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REVIEW PAPER
Efficacy of low-intensity laser therapy in trigeminal neuralgia: a systematic review
1
Exercise and Rehabilitation Sciences Institute, School of Physical Therapy, Faculty of Rehabilitation Sciences, Universidad Andres Bello, Santiago, Chile
Submission date: 2021-07-18
Acceptance date: 2021-09-20
Publication date: 2022-12-19
Physiother Quart. 2022;30(4):14-26
KEYWORDS
TOPICS
ABSTRACT
Introduction:
Trigeminal neuralgia (TN) is a highly prevalent cranial neuropathy, recognized as one of the main chronic orofacial neuropathic pain conditions. Low-intensity laser therapy (LILT) has been proposed as an analgesic alternative for treating neuropathic orofacial pain, although studies appear to be limited, without a consensus on dose. The study aim was to describe the efficacy of LILT in TN treatment.
Methods:
Randomized clinical trials and controlled trials were identified in the PubMed, Scopus, Web of Science, and ScienceDirect databases for May 8, 2021. Three independent researchers reviewed titles and abstracts to determine their eligibility. Risk of bias and quality were assessed with the RoB 2 tool (Cochrane) and PEDro scale. Decreased pain was considered the main outcome, and changes in the temporomandibular joint range of motion, strength, or disability were secondary outcomes.
Results:
The search yielded 1078 articles after eliminating duplicates, reduced to 13 when applying the selection criteria. Nine articles were ascribed a low risk of bias or remained without consensus (69.23%), obtaining an average score of 6 (PEDro). Thirteen trials showed pain reduction at the end of treatment and in follow-up, although with statistical significance for 8 articles only (p < 0.005). A decrease in drug consumption and an increase in serotonin levels were observed in experimental groups, which supports the systemic analgesic effects of local and remote LILT.
Conclusions:
LILT is effective in reducing pain in TN. However, more research is needed to establish a referential dose consensus for TN and other neuropathic pain conditions.
Trigeminal neuralgia (TN) is a highly prevalent cranial neuropathy, recognized as one of the main chronic orofacial neuropathic pain conditions. Low-intensity laser therapy (LILT) has been proposed as an analgesic alternative for treating neuropathic orofacial pain, although studies appear to be limited, without a consensus on dose. The study aim was to describe the efficacy of LILT in TN treatment.
Methods:
Randomized clinical trials and controlled trials were identified in the PubMed, Scopus, Web of Science, and ScienceDirect databases for May 8, 2021. Three independent researchers reviewed titles and abstracts to determine their eligibility. Risk of bias and quality were assessed with the RoB 2 tool (Cochrane) and PEDro scale. Decreased pain was considered the main outcome, and changes in the temporomandibular joint range of motion, strength, or disability were secondary outcomes.
Results:
The search yielded 1078 articles after eliminating duplicates, reduced to 13 when applying the selection criteria. Nine articles were ascribed a low risk of bias or remained without consensus (69.23%), obtaining an average score of 6 (PEDro). Thirteen trials showed pain reduction at the end of treatment and in follow-up, although with statistical significance for 8 articles only (p < 0.005). A decrease in drug consumption and an increase in serotonin levels were observed in experimental groups, which supports the systemic analgesic effects of local and remote LILT.
Conclusions:
LILT is effective in reducing pain in TN. However, more research is needed to establish a referential dose consensus for TN and other neuropathic pain conditions.
REFERENCES (83)
1.
Dahlhamer J, Lucas J, Zelaya C, Nahin R, Mackey S, DeBar L, et al. Prevalence of chronic pain and high-impact chronic pain among adults – United States, 2016. MMWR Morb Mortal Wkly Rep. 2018;67(36):1001–1006; doi: 10.15585/mmwr.mm6736a2.
2.
Kohrt BA, Griffith JL, Patel V. Chronic pain and mental health: integrated solutions for global problems. Pain. 2018;159(Suppl. 1):85–90; doi: 10.1097/j.pain.0000000000001296.
3.
Smith BH, Torrance N. Epidemiology of neuropathic pain and its impact on quality of life. Curr Pain Headache Rep. 2012;16(3):191–198; doi: 10.1007/s11916-012-0256-0.
4.
Karst M, Jasper S, Bernateck M, Stephan M. Clinical diagnostics and therapy of chronic pain syndromes [in German]. Psychother Psychosom Med Psychol. 2012;62(8):320–330; doi: 10.1055/s-0032-1305160.
5.
Treede R-D, Rief W, Barke A, Aziz Q, Bennett MI, Benoliel R, et al. Chronic pain as a symptom or a disease: the IASP Classification of Chronic Pain for the International Classification of Diseases (ICD-11). Pain. 2019;160(1):19–27; doi: 10.1097/j.pain.0000000000001384.
6.
Ro L-S, Chang K-H. Neuropathic pain: mechanisms and treatments. Chang Gung Med J. 2005;28(9):597–605.
7.
Planjar-Prvan M, Bielen I, Baraba R, Buljan R. Pathophysiologic basis of the treatment of neurogenic pain [in Croatian]. Acta Med Croatica. 2004;58(3):197–205.
8.
Murnion BP. Neuropathic pain: current definition and review of drug treatment. Aust Prescr. 2018;41(3):60–63; doi: 10.18773/austprescr.2018.022.
9.
Jensen TS, Baron R, Haanpää M, Kalso E, Loeser JD, Rice ASC, et al. A new definition of neuropathic pain. Pain. 2011;152(10):2204–2205; doi: 10.1016/j.pain.2011.06.017.
10.
Torrance N, Smith BH, Bennett MI, Lee AJ. The epidemiology of chronic pain of predominantly neuropathic origin. Results from a general population survey. J Pain. 2006;7(4):281–289; doi: 10.1016/j.jpain.2005.11.008.
11.
International Association for the Study of Pain. Epidemiology of neuropathic pain: how common is neuropathic pain, and what is its impact? Washington: IASP; 2014.
12.
Smith BH, Torrance N. Epidemiology of neuropathic pain. Pain Manag. 2011;1(1):87–96; doi: 10.2217/pmt.10.5.
13.
Baron R, Binder A, Wasner G. Neuropathic pain: diagnosis, pathophysiological mechanisms, and treatment. Lancet Neurol. 2010;9(8):807–819; doi: 10.1016/S1474-4422(10)70143-5.
14.
Szok D, Tajti J, Nyári A, Vécsei L. Therapeutic approaches for peripheral and central neuropathic pain. Behav Neurol. 2019;2019:8685954; doi: 10.1155/2019/8685954.
15.
Jones MR, Urits I, Ehrhardt KP, Cefalu JN, Kendrick JB, Park DJ, et al. A comprehensive review of trigeminal neuralgia. Curr Pain Headache Rep. 2019;23(10):74; doi: 10.1007/s11916-019-0810-0.
16.
Bendtsen L, Zakrzewska JM, Heinskou TB, Hodaie M, Lacerda Leal PR, Nurmikko T, et al. Advances in diagnosis, classification, pathophysiology, and management of trigeminal neuralgia. Lancet Neurol. 2020;19(9):784–796; doi: 10.1016/S1474-4422(20)30233-7.
17.
Spina A, Mortini P, Alemanno F, Houdayer E, Iannaccone S. Trigeminal neuralgia: toward a multimodal approach. World Neurosurg. 2017;103:220–230; doi: 10.1016/j.wneu.2017.03.126.
18.
Lake WB, Neimat J. Trigeminal neuralgia. In: Harbaugh RE, Shaffrey C, Couldwell WT, Berger MS (eds.), Neurosurgery knowledge update: a comprehensive review. New York: Thieme Medical Publishers; 2015; 293–299.
19.
Maarbjerg S, Gozalov A, Olesen J, Bendtsen L. Trigeminal neuralgia – a prospective systematic study of clinical characteristics in 158 patients. Headache. 2014;54(10):1574–1582; doi: 10.1111/head.12441.
20.
Bennetto L, Patel NK, Fuller G. Trigeminal neuralgia and its management. BMJ. 2007;334(7586):201–205; doi: 10.1136/bmj.39085.614792.BE.
21.
Yadav YR, Nishtha Y, Sonjjay P, Vijay P, Shailendra R, Yatin K. Trigeminal neuralgia. Asian J Neurosurg. 2017;12(4):585–597; doi: 10.4103/ajns.AJNS_67_14.
22.
Cruccu G, Di Stefano G, Truini A. Trigeminal neuralgia. N Engl J Med. 2020;383(8):754–762; doi: 10.1056/NEJMra1914484.
23.
Maarbjerg S, Di Stefano G, Bendtsen L, Cruccu G. Trigeminal neuralgia – diagnosis and treatment. Cephalalgia. 2017;37(7):648–657; doi: 10.1177/0333102416687280.
24.
Xu L, Zhang Y, Huang Y. Advances in the treatment of neuropathic pain. Adv Exp Med Biol. 2016;904:117–129; doi: 10.1007/978-94-017-7537-3_9.
25.
Ariai MS, Mallory GW, Pollock BE. Outcomes after microvascular decompression for patients with trigeminal neuralgia and suspected multiple sclerosis. World Neurosurg. 2014;81(3–4):599–603; doi: 10.1016/j.wneu.2013.09.027.
26.
Han KR, Kim C, Chae YJ, Kim DW. Efficacy and safety of high concentration lidocaine for trigeminal nerve block in patients with trigeminal neuralgia. Int J Clin Pract. 2008;62(2):248–254; doi: 10.1111/j.1742-1241.2007.01568.x.
27.
Pollock BE. Radiosurgery for trigeminal neuralgia: is sensory disturbance required for pain relief? J Neurosurg. 2006;105(Suppl.):103–106; doi: 10.3171/sup.2006.105.7.103.
28.
Sade B, Lee JH. Microvascular decompression for trigeminal neuralgia. Neurosurg Clin N Am. 2014;25(4):743–749; doi: 10.1016/j.nec.2014.06.007.
29.
Vanneste T, Van Lantschoot A, Van Boxem K, Van Zundert J. Pulsed radiofrequency in chronic pain. Curr Opin Anaesthesiol. 2017;30(5):577–582; doi: 10.1097/ACO.0000000000000502.
30.
Weber K. Neuromodulation and devices in trigeminal neuralgia. Headache. 2017;57(10):1648–1653; doi: 10.1111/head.13166.
31.
Singla S, Prabhakar V, Singla RK. Role of transcutaneous electric nerve stimulation in the management of trigeminal neuralgia. J Neurosci Rural Pract. 2011;2(2):150–152; doi: 10.4103/0976-3147.83580.
32.
Sun J, Li R, Li X, Chen L, Liang Y, Zhang Q, et al. Electroacupuncture therapy for change of pain in classical trigeminal neuralgia. Medicine. 2020;99(16):e19710; doi: 10.1097/MD.0000000000019710.
33.
Bjordal JM, Couppé C, Chow RT, Tunér J, Ljunggren EA. A systematic review of low level laser therapy with location-specific doses for pain from chronic joint disorders. Aust J Physiother. 2003;49(2):107–116; doi: 10.1016/s0004-9514(14)60127-6.
34.
Kalhori KAM, Vahdatinia F, Jamalpour MR, Vescovi P, Fornaini C, Merigo E, et al. Photobiomodulation in oral medicine. Photobiomodul Photomed Laser Surg. 2019;37(12):837–861; doi: 10.1089/photob.2019.4706.
35.
Pandeshwar P, Roa MD, Das R, Shastry SP, Kaul R, Srinivasreddy MB. Photobiomodulation in oral medicine: a review. J Investig Clin Dent. 2016;7(2):114–126; doi: 10.1111/jicd.12148.
36.
Ebrahimi H, Najafi S, Khayamzadeh M, Zahedi A, Mahdavi A. Therapeutic and analgesic efficacy of laser in conjunction with pharmaceutical therapy for trigeminal neuralgia. J Lasers Med Sci. 2018;9(1):63–68; doi: 10.15171/jlms.2018.13.
37.
Parker S, Cronshaw M, Anagnostaki E, Bordin-Aykroyd SR, Lynch E. Systematic review of delivery parameters used in dental photobiomodulation therapy. Photobiomodul Photomed Laser Surg. 2019;37(12):784–797; doi: 10.1089/photob.2019.4694.
38.
Clijsen R, Brunner A, Barbero M, Clarys P, Taeymans J. Effects of low-level laser therapy on pain in patients with musculoskeletal disorders: a systematic review and meta-analysis. Eur J Phys Rehabil Med. 2017;53(4):603–610; doi: 10.23736/S1973-9087.17.04432-X.
39.
Cotler HB, Chow RT, Hamblin MR, Carroll J. The use of low level laser therapy (LLLT) for musculoskeletal pain. MOJ Orthop Rheumatol. 2015;2(5):00068; doi: 10.15406/mojor.2015.02.00068.
40.
Khalkhal E, Razzaghi M, Rostami-Nejad M, Rezaei-Tavirani M, Beigvand HH, Tavirani MR. Evaluation of laser effects on the human body after laser therapy. J Lasers Med Sci. 2020;11(1):91–97; doi: 10.15171/jlms.2020.15.
41.
Cameron MH. Lasers and light. In: Cameron MH (ed.), Physical agents in rehabilitation: an evidence-based approach to practice, 6th ed. Philadelphia: Elsevier; 2022; 305–324.
42.
Xu G-Z, Jia J, Jin L, Li J-H, Wang Z-Y, Cao D-Y. Low-level laser therapy for temporomandibular disorders: a systematic review with meta-analysis. Pain Res Manag. 2018;2018:4230583; doi: 10.1155/2018/4230583.
43.
Choy DS. History of lasers in medicine. Thorac Cardiovasc Surg. 1988;36(Suppl. 2):114–117; doi: 10.1055/s-2007-1022985.
44.
Bjordal JM. Low level laser therapy (LLLT) and World Association for Laser Therapy (WALT) dosage recommendations. Photomed Laser Surg. 2012;30(2):61–62; doi: 10.1089/pho.2012.9893.
45.
De la Barra Ortiz HA, Acevedo Cangas S, Cumio Herrera A, Oñate García F, Velásquez Velásquez S. Efficacy of class IV laser in the management of musculoskeletal pain: a systematic review. Physiother Quart. 2021;29(2):1–11; doi: 10.5114/pq.2021.105882.
46.
Karu TI, Hode L. Ten lectures on basic science of laser phototheraphy. Grängesberg: Prima Books; 2007.
47.
Bjordal JM, Johnson MI, Iversen V, Aimbire F, Lopes-Martins RAB. Low-level laser therapy in acute pain: a systematic review of possible mechanisms of action and clinical effects in randomized placebo-controlled trials. Photomed Laser Surg. 2006;24(2):158–168; doi: 10.1089/pho.2006.24.158.
48.
Tomazoni SS, Costa LOP, Joensen J, Stausholm MB, Naterstad IF, Leal-Junior ECP, et al. Effects of photobiomodulation therapy on inflammatory mediators in patients with chronic non-specific low back pain: protocol for a randomized placebo-controlled trial. Medicine. 2019;98(15):e15177; doi: 10.1097/MD.0000000000015177.
49.
Munguia FM, Jang J, Salem M, Clark GT, Enciso R. Efficacy of low-level laser therapy in the treatment of temporomandibular myofascial pain: a systematic review and meta-analysis. J Oral Facial Pain Headache. 2018;32(3):287–297; doi: 10.11607/ofph.2032.
50.
Naeser MA, Hamblin MR. Potential for transcranial laser or LED therapy to treat stroke, traumatic brain injury, and neurodegenerative disease. Photomed Laser Surg. 2011;29(7):443–446; doi: 10.1089/pho.2011.9908.
51.
Antonić R, Brumini M, Vidović I, Muhvić Urek M, Glažar I, Pezelj-Ribarić S. The effects of low level laser therapy on the management of chronic idiopathic orofacial pain: trigeminal neuralgia, temporomandibular disorders and burning mouth syndrome. Med Flum. 2017;53(1):61–67; doi: 10.21860/medflum2017_173373.
52.
Amanat D, Ebrahimi H, Lavaee F, Alipour A. The adjunct therapeutic effect of lasers with medication in the management of orofacial pain: double blind randomized controlled trial. Photomed Laser Surg. 2013;31(10):474–479; doi: 10.1089/pho.2013.3555.
53.
Aghamohammadi D, Amirnaseri R, Peirovifar A, Hossainzadeh H, Eidi M, Ehsaei M, et al. Gasserian ganglion block with or without low-intensity laser therapy in trigeminal neuralgia: a comparative study. Neurosurg Q. 2012;22(4):228–232; doi: 10.1097/WNQ.0b013e3182571c93.
54.
Hashimoto T, Kemmotsu O, Otsuka H, Numazawa R, Ohta Y. Efficacy of laser irradiation on the area near the stellate ganglion is dose dependent: a double-blind crossover placebo-controlled study. Laser Ther. 1997;9(1):7–12; doi: 10.5978/islsm.9.7.
55.
Walker JB, Akhanjee LK, Cooney MM, Goldstein J, Tamzyoshi S, Segal-Gidan F. Laser therapy for pain of trigeminal neuralgia. Clin J Pain. 1987;3(4):183–188.
56.
Stefanoff V. Treatment of trigeminal neuralgia (TN) with local laser irradiation and laser puncture. Int J Oral Maxillofac Surg. 1990;19(6):379–380.
57.
Seada YI, Nofel R, Sayed HM. Comparison between trans-cranial electromagnetic stimulation and low-level laser on modulation of trigeminal neuralgia. J Phys Ther Sci. 2013;25(8):911–914; doi: 10.1589/jpts.25.911.
58.
Walker J. Relief from chronic pain by low power laser irradiation. Neurosci Lett. 1983;43(2–3):339–344; doi: 10.1016/0304-3940(83)90211-2.
59.
Pinheiro AL, Cavalcanti ET, Pinheiro TI, Alves MJ, Miranda ER, De Quevedo AS, et al. Low-level laser therapy is an important tool to treat disorders of the maxillofacial region. J Clin Laser Med Surg. 1998;16(4):223–226; doi: 10.1089/clm.1998.16.223.
60.
Hansen HJ, Thorøe U. Low power laser biostimulation of chronic oro-facial pain. A double-blind placebo controlled cross-over study in 40 patients. Pain. 1990;43(2):169–179; doi: 10.1016/0304-3959(90)91070-Y.
61.
Eckerdal A, Bastian L. Can low reactive-level laser therapy be used in the treatment of neurogenic facial pain? A double-blind, placebo-controlled investigation of patients with trigeminal neuralgia. Laser Ther. 1996;8(4):247–251; doi: 10.5978/islsm.8.247.
62.
Díaz Pérez R, Guzmán Ruiz A, Gutiérrez Valdez DH. Therapeutic laser effectiveness in ailment with orofacial pain [in Spanish]. Av Odontoestomatol. 2018;34(2):87–93.
63.
Moher D, Liberati A, Tetzlaff J, Altman DG, PRISMA Group. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. BMJ. 2009;339:b2535; doi: 10.1136/bmj.b2535.
64.
Ouzzani M, Hammady H, Fedorowicz Z, Elmagarmid A. Rayyan – a web and mobile app for systematic reviews. Syst Rev. 2016;5:210; doi: 10.1186/s13643-016-0384-4.
65.
Maher CG, Sherrington C, Herbert RD, Moseley AM, Elkins M. Reliability of the PEDro scale for rating quality of randomized controlled trials. Phys Ther. 2003;83(8):713–721; doi: 10.1093/ptj/83.8.713.
66.
De Morton NA. The PEDro scale is a valid measure of the methodological quality of clinical trials: a demographic study. Aust J Physiother. 2009;55(2):129–133; doi: 10.1016/s0004-9514(09)70043-1.
67.
Albanese E, Bütikofer L, Armijo-Olivo S, Ha C, Egger M. Construct validity of the Physiotherapy Evidence Database (PEDro) quality scale for randomized trials: item response theory and factor analyses. Res Synth Methods. 2020;11(2):227–236; doi: 10.1002/jrsm.1385.
68.
Sterne JAC, Savović J, Page MJ, Elbers RG, Blencowe NS, Boutron I, et al. RoB 2: a revised tool for assessing risk of bias in randomised trials. BMJ. 2019;366:l4898; doi: 10.1136/bmj.l4898.
69.
Minozzi S, Cinquini M, Gianola S, Gonzalez-Lorenzo M, Banzi R. The revised Cochrane risk of bias tool for randomized trials (RoB 2) showed low interrater reliability and challenges in its application. J Clin Epidemiol. 2020;126:37–44; doi: 10.1016/j.jclinepi.2020.06.015.
70.
Minozzi S, Cinquini M, Gianola S, Castellini G, Gerardi C, Banzi R. Risk of bias in nonrandomized studies of interventions showed low inter-rater reliability and challenges in its application. J Clin Epidemiol. 2019;112:28–35; doi: 10.1016/j.jclinepi.2019.04.001.
71.
McGuinness LA, Higgins JPT. Risk-of-bias VISualization (robvis): an R package and Shiny web app for visualizing risk-of-bias assessments. Res Synth Methods. 2021;12(1):55–61; doi: 10.1002/jrsm.1411.
72.
Stovold E, Beecher D, Foxlee R, Noel-Storr A. Study flow diagrams in Cochrane systematic review updates: an adapted PRISMA flow diagram. Syst Rev. 2014;3:54; doi: 10.1186/2046-4053-3-54.
73.
De Andrade ALM, Bossini PS, Parizotto NA. Use of low level laser therapy to control neuropathic pain: a systematic review. J Photochem Photobiol B. 2016;164:36–42; doi: 10.1016/j.jphotobiol.2016.08.025.
74.
Anju M, Ummer VS, Maiya AG, Hande M. Low level laser therapy for the patients with painful diabetic peripheral neuropathy – a systematic review. Diabetes Metab Syndr. 2019;13(4):2667–2670; doi: 10.1016/j.dsx.2019.07.035.
75.
Lin L, Li J, Lin J, Tang S, Li Y. Effectiveness and safety of low-level laser therapy in diabetic peripheral neuropathy: a protocol for a systematic review and meta-analysis. Syst Rev. 2021;10(1):96; doi: 10.1186/s13643-021-01656-y.
76.
Ordahan B, Karahan AY. Role of low-level laser therapy added to facial expression exercises in patients with idiopathic facial (Bell’s) palsy. Lasers Med Sci. 2017;32(4):931–936; doi: 10.1007/s10103-017-2195-9. Erratum in: Lasers Med Sci. 2019;34(6):1281–1282; doi: 10.1007/s10103-019-02828-y.
77.
Walker JB, Akhanjee LK. Laser-induced somatosensory evoked potentials: evidence of photosensitivity in peripheral nerves. Brain Res. 1985;344(2):281–285; doi: 10.1016/0006-8993(85)90805-4.
78.
Tsuchiya K, Kawatani M, Takeshige C, Matsumoto I. Laser irradiation abates neuronal responses to nociceptive stimulation of rat-paw skin. Brain Res Bull. 1994;34(4):369–374; doi: 10.1016/0361-9230(94)90031-0.
79.
Lambert GW, Kaye DM, Cox HS, Vaz M, Turner AG, Jennings GL, et al. Regional 5-hydroxyindoleacetic acid production in humans. Life Sci. 1995;57(3):255–267; doi: 10.1016/0024-3205(95)00269-c.
80.
Deacon AC. The measurement of 5-hydroxyindoleacetic acid in urine. Ann Clin Biochem. 1994;31(Pt 3):215–232; doi: 10.1177/000456329403100302.
81.
Rossettini G, Carlino E, Testa M. Clinical relevance of contextual factors as triggers of placebo and nocebo effects in musculoskeletal pain. BMC Musculoskelet Disord. 2018;19(1):27; doi: 10.1186/s12891-018-1943-8.
82.
Coarkin PE, Wall CA, King JD, Kozel FA, Daskalakis ZJ. Pain during transcranial magnetic stimulation in youth. Innov Clin Neurosci. 2011;8(12):18–23.
83.
Sokka T. Assessment of pain in patients with rheumatic diseases. Best Pract Res Clin Rheumatol. 2003;17(3):427–449; doi: 10.1016/s1521-6942(03)00020-2.
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