Lasers in Medical Science

https://doi.org/10.1007/s10103-021-03316-y

ORIGINAL ARTICLE

The effectiveness of high-intensity laser therapy in the treatment

of post-stroke patients with hemiplegic shoulder pain: a prospective
randomized controlled study
Nurdan Korkmaz 1 & Eda Gurcay 1 & Yasin Demir 1 & Özge Tezen 1 & İzzet Korkmaz 2 & Merve Örücü Atar 1 & Evren Yaşar 1

Received: 16 December 2020 / Accepted: 2 April 2021

# The Author(s), under exclusive licence to Springer-Verlag London Ltd., part of Springer Nature 2021

Abstract
To evaluate clinical and ultrasonographic efficacy of high-intensity laser therapy (HILT) in patients with hemiplegic shoulder
pain (HSP) accompanied by partial thickness rotator cuff tear (PTRCT). The study was designed as a prospective, randomized,
controlled trial. Patients with HSP accompanied by PTRCT (n = 44) were randomly assigned to HILT and control groups. Both
groups were treated with a multidisciplinary stroke rehabilitation and a therapeutic exercise program to the affected shoulder
supervised by physiotherapists. In addition, HILT group received 3 sessions of the intervention per week for 3 weeks. Primary
outcome measure was visual analogue scale (VAS) for pain. Secondary outcome measures were range of motion (ROM) of the
shoulder joint, Shoulder Pain and Disability Index (SPADI), Brunnstrom Recovery Stage (BRS), Modified Ashworth Scale
(MAS), Nottingham Health Profile (NHP), Functional Independence Measure (FIM), and ultrasonographic PTRCT size.
Participants were assessed at pre- and post-treatment. A total of 41 patients completed the study. A statistically significant
improvement was observed in VAS, ROM, FIM, SPADI, NHP, and PTRCT parameters in HILT group at post-treatment
compared to pre-treatment (all P < 0.05). However, control group indicated significant improvement only in VAS, ROM, and
SPADI parameters (all P < 0.05). When differences in clinical parameters at pre- and post-treatment assessment were compared
between two groups, change in VAS, FIM, BRS, SPADI, NHP, and PTRCT in HILT group was significantly better than control
group (all P < 0.05). HILT combined with therapeutic exercise seems to be clinically and ultrasonographically more effective in
the treatment of patients with HSP accompanied by PTRCT than therapeutic exercise alone in the short term. Further studies are
needed with long-term follow-up. CinicalTrials.gov Identifier: NCT04669405.

Keywords Hemiplegic shoulder pain . Rotator cuff tear . High-intensity laser therapy . Exercise . Ultrasonography

Introduction develops within 6 months in approximately 20 to % 30 of

Hemiplegic shoulder pain (HSP), which is a common compli-
cation in the post-stroke period, has been reported to occur in
16 to 84% of hemiplegic patients. Although it may sometimes
develop within 2 weeks after a stroke, shoulder pain usually
* Nurdan Korkmaz
nurizkorkmaz@hotmail.com
1
Department of Physical Medicine and Rehabilitation, Health
Sciences University, Gaziler Physical Medicine and Rehabilitation
Education and Research Hospital, Ankara, Turkey
2
Department of Orthopaedic Surgery, Ankara City Hospital,
Ankara, Turkey
cases, and sometimes the symptoms may become permanent
[1, 2]. HSP restricts functional recovery and participation in
rehabilitation [3].
The exact etiology of HSP is unknown and often multifac-
torial. Thus far, several pathological processes have been
identified thought to be related of HSP: subluxation of the
joint, adhesive capsulitis, complex regional pain syndrome,
rotator cuff tear, spasticity, and others [4]. Rotator cuff tears
in particular have attracted attention as an important responsi-
ble of HSP [5, 6]. In previous studies, 22 to 34% of patients
with HSP were determined to have rotator cuff tear [6–8]. For
a long time, the clinical usefulness of ultrasonography as a
modality in the diagnosis of rotator cuff tears is known [9].
In a prospective study by Teefey et al., it was reported that
ultrasonography and magnetic resonance imaging were

comparable degrees of accuracy for diagnosis and measuring
tear size of rotator cuff tear [10].
While treatment of rotator cuff tears can be conservative or
surgical, many of them, especially partial thickness tears,
symptomatically improve with conservative management
[11, 12]. Conservative treatment consists of analgesic medi-
cations, such as non-steroidal anti-inflammatory drugs, lido-
caine and corticosteroids injections to the subacromial region,
a therapeutic exercise program targeted at increasing range of
motion (ROM), strengthening the muscles around the joint,
proprioceptive training, and physiotherapy included hot-cold
packs, ultrasound therapy, transcutaneous electrical stimula-
tion, extra-corporeal shock wave therapy, pulsed electromag-
netic fields, microwave diathermy and low-intensity laser
therapy (LILT) [13, 14]. In recent years, high-intensity laser
therapy (HILT) has been considered as a treatment option for
shoulder pain. HILT increases microcirculation and tissue re-
generation and lowers edema, inflammation, and pain with its
photomechanical, thermal, electrical, and biostimulating ef-
fects in deep tissues that cannot be reached with LILT. It has
some advantages over LILT, i.e., having higher power, greater
tissue penetration capasity to deep tissues, the short emission
time, and long rest periods preventing heat accumulation
[15–17].
In recent studies, effectiveness of HILT has been shown in
the treatment of subacromial impengement syndrome, rotator
cuff tendinopathy, and frozen shoulder [16, 18–22]. However,
to our knowledge, the effectiveness of HILT in patients with
HSP with partial thickness rotator cuff tear (PTRCT) is un-
known. In this study, we intended to investigate the effective-
ness of HILT on pain, disability, function, and quality of life in
patients with HSP accompanied by PTRCT. In addition, it was
intended to research the effect of HILT on the size of PTRCT
evaluated ultrasonographically with the thought that HILT
may be positively effective in muscle ruptures due to its fea-
tures such as increasing cell metabolism, vascular permeabil-
ity, and blood flow.
Materials and methods
Participants
This prospective randomized controlled study was conducted
after approval from the local ethics committee of the medical
center (19/2456). The study was performed according to the
Declaration of Helsinki. It was registered in the Clinicaltrials.
gov database (NCT04669405). Written informed consent was
received from all patients participating in the study.
According to the power analysis described in the study
conducted by Kim et al. [22], at least 40 patients were recruit-
ed when the mean difference was 0.75 for visual analogue
scale (VAS).
Lasers Med Sci
Patients with HSP (at least 4/10 points from VAS) aged
18–75 years with hemiplegia duration > 6 months, suffered a
stroke resulting in unilateral hemiplegia for the first time, and
who had PTRCT after ultrasonographic evaluation due to
shoulder pain were included in the study. Cases who had
inflammatory rheumatic disease, cervical radiculopathy, dia-
betes mellitus, thyroid disease, coronary heart disease, cardiac
pacemaker, neurological disease, shoulder surgery, and shoul-
der injection in the last 3 months were excluded.
Study design
Seventy-three patients were screened, and 44 of them who met
the inclusion criteria and agreed to participate in the study
were recorded. Figure 1 demonstrates the CONSORT dia-
gram for the participants. The patients were randomly divided
into two groups using the closed envelope method. An inde-
pendent person who did not participate in the research created
the treatment allocations (HILT combined therapeutic exer-
cise or therapeutic exercise) to be randomly selected in closed
opaque envelopes. When a patient agreed to enter the study,
an envelope was opened and the patient was offered the allo-
cated treatment regimen. Group 1 (HILT group, n = 22) re-
ceived 3 sessions of HILT per week for 3 weeks in addition to
a therapeutic exercise program which performed 5 sessions
per week for 3 weeks. Group 2 (control group, n = 22) re-
ceived a therapeutic exercise program for HSP of 5 sessions
per week for 3 weeks. HILT was applied on the same day
before the therapeutic exercise program.
All patients (HILT group and control group) received mul-
tidisciplinary stroke rehabilitation, determined by the their
neurological level, applied by rehabilitation nurses, occupa-
tional therapists, physiotherapists, and speech therapists. Also
a therapeutic exercise program for the HSP, including passive,
active supported and active ROM exercises, stretching,
strengthening, and mobilization exercises were performed in
line with the level of motion limitation and pain intensity to all
patients by physiotherapists.
HILT was applied to group 1 patients by a single physiatrist
who was experienced in using laser device (BTL-6000 high-
intensity laser 12 W, Stevenage, Hertfordshire, UK). The laser
device produces a maximum of 12 W power and emits wave-
length of 1064 nm (Nd: YAG laser) [15]. In HILT group, we
used the device to the rotator cuff muscles area in two phases:
phase I and phase II. The pulse modality was used in phase I
for the analgesic effect. A standard frequency of 25 Hz is
applied. The first four therapy sessions were analgesic effect,
using a power of 8 W, a dose of 12 J/cm2, to 25 cm2 area, for a
total of 300 J of energy, for 2.5 min [19]. The beams were
transmitted to the area of rotator cuff muscles, forming a circle
from outside to inside. The continuous wave modality was
used in phase II for biostimulation effect. The subsequent five
sessions were biostimulation effect, using a power of 7 W, a
Lasers Med Sci

Fig. 1 CONSORT diagram for

the participants

dose of 100 J/cm2, to 25 cm2 area, for a total of 2500 J of of 5 items assessing pain and 8 items assessing disability. The
energy, for 5 min and 57 s [19]. The beams were administered score varied from 0 to 100%, with higher scores reflected
in the longitudinal direction to the area of rotator cuff muscles. greater pain and disability [25].
A constant distance of 3 cm is supplied using a fixed spacer
between the skin and light source (Fig. 2). Protective goggles
were used for both the practitioner and the patient during laser
applications.

Clinical and ultrasonographic assessment

Demographic and disease characteristics of each patient in-

cluding age, gender, education, dominant hand, stroke dura-
tion, stroke type, and hemiplegic side were recorded. All pa-
tients are assessed clinically and ultrasonographically (Fig. 3)
just before and at the end of treatment using the measurements
reported below. Primary outcome measure was VAS for pain.
Secondary outcome measures were passive ROM of the
shoulder joint, Shoulder Pain and Disability Index (SPADI),
Brunnstrom Recovery Stage (BRS), Modified Ashworth
Scale (MAS), Nottingham Health Profile (NHP), Functional
Independence Measure (FIM), and ultrasonographic PTRCT
size.
Pain. Severity of pain was assessed using the standard
10 cm VAS with 0 meant “no pain” at one end, and 10 meant
“unbearable pain” at the other end [23].
ROM. Passive ROM measurements of shoulder external
rotation, abduction, and flexion movements were recorded
by a universal goniometer [24].
Shoulder functional status. It was evaluated using the
SPADI, which is a self-administered questionnaire composed Fig. 2 Application of high-intensity laser therapy
 Lasers Med Sci

component are weighted to give a score between 0 and 100.

Higher NHP scores show a higher level of trouble [29, 30].
Shoulder ultrasonography was performed on all patients by
a physiatrist experienced in musculoskeletal ultrasonography
and blinded to the treatment group of the patients, using a 5–
12 MHz linear-array transducer (Logiq-e portable; GE
Healthcare, China). According to the previously described
techniques, partial thickness in rotator cuff was diagnosed
when there was a hypoechoic/anechoic focus in the cuff ma-
terial or a hypoechoic/anechoic defect in the tendon that holds
the bursal or articular surface [31]. In order to determine the
tear size, the maximum anteroposterior diameter of the rotator
cuff tear was measured in transverse views (perpendicular to
the long axis of the cuff) [32]. Ultrasound images of PTRCT
are taken in a seated position with the hand placed on the
lower back, shoulder extended and internally rotated (Fig. 4).

Statistical analysis

Statistical analyses were performed using SPSS for Windows,

Fig. 3 Transverse ultrasound images of partial thickness rotator cuff tear
(arrow) at pre-treatment (a) and post-treatment (b) with high-intensity
laser therapy. D, deltoid muscle; ST, supraspinatus tendon; H, humerus;
sc, subcutaneous tissue
version 16.0 (SPSS Inc., Chicago, IL, USA). The
Kolmogorov-Smirnov test was performed to verify that if var-
iables were normally distributed. Continuous variables were
expressed in mean and standard deviation or median and min-
max values for normally or abnormally distributed data, re-
spectively. Categorical variables were compared using the
Chi-square test, and presented as frequency (%). Student’s T
test or Mann-Whitney U test was performed for group

Motor recovery. BRS was used to appreciate the motor

function level in the patients. The recovery is divided into
six stages: In the 1st stage, there is complete flaccidity, and
no voluntary movements in the involved body area, while the
6th stage indicates normal function [26].
Spasticity. The five-point MAS, a clinical scale ranging
from 0 to 4 (0 being normal muscle tone, and 4 being rigid),
was used for measuring spasticity and muscle tone. In this
study, we evaluated MAS according to shoulder adductor
and internal rotator spasticity [27].
Functional status. FIM is a universal assessment tool
consisting of a total of 18 items that explores an individual’s
several physical and social functions, such as self-care, trans-
fer, locomotion, sphincter control, communication, and social
cognition. Each item is scored on a 7-point ordinal scale rang-
ing from complete independence (score = 7) to complete de-
pendence (score = 1). Higher FIM scores indicate higher
levels of independence [28].
Quality of life. NHP, a life quality test, includes 38 yes/no
statements regarding pain, physical mobility, emotional reac- Fig. 4 Positioning of the patient during ultrasound measurements of the
tions, sleep, social isolation, and energy level. Ratings on each partial thickness rotator cuff tear
Lasers Med Sci

comparisons for normally or abnormally distributed data, re- only the VAS, ROM, and SPADI parameters improved sig-
spectively. Repeated measurements within groups were nificantly in the control group (all P < 0.05) (Table 2).
assessed by Wilcoxon test. P values of < 0.05 were considered The comparison of the changes (Δ) in clinical parameters
as statistically significant. before and after treatment between the two groups is shown in
Table 3. The change in parameters of VAS, FIM, BRS,
SPADI-pain, SPADI-disability, SPADI-total, NHP-pain,
NHP-emotion, NHP-sleep, NHP-social, NHP-total, and
Results
PTRCT size is statistically significantly better in the HILT
group than in the control group (Table 3).
In the present study, 22 of 44 patients were allocated to the
HILT group and 22 to the control group. Since 3 patients from
the control group could not continue the treatment, the study
was completed with 22 people in the HILT group and 19
Discussion
people in the control group. The demographic data of both
The current prospective study compared the treatment results in
groups are summarized in Table 1. There was no statistically
patients with HSP accompanied by PTRCT who received HILT
significant difference between the groups in terms of age,
combined therapeutic exercise with those who received therapeu-
gender, hemiplegic side, disease duration, stroke type, and
tic exercise alone. Both HILT and control groups demonstrated a
dominancy.
clinically and statistically significant improvement in terms of
Table 2 shows intragroup and intergroup results of clinical
pain, disability, and ROM in shoulder joint immediately post-
parameters. Pre-treatment values of all parameters (VAS,
treatment compared to pre-treatment. The quality of life and
SPADI, FIM, BRS, NHP, MAS, PTRCT size, flexion, and
function also showed a significant increase after treatment com-
abduction) except external rotation were comparable between
pared with pre-treatment in the HILT group. Improvements in
the groups. When the clinical parameters in post-treatment
pain, disability, function, and quality of life were better in the
period were compared to pre-treatment values within the
HILT group compared to the control group in the pre- and post-
groups themselves, a statistically significant improvement is
treatment evaluation. In addition, the size of the PTRCT was
observed in the parameters of VAS, ROM, FIM, SPADI,
evaluated ultrasonographically before and after treatment. Size
NHP, and PTRCT size in the HILT group (all P < 0.05), while
of PTRCT did not change after treatment in the control group
compared to its pre-treatment value, whereas it decreased signif-
Table 1 Demographic characteristics of the groups icantly in the HILT group.
Multifactorial conditions such as soft tissue lesions, neuro-
HILT group Control group P value
(n = 22) (n = 19)
logical abnormalities, and muscle tone impairment are often
blamed in the etiology of shoulder pain in patients with hemi-
Age, year 65.7 ± 11.6 60.4 ± 12.1 0.132 plegia [4]. Previous studies have reported that rotator cuff tear
Gender 0.139 and subacromial-subdeltoid bursitis, which may coexist, are
Male, n (%) 10 (45.5) 13 (68.4) soft tissue lesions that can significantly cause HSP [33].
Female, n (%) 12 (54.5) 6 (31.6) Therefore, in this study, we applied HILT to patients with
Education 0.105 HSP with PTRCT and investigated the effects of HILT on
Illiterate, n (%) 5 (22.7) 1 (5.3) recovery in these patients.
Primary school, n (%) 10 (45.5) 5 (26.3) Recently, HILT has been used for management of many dif-
High school, n (%) 3 (13.6) 7 (36.8) ferent musculoskeletal conditions including low back and neck
University, n (%) 4 (18.2) 6 (31.6) pain [34], knee pain [35], and shoulder pain [34]. In a 2-week
Stroke duration (month) 16.5 ± 8.1 16.8 ± 10.7 0.874 study in which Santamato et al. compared HILT with ultrasound
Dominancy N/A therapy in patients with subacromial impingement syndrome, it
Right, n (%) 22 (100) 19 (100) was reported that there was a significant reduction in pain and
Left - - statistically significant intergroup differences in movement, func-
Hemiplegic side 0.364 tional scores, and muscle strength in the HILT group compared
Right, n (%) 10 (45.4) 6 (31.6) to the ultrasound treatment group after 10 treatment sessions
Left, n (%) 12 (54.5) 13 (68.4) [16]. Kim et al. compared the short-term effects of HILT with
Stroke type 0.100 placebo HILT in patients with frozen shoulder. They advised
Ischemic, n (%) 15 (68.2) 17 (89.5)
home-based exercise program including gentle ROM and stretch
Hemorrhagic, n (%) 7 (31.8) 2 (10.5)
exercises to the both groups, and they found that patients with
frozen shoulder experienced significant pain relief during 3
HILT high-intensity laser therapy; N/A not applicable weeks of treatment with HILT and 8 weeks of follow-up [22].
 Lasers Med Sci

Table 2 Pre-treatment and post-

treatment comparisons of results Parameters Groups Pre- Post- P value
of clinical parameters within- and treatment treatment
between-groups
VAS HILT 8.3 ± 1.8 4.8 ± 2.1 < 0.001*
Control 8.4 ± 1.5 7.6 ± 1.8 0.001*
P 0.978 0.001*
Flexion HILT 144.7 ± 25.8 156.8 ± 23.7 < 0.001*
Control 149.7 ± 18.5 159.4 ± 12.6 0.002*
P 0.769 0.550
Abduction HILT 133.1 ± 29.6 156.3 ± 27.1 < 0.001*
Control 141.5 ± 26.9 156.8 ± 17.2 0.002*
P 0.320 0.423
External rotation HILT 36.8 ± 18.3 53.6±13.8 < 0.001*
Control 55.2 ± 15.4 64.4±14.3 0.007*
P 0.001* 0.022*
BRS HILT 2 (8) 2(9) 0.025
Control 2(9) 2(9) 1.000
P 0.575 0.945
MAS HILT 1(12) 1(14) 0.564
Control 2(8) 2(8) 1.000
P 0.569 0.390
FIM HILT 73.0 ± 13.6 77.1 ± 13.3 0.002*
Control 75.4 ± 11.0 76.0 ± 11.5 0.157
P 0.276 0.926
SPADI_pain HILT 80.7 ± 19.8 50.4 ± 22.1 < 0.001*
Control 78.1 ± 23.3 73.5 ± 22.7 0.049*
P 0.738 0.002*
SPADI_ HILT 81.3 ± 23.6 70.1 ± 26.9 0.001*
disability Control 93.9 ± 11.0 90.3 ± 12.7 0.043*
P 0.060 0.010*
SPADI_total HILT 84.1 ± 18.3 58.1 ± 25.2 < 0.001*
Control 88.9 ± 11.3 83.6 ± 13.5 0.010*
P 0.427 0.001*
NHP_pain HILT 50.5 ± 35.3 16.9 ± 25.7 < 0.001*
Control 47.5 ± 35.9 42.5 ± 35.4 0.068
P 0.752 0.005*
NHP_emotion HILT 52.3 ± 37.8 25.8 ± 24.3 0.009*
Control 48.6 ± 39.5 47.6 ± 37.44 0.483
P 0.546 0.119
NHP_sleep HILT 31.2 ± 33.6 19.8 ± 24.7 0.050
Control 27.6 ± 33.3 30.6 ± 35.5 0.498
P 0.701 0.367
NHP_social HILT 54.1 ± 40.9 29.4 ± 35.6 0.003*
Control 54.9 ± 43.7 52.2 ± 42.4 0.180
P 1.000 0.088
NHP_physical HILT 78.9 ± 20.1 67.3 ± 20.0 0.022*
Control 74.1 ± 20.5 73.5 ± 20.2 0.465
P 0.441 0.254
NHP_energy HILT 89.6 ± 23.9 74.5 ± 33.2 0.020*
Control 88.0 ± 25.4 83.9 ± 30.0 0.225
P 0.850 0.314
NHP_total HILT 356.9 ± 127.7 233.9 ± 97.9 < 0.001*
Control 340.9 ± 126.9 330.4 ± 132.3 0.203
P 0.8140 009*
PTRCT HILT 0.81 ± 0.30 0.59 ± 0.20 <0.001*
Control 0.74 ± 0.21 0.75 ± 0.19 0.979
P 0.574 0.024*

BRS, Brunnstrom recovery staging; HILT, high-intensity laser therapy; VAS, visual analogue scale; MAS, mod-
ified Ashworth scale; FIM, functional independence measure; SPADI, shoulder pain and disability index; NHP,
Nottingham health profile; PTRCT, partial thickness rotator cuff tear

Hence, in the treatment of shoulder pain, HILT has been reported groups after treatment compared to pre-treatment values. In the
to be an effective method in reducing pain and disability after control group, SPADI_disability at pre-treatment was higher,
treatment and in short-term follow-up [16, 36]. In the present although not statistically significant. However, when the change
study, shoulder pain and disability decreased significantly in both at pre-treatment and post-treatment values was compared,
Lasers Med Sci

Table 3 Effect of treatment types on clinical improvement thought that the difference in pre-treatment external rotation be-
HILT group Control group P value tween the groups was not the reason of the ultimate differences in
(n = 22) (n = 19) the post-intervention, especially the primary outcome. These re-
sults demonstrated that HILT combined therapeutic exercise sig-
VASΔ (T0-T1), % 3.5 ± 1.7 0.73 ± 0.65 < 0.001* nificantly increased the range of external rotation compared to
FlexionΔ (T1-T0) 12.0 ± 7.1 9.7 ± 10.9 0.162 therapeutic exercise alone.
AbductionΔ (T1-T0) 23.1 ± 17.2 15.2 ± 17.3 0.103 Some studies have focused on the efficacy of various treat-
External RotationΔ (T1-T0) 16.8 ± 12.6 9.2 ± 12.1 0.037* ment methods in HSP treatment such as neuromuscular electrical
BRSΔ (T1-T0)(median) 0 (17) 0 (19) 0.028* stimulation, transcutaneous nerve stimulation [37], Kinesio tap-
MASΔ (T0-T1)(median) 0 (19) 0 (19) 0.582 ing [38], suprascapular nerve block [39], and botulinum toxin
FIMΔ (T1-T0) 4.1 ± 4.2 0.52 ± 1.5 0.002* injection [33]. Most of these studies only evaluated outcome
SPADI_painΔ (T0-T1) 30.2 ± 17.4 4.5 ± 9.3 < 0.001* scales such as pain and ROM, and fewer examined function
SPADI_disabilityΔ (T0-T1) 11.2 ± 15.9 3.6 ± 6.7 0.045* and quality of life. However, in our study, we assessed the effec-
SPADI_totalΔ (T0-T1) 25.9 ± 16.8 5.3 ± 8.3 < 0.001* tiveness of HILT on pain and ROM, as well as on functionality,
NHP_painΔ (T0-T1) 33.6 ± 29.1 5.1 ± 11.7 0.001* disability, motor recovery, and quality of life in patients with
NHP_emotionΔ (T0-T1 26.5 ± 40.4 0.9 ± 26.1 0.039* HSP with PTRCT. In the present study, it was found that func-
NHP_sleepΔ (T0-T1) 11.3 ± 26.0 − 3.0 ± 14.5 0.017* tionality and quality of life improved significantly after treatment
NHP_socialΔ (T0-T1) 24.7 ± 34.3 2.7 ± 8.7 0.005* in HILT group. However, there was no significant difference in
NHP_PhysicalΔ (T0-T1) 11.6 ± 20.1 0.6 ± 6.9 0.013* post-treatment functionality and quality of life in the control
NHP_Energy Δ(T0-T1) 15.1 ± 29.1 4.1 ± 21.6 0.178 group compared to pre-treatment. In addition, improvement rates
NHP_TotalΔ (T0-T1) 122.9 ± 106.1 10.5 ± 51.4 < 0.001* in functionality and quality of life in the HILT group compared to
PTRCTΔ (T0-T1) 0.21 ± 0.16 − 0.01 ± 0.09 < 0.001* before treatment were significantly higher than those in the con-
trol group. These higher improvement rates in HILT group may
BRS, Brunnstrom recovery staging; T0, before treatment assessment; T1, be due to the several positive effects of HILT on tear healing,
after treatment assessment; HILT, high-intensity laser therapy; VAS, visu-
al analogue scale; MAS, modified Ashworth scale; FIM, functional inde- inflammation, and pain.
pendence measure; SPADI, shoulder pain and disability index; NHP, HILT have thermal, mechanical, electrical, photochemical,
Nottingham health profile; PTRCT, partial thickness rotator cuff tear and biostimulant effects and induce electromagnetic field, pho-
toelectric, electrochemical, and other changes on applied tissues.
although there was a decrease in SPADI_disability values in both As a result of these effects, HILT has been known to reduce
groups, this decrease was significantly higher in the HILT group. inflammation and painful symptoms by increasing cell metabo-
We thought that these results were due to the application of lism, vascular permeability, and blood flow [15, 34, 40, 41]. Due
hospital-based exercise program in the company of a physiother- to these effects, the size of the tear in the rotator cuff was mea-
apist in our study. Moreover, the effect of HILT combined with sured ultrasonographically, based on the idea that HILT may be
therapeutic exercise on pain and disability was superior to ther- effective in patients with HSP with PTRCT. Thus, the results
apeutic exercise alone. were evaluated with more objective and specific imaging. In
Various studies examining the effect of HILT on shoulder the HILT group, post-treatment PTRCT size was found to be
disorders have evaluated shoulder ROM in different directions significantly reduced compared to pre-treatment size, while there
[21, 22, 37]. Since limitations generally in abduction, flexion, was no change in PTRCT size in the control group. When the
and external rotation were detected in shoulder pain caused by changes in PTRCT sizes at pre- and post-treatment were com-
hemiplegia [34], both due to soft tissue disorders and changes in pared between the two groups, the recovery was significantly
muscle tone, ROM in these directions was evaluated in our study. higher in the HILT group compared with the control group.
In both groups, there was a significant increase in ROM at post- The results strongly suggested that HILT application could re-
treatment compared to pre-treatment. When the change in ROM store partial tears in the supraspinatus muscle. These may have
at pre- and post-treatment was calculated in both groups, the been caused by the rapid anti-inflammatory and reparative prop-
amount of change in the HILT group was higher, although it erties of HILT as described in previous studies [36]. One study
was not statistically significant in flexion and abduction. evaluating rotator cuff tear size ultrasonographically emphasized
Although external rotation was statistically lower at pre- that the development of pain in shoulders with asymptomatic
treatment in the HILT group, when the amount of change in rotator cuff tear was associated with increased tear size, and
external rotation before and after treatment was compared in both larger tears were more likely to develop pain than smaller tears
groups, the increase in external rotation in the HILT group was [32]. Therefore, in our study, we think that the significant de-
significantly higher than in the control group. External rotation crease in PTRCT size after treatment in the HILT group contrib-
was significantly lower in the HILT group than in the control uted to the greater reduction in pain in this group. In the literature,
group after treatment as well as before treatment. Therefore, we the clinical benefits of laser therapy in musculoskeletal disorders

appeared both when used as monotherapy and when used with a
regular exercise [42, 43]. It has been reported that a combination
of laser therapy with an exercise regimen would be more appro-
priate in clinical settings [22]. Elsodany et al. concluded in their
study that the combined effect of exercise and HILT was superior
to the placebo HILT with exercise in shoulder pain due to rotator
cuff tendinopathy [21]. Our study also showed that therapeutic
exercise combined with HILT was significantly more effective in
improving pain, functionality, disability, quality of life, and
PTRCT size compared to therapeutic exercise alone. Placebo
interventions can be performed by medical researchers to com-
plement organized therapy and increase the comparability of
treatments [44]. On the other hand, the clinical use of placebo
interventions remains controversial [45]. Therefore, we preferred
to apply therapeutic exercise alone to control group in this study.
Study limitations
This study has several limitations: (I) The lack of sufficient
follow-up time to obtain long-term effects of HILT, which is
necessary to precisely assess the advantages of these treat-
ments, which can provide important information for the pa-
tients’ rehabilitation. Since most of the patients in our study
applied to our hospital from outside of the city, it was predict-
ed that they would not be followed up for a long time, and
thus, they were evaluated immediately after the treatment.
Therefore, additional studies with longer follow-up periods
are needed. (II) HILT effectiveness could be examined by
comparing it with different conservative interventions other
than therapeutic exercise. (III) Although the physiotherapists
who applied therapeutic exercise for HSP were blinded to the
treatment group, having more than one physiotherapist includ-
ed in the study may be another limitation that increases the
risk of subjective assessment. However, to the best of our
knowledge, this is the first randomized controlled clinical trial
to examine the effects of HILT on HSP with PTRCT. In ad-
dition, the evaluation of HILT efficacy with different factors
(e.g., pain, disability, function, quality of life) and ultrasonog-
raphy was the advantage of this study.
Conclusions
The results of our study suggested that applying HILT combined
with therapeutic exercise was more beneficial in improving pain,
disability, function, and quality of life than therapeutic exercise
alone in shoulder pain accompanied by PTRCT in hemiplegic
patients in the short-term. Moreover, HILT reduced the size of
PTRCT as demonstrated by ultrasonographic assessment.
However, additional studies are needed to investigate the long-
term effectiveness of HILT.
Lasers Med Sci
Declarations
Ethics approval The study was conducted after approval from the local
ethics committee of the medical center (19/2456).
Consent to participate Written informed consent was received from all
patients participating in the study.
Conflict of interest The authors declare no competing interests.
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