is imperative to rule out other possible shoulder pathologies, besides confirming the clinical diagnosis beyond an element of doubt. In summary, we chose LLLT owing to its lack of side effects, while being noninvasive and well tolerated by the elderly. By contrast, traditional methods of treatment for painful shoulders of the elderly caused by adhesive capsulitis involve nonsteroidal anti-inflammatory agents as well as conventional physiotherapy, such as ultrasound therapy and electrical stimulation therapy. None of these therapies has the biomodulation effects offered by LLLT, such as improve- ment in microcirculation or the upregulation of several genes involved in energy metabolism and oxidative phosphoryla- tion, which stimulates an increase in adenosine triphosphate production, which in turn regulates other cellular processes, leading to the normalization of biological functions at the cellular level. For instance, therapeutic ultrasound devices do not even have anti-inflammatory effects let alone any biomodulation effects.14 In general, for any conservative treatment of adhesive capsulitis to be meaningful, the treatment modality must have lasting effects and benefits for the patient, rather than providing only transient pain relief, such as the administration of painkillers does. We are not aware of any clinical study reporting on the medium-term efficacy of LLLT in the man- agement of shoulder adhesive capsulitis. In the study reported here, LLLT showed evidence of lasting benefit and represents a viable option to choose rather than surgery, particularly in the elderly population, in whom concomitant medical comorbidities may well increase the risk of surgery.
Limitations and future directions This study lacked a control group, which represents a weakness and is acknowledged as such. A control group was not included, as the majority of patients do not give consent to the idea of
a sham laser light source. The fact that the patient population included subjects who failed to respond to a combination of con- ventional physical therapy and nonsteroidal anti- inflammatory medications but responded positively to LLLT warrants further large-scale double-blind placebo-controlled studies to further confirm the clinical results of this study, provided lasers of similar wavelength, power density, and application time, and the six points of application are the same, together with the two additional acupuncture points of Bingfeng and Tianzong to make any clinical results comparable.
Conclusion The current prospective review of a patient cohort of 35 elderly patients with documented symptomatic adhesive capsulitis of 50 painful shoulders showed a significant posi- tive clinical response in patients, as evidenced by the marked improvement in their Constant–Murley scores, not only in the short-term but also in the medium-term, as the mean clinical follow-up in this prospective study was 2 years. Further large-scale studies are worthwhile to further explore the use of LLLT, not only in the treatment of adhesive capsulitis but also in other painful shoulder conditions, such as partial rotator-cuff tears.
Disclosure The authors declare no conflicts of interest in this work.