [13, 51–54] and also when used in combination with
carpal tunnel syndrome, and tendonitis [32, 33]. A system- stretching and regular exercises in orthopedic conditions
atic review reported that acute neck pain decreased immedi- [55, 56]. The clinical implications of the present study
ately after laser therapy and up to 22 weeks after complete include the use of HPLT as an effective treatment modality
treatment [34]. for athletes with PHT.
At different levels, several physiological effects of laser The present study also has some limitations. No control
therapy have been reported that produce analgesic effects. At group was included in the study where participants did not
the tissue level, laser causes reduction of histamine and brady- receive any treatment. Therefore, the reduction in NPRS
kinin release from the injured tissues [35], increases the pain scores may be due to time travel or avoidance of strenuous
thresholds [36], and reduces the secretion of substance P from activities for 3 weeks and may not be due to the intervention
peripheral nociceptors [37]. Laser therapy slows the transmis- applied. Moreover, the experimental group did not include
sion of pain signals by decreasing the conduction velocity and the conventional physiotherapy treatment; therefore, it cannot
increasing the latency of sensory nerves, which in turn inhibit be concluded that the improvements observed in the experi-
Aδ- and C fiber transmission [38]. Furthermore, laser treat- mental group were additional effects of HPLT. Another limita-
ment inhibits pain centrally, by increasing the secretion of tion is the lack of long-term follow-up. The athletes were not
endogenous opioids (β-endorphin) [39]. Specifically, HPLT assessed after their return to the sport. It may be possible that
application has been found to assist in pain relief [15], recov- the improvement in pain and maximum torque was short-
ery from nerve paralysis [40], and wound repair [41]. It was lived. Therefore, future research is needed that includes con-
also used to provide relief from shoulder pain [8], low back trol group and long-term follow-up. In addition, only male
pain [12], and chronic ankle pain [42]. HPLT has not been athletes were recruited in the study. Therefore, the results of
found to reduce inflammation, but it had an analgesic effect this study cannot be generalized to female athletes. More
on nerve endings [43, 44]. research is needed to recruit female athletes with large sample
The analgesic effects of HPLT obtained in the present size. Future research should also compare HPLT with LPLT to
study can be explained by two mechanisms. If it is used in examine which one is more effective for pain reduction in
pulse mode, it has analgesic effects on nerve endings [43, patients with PHT.
6 BioMed Research International

4. Conclusions [8] A. Santamato, V. Solfrizzi, F. Panza et al., “Short-term effects

of high-intensity laser therapy versus ultrasound therapy in
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The authors declare that there is no conflict of interest [12] M. S. M. Alayat, A. M. Atya, M. M. E. Ali, and T. M. Shosha,
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The authors are grateful to the Researchers Supporting
high-intensity laser therapy versus ultrasound therapy in the
Project number RSP-2021/382, King Saud University, treatment of low back pain: a randomized controlled trial,”
Riyadh, Saudi Arabia for funding this research. European Journal of Physical and Rehabilitation Medicine,
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