Lasers in Medical Science

, Volume 31, Issue 3, pp 459–469 | Cite as

LLLT for the management of patients with ankylosing spondylitis

  • D. Stasinopoulos
  • K. Papadopoulos
  • D. Lamnisos
  • A. Stergioulas
Original Article


This study aimed to compare the effectiveness of the combined low-level laser therapy (LLLT) and passive stretching with combined placebo LLLT laser and the same passive stretching exercises in patients suffering from Αnkylosing spondylitis. Forty-eight patients suffering from Αnkylosing spondylitis participated in the study and were randomized into two groups. Group A (n = 24) was treated with a λ = 820 Ga-Al-As laser CW, with power intensity = 60 mW/cm2, energy per point in each session = 4.5 J, total energy per session = 27.0 J, in contact with specific points technique, plus passive stretching exercises. Group B (n = 24), received placebo laser plus the same passive stretching exercises. Both groups received 12 sessions of laser or placebo within 8 weeks; two sessions per week (weeks 1–4) and one session per week (weeks 5–8). Pain and function scales were completed before the treatment, at the end of the fourth and eighth week of treatment, and 8 weeks after the end of treatment (follow-up). Group A revealed a significant improvement after 8 weeks of treatment in all pain and function scales. At 8-week follow-up, the improvement remained only for the pain, while for all other function outcomes the differences were not statistically significant. The results suggested that after an 8-week treatment and after a follow-up, the combination of LLLT and passive stretching exercises decreased pain more effectively than placebo LLLT along with the same passive stretching exercises in patients with Αnkylosing spondylitis. Future studies are needed to establish the relative and absolute effectiveness of the above protocol.


LLLT Ankylosing spondylitis Passive stretching 



We would like to thank all the subjects for the enthusiastic contribution and patience during this project. We are also thankful to Dr. P. Baltopoulos (Associate Professor of Department of Sports Sciences, University of Athens) for his comments; Dr. D. Sotiropoulos (director of Panarkadikon Orthopedic Clinic) for patients referred to the lab; Director of the Lab Health and Fitness Management Dr. A. Tripolitsioti for her assistance in subjects randomization; Physical therapist L. Papadolias for patients evaluation; and Physical therapists D. Kokkinis and and A. Tyflidis for their help during the study protocol.


  1. 1.
    Van Den Berg R, Baraliakos X, Braun J, van der Heijide D (2012) First update of the current evidence for the management of ankylosing apondylitis with non-pharmacological treatment and non-biologic drugs: a systematic literature review for the ASAS/EULAR management recommendations in ankylosing spondylitis. Rheumatology 51(8):1388–1396CrossRefPubMedGoogle Scholar
  2. 2.
    Braun J, Baraliakos X, Godolias G, Bohm H (2005) Therapy of ankylosing spondylitis. Part II: biological therapies in the spondyloarthritides. Scand J Rheumatol 34(3):178–190CrossRefPubMedGoogle Scholar
  3. 3.
    Van Denderen JC (2015) The evolving treatment of ankylosing spondylitis. Dissertation, Vrije Universiteit: AmsterdamGoogle Scholar
  4. 4.
    Braun J (2003) International ASAA consensus statement for the use of anti-tumour necrosis factor agents in patients with AS. Ann Rheum Dis 62:817–824CrossRefPubMedPubMedCentralGoogle Scholar
  5. 5.
    Kumar VS, Das S, Sampath TS (2011) A review on ankylosing spondylitis. Int J Pharm Bio Sci 2(3):187–193Google Scholar
  6. 6.
    Ravisankar P, Bhargavi PD, Jyothi VDR, Sampath R et al (2015) Ankylosing spondylitis-contemporary detailed analysis on diagnosis, management and medication. Indo Am J Pharm 5(9):2944–2956Google Scholar
  7. 7.
    Scalapino KL, Davis JC Jr (2003) The treatment of ankylosing spondylitis. Clin Exper Med 2:159–165CrossRefGoogle Scholar
  8. 8.
    Smolen JS, Braun J, Dougadois M, Emery P et al (2014) Treating spondyloarthritis, including AS and PA, to target: recommendations of an international task force. Ann Rheum Dis 73:6–16CrossRefPubMedPubMedCentralGoogle Scholar
  9. 9.
    Braun J, Bollow M, Neure L, Seipelt E, Seyrekbasan F, Herbst H, Eggens U, Distler A, Sieper J (1995) Use of immunohistologic and in situ hybridization techniques in the examination of sacroiliac joint biopsy specimens from patients with ankylosing spondylitis. Arthritis Rheum 38:499–505. 29Google Scholar
  10. 10.
    Pham T, Van Der Heijde D, Calin A, Khan MA, Van Der Linden S, Bellamy N, Dougados M (2003) Initiation of biological agents in patients with ankylosing spondylitis: results of a Delphi study by the ASAS Group. Ann Rheum Dis 62:812–816CrossRefPubMedPubMedCentralGoogle Scholar
  11. 11.
    Sherlock J, Joyce-Shaikh B, Turnerm SP, ChiChao C et al (2012) IL-23 induces spondyloarthropathy by acting on ROR-γt + CD3 + CD4 − CD8− entheseal resident T cells. Nat Med 18:1069–1076CrossRefPubMedGoogle Scholar
  12. 12.
    Khan MA (2002) Ankylosing spondylitis: introductory comments on its diagnosis and treatment. Ann Rheum Dis 61(Suppl III):3–7CrossRefGoogle Scholar
  13. 13.
    Watson T (2000) The role of electrotherapy in contemporary physiotherapy practice. Manual Ther 5:132–141CrossRefGoogle Scholar
  14. 14.
    Robertson V, Ward A, Low J, Reed A (2006) Electrotherapy explained. Principles and practice, 4th edn. Butterworth Heinemann, EdinbourghGoogle Scholar
  15. 15.
    Bjordal JM, Lopes-Martins RAB, Rodrigo AB, Jon Joensen J, Ljunggren AE, Couppe C, Stergioulas A, Johnson MI (2008) Systematic review with procedural assessments and meta-analysis of low level laser therapy in lateral elbow tendinopathy (tennis elbow). BMC Musculoskelet Disord 9:75CrossRefPubMedPubMedCentralGoogle Scholar
  16. 16.
    Stergioulas A, Stergioula M, Aarskog R, Lopes-Martins RA, Bjordal JM (2008) Effects of low-level laser therapy and eccentric exercises in the treatment of recreational athletes with chronic Achilles tendinopathy. Am J Sports Med 36(5):881–887CrossRefPubMedGoogle Scholar
  17. 17.
    Stergioulas A (2007) Effects of low level laser and plyometric exercises in the treatment of lateral epicondylitis. Photomed Laser Surg 25:132–191CrossRefGoogle Scholar
  18. 18.
    Stergioulas A (2004) Low-level laser treatment can reduce edema in second degree ankle sprains. Laser Med Sci Surg 21(2):125–128Google Scholar
  19. 19.
    Stasinopoulos D, Stasinopoulos I, Manias P, Stasinopoulou K (2008) Comparing the effects of exercise program and low-level laser therapy with exercise program and polarized polychromatic non-coherent light (bioptron light) on the treatment of lateral elbow tendinopathy. Photomed Laser Surg 27(3):513–520CrossRefGoogle Scholar
  20. 20.
    Stasinopoulos D, Johnson M (2005) Effectiveness of low-level laser therapy for lateral elbow tendinopathy. Photomed Laser Surg 23(4):425–430CrossRefPubMedGoogle Scholar
  21. 21.
    Tumilty SJ (2010) Low level laser therapy for the treatment of tendinopathy with emphasis on the Achilles tendon. Thesis, School of Physiotherapy, University of Otago, p 24–29Google Scholar
  22. 22.
    Joensen J (2013) Biophysical and biological effects from infrared low-level-laser-therapy. Thesis, University of Bergen-Faculty of Medicine and DentistryGoogle Scholar
  23. 23.
    Apostolopoulos N, Metsios GS, Flouris AD, Koutedakis Y, Wyon MA (2015) The relevance of stretch intensity: a review. Front Psychol 6:1128CrossRefPubMedPubMedCentralGoogle Scholar
  24. 24.
    Alter MJ (2004) Science of flexibility. Human Kinetics, Champain, pp 17–373Google Scholar
  25. 25.
    Karapolat H, Eyigor S, Zoghi M, Akkoc Y, Kirazli Y, Keser G (2009) Are swimming or aerobic exercise better than conventional exercise in ankylosing spondylitis patients? A randomized controlled study. Eur J Phys Rehabil Med 45:449–457PubMedGoogle Scholar
  26. 26.
    Analay Y, Ozcan E, Karan A, Diracoglu D, Aydin R (2003) The effectiveness of intensive group exercise on patients with ankylosing spondylitis. Clin Rehabil 17:631–636CrossRefPubMedGoogle Scholar
  27. 27.
    Fernández-de-las-Peñas C, Alonso-Blanco C, Morales-Cabezas M, Miangolarra-Page JC (2005) Two exercise interventions for the management of patients with ankylosing spondylitis: a randomized controlled trial. Am J Phys Med Rehabil 84:407–419CrossRefPubMedGoogle Scholar
  28. 28.
    Ince G, Sarpel T, Durgun B, Erdogan S (2006) Effects of a multimodal exercise program for people with ankylosing spondylitis. Phys Ther 86:924–935PubMedGoogle Scholar
  29. 29.
    Cagliyan A, Kotevoglu N, Onal T, Tekkus B, Kuran B (2007) Does group exercise program add anything more to patients with ankylosing spondylitis. J Back Musculoskelet Rehab 20:79–85Google Scholar
  30. 30.
    Bulstrone SJ, Barefoot J, Harrison RA, Clark AK (1987) The role of passive stretching in the treatment of ankylosing spondylitis. Br J Rheumatol 26(1):40–42CrossRefGoogle Scholar
  31. 31.
    Rudwaleit M, Khan MA, Sieper J (2005) The challenge of diagnosis and classification in early ankylosing spondylitis: do we need new criteria? Arthritis Rheum 52:1000–1008CrossRefPubMedGoogle Scholar
  32. 32.
    Altan L, Bingöl U, Aslan M, Yurtkuran M (2006) The effect of balneotherapy on patients with ankylosing spondylitis. Scand J Rheumatol 35(4):383–389CrossRefGoogle Scholar
  33. 33.
    Altan L, Bingol U, Aykas M, Yurkuran M (2003) Investigation of the effect of GaAs laser therapy on cervical myofascial pain syndrome. Rheumatol Int 25(1):23–27CrossRefPubMedGoogle Scholar
  34. 34.
    Kay AD, Blazevich AJ (2012) Effect of acute static stretch on maximal muscle performance: a systematic review. Med Sci Sports Exerc 44(1):154–164CrossRefPubMedGoogle Scholar
  35. 35.
    Kisner C, Colby LA (2012) Therapeutic exercises, foundations and techniques, 3rd edn. F.A. Davis, PhiladelphiaGoogle Scholar
  36. 36.
    Page P (2012) Current concepts in muscle stretching for exercise and rehabilitation. Int J Sports Phys Ther 7(1):109–119PubMedPubMedCentralGoogle Scholar
  37. 37.
    Williamson A, Hoggar B (2005) Pain: a review of three commonly used pain rating scales. J Clin Nurs 14(7):798–804CrossRefPubMedGoogle Scholar
  38. 38.
    Jenkinson TR, Mallorie AM, Whitelock HC (1994) Defining spinal mobility in ankylosing spondylitis: the Bath AS Metrology Index. J Rheumatol 21(9):1694–1698PubMedGoogle Scholar
  39. 39.
    Haywood KL, Garatt AM, Jordan K, Dziedzic K, Dawes PT (2005) Spinal mobility in ankylosing spondylitis: reliability, validity and responsiveness. Rheumatology (2004) 43(6):750–757CrossRefGoogle Scholar
  40. 40.
    Dagfinrud H, Hagen KB, Kvien TK (2008) Physiotherapy for ankylosing spondylitis. Cochrane review CD002822.pub3Google Scholar
  41. 41.
    Williams MA, MacCarthy J, Chort A, Cooke MW, Gates S (2010) A systematic review of reliability and validity studies of methods for measuring active and passive cervical range of motion. J Manipulative Physiol Ther 33(2):138–155CrossRefPubMedGoogle Scholar
  42. 42.
    Sieper J, Rudwaleit M, Baraliakos X, Brandt J, Braun J, Burgos-Varfas R, Dugados M et al (2009) The Assessment of SpondyloArthritis international Society (ASAS) handbook: a guide to assess spondyloarthritis. Ann Rheum Dis 68:ii1–ii44. doi: 10.1136/ard.2008.104018 PubMedGoogle Scholar
  43. 43.
    Van Der Heijde D, Calin A, Dougados M, Khan M, Van Der Linden S, Bellamy N (1999) Selection of instruments in the core set for dc-art, smard, physical therapy and clinical record keeping in ankylosing spondylitis. Progress report of the ASA working group. J Rheumatol 26:951–954PubMedGoogle Scholar
  44. 44.
    Chatzitheodorou D, Kabitsis C, Papadopoulos NG, Galanopoulou V (2007) Evaluation of the Greek version of the Bath Ankylosing Spondylitis Functional Index: reliability, validity and factor analysis. Cl Exp Rheumatol 25(4):571–576Google Scholar
  45. 45.
    Braun J, Sieper J (2007) Ankylosing spondylitis. Lancet 369(9570):1379–1390CrossRefPubMedGoogle Scholar
  46. 46.
    Brenn D, Richter F, Schaible HG (2007) Sensitization of unmyelinated sensory fibers of the joint nerve to mechanical stimuli by interleukin-6 in the rat: an inflammatory mechanism of joint pain. Arthritis Rheum 56:351–359CrossRefPubMedGoogle Scholar
  47. 47.
    Kawasaki Y, Zhang L, Cheng JK, Ji RR (2008) Cytokine mechanisms of central sensitization: distinct and overlapping role of interleukin-1beta, interleukin-6, and tumor necrosis factor-alpha in regulating synaptic and neuronal activity in the superficial spinal cord. J Neurosci 28:5189–5194CrossRefPubMedPubMedCentralGoogle Scholar
  48. 48.
    Furst DE, Keystone EC, Braun J, Breedveld FC, Burmester GR, De Benedetti F, Dörner T, Emery P, Fleischmann R, Gibofsky A, Kalden JR, Kavanaugh A, Kirkham B, Mease P, Sieper J, Singer NG, Smolen JS, Van Riel PL, Weisman MH, Winthrop K (2011) Updated consensus statement on biological agents for the treatment of rheumatic diseases, 2010. Ann Rheu Dis 70(Suppl 1):2–36CrossRefGoogle Scholar
  49. 49.
    Bjordal JM, Couppé C, Chow RT, Tunér J, Ljunggren EA (2003) A systematic review of low-level laser therapy with location specific doses for pain from chronic joint disorders. Aust J Physiother 49:107–116CrossRefPubMedGoogle Scholar
  50. 50.
    Karu T (2007) Ten lectures on basic science of laser phototherapy. Prima Books, SwedenGoogle Scholar
  51. 51.
    Murrell GA (2007) Oxygen free radicals and tendon healing. J Shoulder Elbow Surg 16(5 Suppl):208–214CrossRefGoogle Scholar
  52. 52.
    Xia W, Szomor Z, Wang Y, Murrell GA (2006) Nitric oxide enhances collagen synthesis in cultured human tendon cells. J Orthop Res 24(2):159–172CrossRefPubMedGoogle Scholar
  53. 53.
    Karu T (1999) Primary and secondary mechanisms of action of visible to near-IR radiation on cells. J Photochem Photobiol B-Biol 49:1–17CrossRefGoogle Scholar
  54. 54.
    Chow RT, Johnson MI, Lopes-Martins RA, Bjordal JM (2009) Efficacy of low-level laser therapy in the management of neck pain: a systematic review and meta-analysis of randomised placebo or active-treatment controlled trials. Lancet 374:1897–1908CrossRefPubMedGoogle Scholar
  55. 55.
    Feraresi D, Parizotto CF (2013) Low-level laser therapy and light emitting diode therapy on muscle tissue: performance, fatigue and repair. In: Hamblin MR, Huang YY (eds) Hand book of photomedicine, Taylor & Francis pp 611–631Google Scholar
  56. 56.
    Lopes-Martins RA, Marcos RL, Leonardo PS, Priantini AC, Muscara MN, Aibire F, Frifgo L, Iversen V, Bjordal JM (2006) Effect of low-level laser Ga-Al-As 655 nm) on skeletal muscle fatigue induced by electrical stimulation in rats. J Appl Physiol 101(1):283–288CrossRefPubMedGoogle Scholar
  57. 57.
    Konstantinovic LM, Kanjuh ZM, Milovanovic AN, Cutoviv MR, Djurovic AG, Savic VG, Dragin AS, Milovanovic ND (2010) Acute low back pain with radiculopathy: a double-blind, randomized, placebo-controlled study. Photomed Laser Surg 28(4):553–560CrossRefPubMedGoogle Scholar
  58. 58.
    Jovicic M, Konstantinovic L, Lazovic M, Jovicic V (2012) Clinical and functional evaluation of patients with acute low back pain and radiculopathy treated with different energy doses of low level laser therapy. Vojnosanit Pregl 69(8):656–662CrossRefPubMedGoogle Scholar
  59. 59.
    Djavid GE, Mehrdad R, Ghasemi M, Hasan-Zadeh H, Sotoodeh-Manesh A, Pouryaghoub G (2007) In chronic low back pain, low level laser therapy combined with exercise is more beneficial than exercise alone in the long term: a randomised trial. Aust J Physiother 53(3):155–160CrossRefPubMedGoogle Scholar
  60. 60.
    Fiore P, Panza F, Cassatella G (2011) Short-term effects of high-intensity laser therapy versus ultrasound therapy in the treatment of low back pain: a randomized controlled trial. Eur J Phys Rehab Med 47(3):367–373Google Scholar
  61. 61.
    Ay S, Dogan SK, Evcik D (2010) Is low-level laser therapy effective in acute or chronic low back pain? Clin Rheumatol 29:905–910CrossRefPubMedGoogle Scholar
  62. 62.
    Fulop AM, Dhimmer S, Deluca JR, Johanson DD, Lenz RV, Patel KB (2010) A meta-analysis of the efficacy of laser phototherapy on pain relief. Clin J Pain 26:729–736PubMedGoogle Scholar
  63. 63.
    Kingsley JD, Demchak T, Mathis R, Kingsley JD, Demchak T, Mathis R (2014) Low-level laser therapy as a treatment for chronic pain. Front Physiol 5:306CrossRefPubMedPubMedCentralGoogle Scholar
  64. 64.
    Yousefi-Nooraie R, Schonstein E, Heidari K, Rashidian A, Pennick V, Akbari-Kamrani M, Irani S, Shakiba B, Mortaz Hejri SA, Mortaz Hejri SO, Jonaidi A (2008) Low level laser therapy for nonspecific low-back pain. Cochrane Database Syst Rev 2:CD005107PubMedGoogle Scholar
  65. 65.
    Chou R, Huffman LH (2007) Non pharmacologic therapies for acute and chronic low back pain: a review of the evidence for an American Pain Society/American College of Physicians clinical practice guideline. Ann Int Med 147(7):492–504CrossRefPubMedGoogle Scholar
  66. 66.
    Aydin E, Gunduz O, Akcan E, Akyuz G (2013) Effectiveness of low level laser therapy on pain and functional status in ankylosing spondylitis. Turk J Phys Med Rehab 59:299–303Google Scholar
  67. 67.
    Kjeken I, Bo I, Ronningen A et al (2013) A three-week multidisci- plinary in-patient rehabilitation programme had positive long-term effects inpatients withankylosingspondylitis:randomizedcontrolled trial. J Rehabil Med 45(3):260–267CrossRefPubMedGoogle Scholar
  68. 68.
    Aytekin E, Caglar NS, Ozgonenel L, Tutun S, Demiryontar DY, Demir SE (2012) Home-based exercise therapy in patients with ankylosing spondylitis: effects on pain, mobility, disease activity, quality of life, and respiratory functions. Clin Rheumatol 31:91–97CrossRefPubMedGoogle Scholar
  69. 69.
    Altan L, Korkmaz N, Dizdar M, Yurtkuran M (2012) Effect of Pilates training on people with ankylosing spondylitis. Rheumatol Int 32:2093–2099CrossRefPubMedGoogle Scholar
  70. 70.
    Strumse YAS, Bjørn-Yngvar Nordvåg BY, Stanghelle JK, Røisland JK, Winther M, Pär-Arne Pajunen PA, Torhild GT, Berit Flatø B (2011) Efficacy of rehabilitation for patients with ankylosing spondylitis: comparison of a four-week rehabilitation programme in a Mediterranean and a Norwegian setting. J Rehabil 43:534–542CrossRefGoogle Scholar
  71. 71.
    Rosu MO, Topa I, Chirieac R, Ancuta C (2014) Effects of Pilates, McKenzie and Heckscher training on disease activity, spinal motility and pulmonary function in patients with ankylosing spondylitisGoogle Scholar
  72. 72.
    Rodriguez-Lozano C, Juanola X, Cruz-Martinez J et al (2013) Outcome of an education and home-based exercise programme for patients with ankylosing spondylitis: a nationwide randomized study. Clin Exp Rheumatol 31:739–748PubMedGoogle Scholar
  73. 73.
    Elvan M, Khan MA (2008) Does physical therapy still have a place in the treatment of ankylosing spondylitis? Curr Opin Rheumatol 20(3):282–286CrossRefGoogle Scholar
  74. 74.
    Passalent LA (2011) Physiotherapy for ankylosing spondylitis: evidence and application. Curr Opin Rheumatol 23(2):142–147CrossRefPubMedGoogle Scholar
  75. 75.
    Dagfinrud H, Kvien TK, Hagen KB (2008) Physiotherapy interventions for ankylosing spondylitis. Cochrane Database Syst Rev 2008:CD002822Google Scholar
  76. 76.
    Giannotti E, Sabina Trainito S, Arioli G, Vincenzo Rucco V, Masiero S (2014) Effects of physical therapy for the management of patients with ankylosing spondylitis in the biological era. Clin Rheumatol 33:1217–1230CrossRefPubMedGoogle Scholar
  77. 77.
    Norris CM (1999) The complete guide to stretching. Human Kinetics Publishing, Windsor, pp 23–76Google Scholar
  78. 78.
    Bjordal JM, Lopes-Martins BA (2013) Low-level laser therapy in arthritis and tendinopathies. In: Hamblin MR Huang YY (eds) Hand book of photomedicine, Taylor & Francis pp 603–610Google Scholar
  79. 79.
    Carroll J (2013) Irradiation parameters, doses and devices. In: Hamblin MR, Huang YY (eds) Hand book of photomedicine, Taylor & Francis pp 563–568Google Scholar
  80. 80.
    WALT (2010) World Association for Laser Therapy, Dosage recommendations [Online]. WALT. Available: Accessed date 15 Sept 2015
  81. 81.
    Simons DG, Travell JG, Simons LS (1999) Travell & Simons’ myofascial pain and dysfunction: upper half of body. Williams & Wilkins pp 801–840Google Scholar

Copyright information

© Springer-Verlag London 2016

Authors and Affiliations

  • D. Stasinopoulos
    • 1
  • K. Papadopoulos
    • 1
  • D. Lamnisos
    • 1
  • A. Stergioulas
    • 2
  1. 1.Physiotherapy Program, Department of Health Sciences, School of Sciences, European University CyprusLaureate International UniversitiesEngomiCyprus
  2. 2.Lab of Health, Fitness and Disability Management, Faculty of Human Movement and Quality of LifeUniversity of Peloponnese, Efstathiou & Stamatikis Balioti & PlateonSpartaGreece

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