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Therapeutic effects of the combined use of Tecar, Shockwave (rESWT) and Class IV Laser (LLLT) on acute, non-specific neck pain

Abstract

There is no clear evidence or understanding of what causes neck pain. The prevalence of neck pain is generally higher in women and in the 35-49-year age group.1 The following is a case report of an individual experiencing acute non-specific neck pain. Their treatment involves three different types of therapy including Tecar Therapy, Radial Extracorporeal Shockwave Therapy (rESWT), and Class IV Low-Level Laser Therapy (LLLT). It is suggested here that the combined mechanisms of each of these different modalities creates a synergistic therapeutic effect when performed in a particular order (Tecar, rESWT, and LLLT, respectively). Significant improvements were assessed and recorded post-treatment after a few weeks, and a one-year follow-up using the Vernon-Mior Neck Disability Index and ROM tests.

Introduction

Neck pain is a very common occurrence most people will experience within their lives. Approximately 15%-20% of people report neck pain each year, with 1.5%-1.8% of adults seeking ambulatory care.2 In 2017, there were an estimated 288.7 million global cases.3 Two of every three people will experience neck pain at a certain time during their life.4 There isn’t a clear understanding of neck pain in terms of both causes and treatments. In terms of chronic neck pain, there is much uncertainty of the physiological processes, meaning that in many cases there are low chances of clinicians accurately identifying specific causes of it.2 However, zygapophyseal joint pain specifically seems to be the most common source for chronic neck pain. Three studies have shown that zygapophyseal joint pain after whiplash is the single most common basis for chronic neck pain, accounting for at least 50% of cases and occurring in up to 80% of motor-collision accident victims.5 It is also assumed that muscles, synovial joints, intervertebral disks, dura mater, and vertebral arteries are potential sources of pain due to the nature of innervation of these structures.2,5 Though rare and non-inclusive of most incidents of neck pain, there are many other tenable causes of neck pain. These could include internal carotid artery dissection, vertebral artery dissection, polymyalgia rheumatica, fibromyalgia, diffuse idiopathic skeletal hyperostosis, torticollis, paget’s disease, soft-tissue injuries, fractures and postural disorders.5 Neck pain is a major economic burden due to high usage of healthcare services, work absenteeism, and insurance. The annual prevalence of non-specific neck pain in developed countries ranges from 27%-48%.6 Surveys of workers show that the annual prevalence of activity limitations related to neck pain varies from 11% in the UK to 14.1% in Quebec, Canada.7 The high cost of non-specific neck pain for society makes optimal management a key priority. There are many treatments and interventions patients could receive to address neck pain. These may include educational videos after whiplash injury, select exercise interventions, mobilization when used with exercise, medication, acupuncture, and electromagnetic therapy/TENS.2,3 Acupuncture is shown to have both immediate and long-lasting effects on neck pain,3 but further evidence is needed to eliminate unreliability and the risk of bias.8 Exercise, manual therapies and medication are the most widely used treatment modalities in terms of non-specific neck pain.6 In terms of joint mobilization evidence as a treatment for neck pain, multiple systematic reviews have come to slightly different conclusions.2 One literature review indicates that there is moderate evidence that manual therapies improve pain and function in adults with non-specific neck pain with short-term effects of thoracic manipulation, and short-, medium-, and long-term effects of cervical manipulation when combined with electrothermal therapy.6 Regarding medication, different prescriptions are often used for chronic mechanical neck pain, including non-steroidal anti-inflammatory drugs, muscle relaxants, opiates, antidepressants, and other analgesics.2 NSAIDS and muscle relaxants, although common, do not carry enough evidence of its effectiveness and carry the side-effects of GI discomfort and drowsiness.3

The Simply Align Technique (SAT) used in this case report, developed over five years, involves the combination of three different effective modalities to help alleviate many types of pain, including neck pain. It is suggested that when performed in a certain order, it provides the most effective results for pain-relief. SAT includes the application of Tecar therapy/radiofrequency (Capacitive Resistive Electric Transfer), followed by radial extracorporeal shockwave therapy (rESWT), and low-level laser therapy (LLLT). Tecar therapy is a form of high-frequency electromagnetic energy that works by heating the tissues.9 It uses frequencies between 300 KHz and 1 MHz to stimulate self-regeneration of the body.10 Tecar therapy includes the use of both capacitive and resistive systems. The capacitive system with capacitive electrodes focuses on tissues with higher electrolyte content such as soft tissues and muscles, while the resistive system focuses on tissues such as tendons, bones and articulations.10,11 The Tecar therapy mechanism is based on the interaction of radiofrequency currents, which results in tissue temperature increase, pain relief, relaxation, increase of local blood circulation and edema reduction.12 Shockwave therapy, or ESWT (extracorporeal shockwave therapy), is a well-researched and commonly used modality to treat various conditions. It has been successfully used over the past 20 years with respect to management of orthopaedic conditions, and is widely accepted as a safe, easy and acceptable option for tendon and other musculoskeletal system pathologies.13 ESWT has been shown to induce cavitation, which increases the permeability of cell membranes and ionization of biological molecules, stimulates ATP production, modulates angiogenesis, anti-inflammatory effects, and wound-healing, and lastly promotes chondroprotective effects, neovascularization, anti-apoptosis, and tissue and nerve regeneration.14 This case report is based on the utilization of radial shockwave therapy, which is distinct from focused shockwave therapy. It may be suggested that while radial ESWT is suitable for treating large areas, focused ESWT can be concentrated deep inside the body.14 Low-level laser therapy (LLLT) is a light source treatment that has been shown in multiple studies to stimulate cell growth and regeneration, increase cell metabolism, and invoke an anti-inflammatory response. There are a variety of lasers varying from 600 nm to 900 nm wavelengths. Studies have reported changes after the use of LLLT in biochemical markers of inflammation, distribution of inflammatory cells, decreased events of edema, hemorrhage, and necrosis, and similar anti-inflammatory effects as anti-inflammatory drugs.15

Case report/History

Written consent was obtained from this patient to report the following findings. A 51-year-old female had been experiencing recent neck pain for approximately one week before seeking treatment. The apparent reason for the neck pain is working at a desk from home for prolonged periods of time behind a computer as a marketer. The neck pain started off as a tense, aching sensation, but eventually became more severe. The patient had experienced difficulties turning her head to check blind spots while driving, and had also experienced sleeping difficulties. Naproxen was prescribed by her doctor to help alleviate the pain and she was told that it could have been muscle strain. Past medical history include hypothyroidism which she takes Luvox for.  She also smokes less than a pack per day. No immediate red flags with respect to major infection, history of cancer, night pain, major trauma, signs and symptoms of CVA were identified.  Nor were there any psychosocial issues noted. Family history was also unremarkable.

Findings

At initial assessment during cervical flexion 28, extension of 12, right lateral flexion of 18, left lateral flexion of 16, right rotation of 24 and left rotation of 13 degrees were measured using an Acumar digital dual inclinometer.  All ranges were limited due to moderate-to-severe pain most noticeable during left cervical rotation. During palpation, muscle hypertonicity was noted in bilateral scalenes, suboccipitals and upper traps right more than the left.  She rated her neck pain as 8/10 on the VAS, and was diagnosed with acute cervical sprain and strain with associated ROM reduction. The Neck Disability index (NDI) of 33/50 on first was also recorded. 

Treatment

The treatment plan involved 6 sessions in total. The treatment involved the Simply Align Technique (SAT), which uses advanced healing and pain relief modalities including Tecar therapy (BTL Target Radiofrequency Elite) for 10 minutes (5 minutes of capacitive and 5 minutes of resistive electrode), shockwave therapy (Zimmer EnPulse) of 500 shots at 60 mJ, and Class 4 low-level laser therapy (Apollo Class IV laser) of 700-1000 J for 4 minutes on the cervical spine, scalenes, suboccipital and upper trapezius muscles (Fig.1) . Simple exercises such as neck extensions, flexions and rotations were used to improve range of motion. Similar treatment was performed every session. The patient was also instructed to perform daily neck rotations for 15 repetitions every few hours at home. The use of heat and ice as needed was also recommended at home.

Figure 1:  Sequence of Radio-frequency, Shockwave and Laser from left to right. 

Follow-up

Following up after one session with SAT, the patient’s pain was significantly reduced, with a report of 4/10 on the VAS. The patient experienced much better cervical rotation ROM. The patient also claimed that they are able to sleep more comfortably compared to pre-treatment. After the third session, the patient felt better again. After the fourth session, the patient felt even better, could rotate more and tolerate the treatment with less pain. After the fifth session or approximately one month follow-up, the patient reported 0/10 on the VAS, indicating no pain at all, but still had tightness on the right side of her neck while turning. After her 6th and final session (5 weeks later), the patient was pain-free and had no tightness in the neck with full ROM, flexion of 60, extension of 60, lateral flexion of 45 and rotation of 80 degrees bilaterally. According to the neck disability index, the patient had improved immensely in all categories (pain, personal care, lifting, reading, headaches, concentration, work driving, sleeping and recreation) with a score of 2/50 and VAS of 0/10. A year follow-up of the neck disability index still remained at virtually no disability at 1/50 and VAS of 1/10. 

Discussion

Although there is research supporting the individual use of Tecar, rESWT, and LLLT, there are no articles or research papers indicating the positive effects with the combined use of these three modalities. In the case of Tecar therapy, a study involving 30 patients experiencing pain and limited mobility in the cervico-cranial and cervico-brachial region, showed a significant statistical difference was displayed comparing the treatment group to the control group.12 The treatment group, which involved Tecar therapy with post-isometric relaxation exercises, showed 68.40% of trials with pain relief effects described by VAS upon palpation.12 The control group on the other hand, which received only post-isometric relaxation exercises, experienced only 29.71% of trials with pain relief.12 Greater ROM was also reported, with greater lateral neck flexion, neck extension, and cervical spine rotation ROM improvement in the treatment group.12 It is suggested that greater levels of pain relief and greater range of motion are due to greater muscle relaxation from the activation of local blood circulation and metabolic processes.12 In a meta-analysis of seven articles involving athletes with acute and chronic musculoskeletal pathologies, it was concluded that Tecar therapy is able to treat knee, shoulder, hip, ankle, spinal column, hand, and muscle injuries rapidly and efficiently, creating relief from inflammatory, osteoarticular and muscular disorders.11

With respect to ESWT it has been proven to be an effective and safe treatment with high quality RCT’s yielding statistically significant differences in both radial and focused ESWT experiencing positive outcomes compared to alternative/placebo modalities with no reports of serious detrimental effects.13 These findings demonstrate that 88.5% of all RCT’s with rESWT, and 81.5% of all RCT’S with fESWT, experienced positive outcomes in comparison to other methods.13 These were achieved with the certain conditions of plantar fasciopathy, non-calcific tendinopathy of the supraspinatus tendon, calcifying tendonitis of the shoulder, achilles tendinopathy, and lateral epicondylitis.13 Greater trochanter pain syndrome, patellar tendinopathy, achilles tendinopathy and bone nonunions were all also shown to have experienced positive effects after the use of rESWT.14 ESWT is considered to be a good alternative to surgery for tendinopathies and nonunions due to its efficacy, safety and non-invasiveness,14 making it more convenient and economical to do.

In the case of LLLT, in a meta-analysis comprised of 15 studies involving 1039 participants with lower back pain, a significant reduction of pain was shown from the use of laser treatment at short-term follow up.16 In a study by Konstantinovic and colleagues, which took 60 subjects who received a course of 15 treatments of LLLT over 3 weeks, revealed that LLLT gave more effective short-term relief of arm pain and increased range of neck extension in patients with acute neck pain with radiculopathy.15 In another study involving 28 high-level soccer athletes, pre-exercise LLLT was able to increase performance and improve biochemical markers related to skeletal muscle damage and inflammation,17 which may suggest that LLLT could be a good way to promote skeletal muscle recovery and enhance performance. Though much of the current evidence of LLLT for the treatment of neck pain is limited and inconclusive, many studies show that generally LLLT may be beneficial for individuals dealing with pain.18 The clear changes in biochemical markers related to anti-inflammatory effects also reveal why LLLT may be a good option for the treatment of neck pain.19

It is suggested here that the use of these three modalities, especially in a particular order, creates a synergistic therapeutic effect. The use of Tecar therapy could possibly benefit both rESWT and LLLT. Tecar therapy may benefit rESWT by inducing pain relief and relaxation, as rESWT may be painful and discomforting toward the patient. Tecar therapy is favoured by many patients, it feels very pleasant and could be known as the ‘feel-good’ technique of the three. Pain relief and relaxation before the rESWT shock waves are generated into the tissue may help alleviate any discomfort allowing a higher intensity to be used. Tecar therapy will also increase the local blood circulation to the injured area, inducing vasodilation and promoting oxygenation, which may enhance the effects of rESWT such as cavitation and the increase in permeability of cell membranes. Increase in local blood circulation from Tecar and increase in permeability of cell membranes from rESWT may stimulate more the cell growth, cell regeneration, and anti-inflammatory effects of LLLT. 

A key area of this case report was to explore the passive treatments of the modalities. Although SAT appears to be more passive, general range of motion can be administered during use of each modality.  Although not performed in this case, manual passive or active stretches can be done during each phase of this technique.  In addition, exercises can be followed up at home after the application of the SAT.

This study has several limitations. Due to this paper being a case report, only one participant has been observed, meaning there is no control group or randomization. This limits the generalizability of validity. The patient initially experienced acute, non-specific neck pain, implicating the patient may have potentially healed without the application of SAT or exercise, although timing would be unknown. Overtime, the active interventions done at home such as exercise could have acted as a confounding variable to the effects of the three modalities. This experiment was performed on cervical spine and one can argue that this is very expensive approach and not feasible for most small private chiropractic or physiotherapy clinics, however, SAT, in our experience, has been used throughout the day for all the major joints and musculoskeletal issues such as back pain, mild to moderate knee arthritis, anterior knee pain, chronic and acute ankle sprain, thoracic back and lower back. With respect to conditions of elbow, shoulder and hips a pneumatic shockwave is used for deeper cavitation and better results instead of Zimmer enPulse electromagnetic shockwave used here.  It is our understanding that many clinics utilize one or two of the above advanced modalities such as shockwave or laser already.  It is also our understanding and first hand experience from our trips to European countries that physiotherapists working with athletes use above modalities regularly. We have noticed that only in North America there is a lag in adopting such advance modalities in physical rehabilitation clinics.  This may be due to lack of research, price, experience, teaching institutions and pending Heath Canada or FDA approvals of such modalities. 

Some considerations for future research and use include that the replication of SAT by another practitioner may be costly as it requires having all three modalities. Combining three modalities done here makes it difficult to know which therapy is best on its own. It is also difficult to establish if one modality is superior or more applicable to another for certain locations of pain or injuries. Although significant improvements have shown both subjective and objective improvements in the past five years with SAT technique for most common MSK conditions in private clinic settings, more research is required. 

Summary

Considering that neck pain is a very common issue without a known gold standard treatment up to date new techniques are welcomed. Common neck pain treatments include exercise interventions, medication, acupuncture, manual therapy, and electromagnetic therapy/TENS. Evidence for manual therapy has mixed conclusions from many studies. Medication may not be an effective long-term solution to relieve pain, as it may not speed up the process of recovery and may have side effects such as GI upset and drowsiness. Surgery on the other hand is an option that may be a better choice depending on the severity of the condition, but is both costly and time-consuming for the patient. Advance modalities such as Tecar, Shockwave and Laser therapy and their combination (SAT) may therefore be a good option to consider. Tecar therapy helps improve blood flow and circulation to injured areas, and promote relaxation, which may help with shockwave and laser therapy. Shockwave therapy will induce cavitation, stimulate ATP production and angiogenesis. Laser therapy will reduce inflammation and stimulate cell growth and regeneration. This case report involving a 51-year-old woman revealed that the use of Tecar, Shockwave and Laser therapies in combination was extremely beneficial to her neck pain with the use of SAT. Significant results were reported at approximately one month and one year follow-up. Patient satisfaction with the treatment according to the VAS displayed a significant improvement in pain reduction, reducing the initial score of 8/10 to 0/10 after the fifth session. The patient improved in all categories of the neck disability index (pain, personal care, lifting, reading, headaches, concentration, work driving, sleeping and recreation). By the end of the sixth session, the patient has experienced significant cervical ROM improvements, and consequently, the tightness in her neck has completely disappeared. It is evident that the use of Tecar therapy, rESWT and LLLT provide a substantial positive effect on healing and reducing pain of individuals experiencing discomfort. SAT is not limited to treating only neck pain, as it could also help with many other conditions such as pain or injuries regarding the lower back, upper back, knees and etc. Further research through high quality experiments on these three modalities in combination is recommended to both demonstrate and test the optimal effects of treatment for individuals with neck pain and other common MSK issues seen in private practise. 

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