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1 ScienceDirect 66
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4 Biomedical Journal 69
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6 journal homepage: www.elsevier.com/locate/bj
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9 Original Article 75
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Comparison of the effects between lasers applied to 77
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myofascial trigger points and to classical acupoints 79
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16 for patients with cervical myofascial pain 81
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18 Q6 syndrome 83
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21 Q5 Wei-Han Chang a, Li-Wen Tu a, Yu-Cheng Pei b,c,d,e, Chih-Kuang Chen a,c, 87
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Szu-Heng Wang b, Alice MK. Wong a,e,f,* 88
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24 a
Department of Physical Medicine and Rehabilitation, Chang Gung Memorial Hospital at Taoyuan, 333, Taoyuan, 90
25 Taiwan 91
26 b
Department of Physical Medicine and Rehabilitation, Chang Gung Memorial Hospital at Linkou, 333, Taoyuan, 92
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Taiwan
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School of Medicine, Chang Gung University, 333, Taoyuan, Taiwan
29 d 95
Center of Vascularized Tissue Allograft, Chang Gung Memorial Hospital at Linkou, 333, Taoyuan, Taiwan
30 e 96
31 Healthy Aging Research Center, Chang Gung University, 333, Taoyuan, Taiwan
f 97
32 Graduate Institute of Rehabilitation Science, Chang Gung University, 333, Taoyuan, Taiwan
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35 Q1 article info abstract 101
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37 Article history: Objectives: To compare the immediate effectiveness of low-level laser therapy applied to 103
38 Received 3 December 2018 classical acupoints versus trigger points for patients with cervical myofascial pain syn- 104
39 Accepted 25 May 2020 drome (MPS). 105
40 Available online xxx Materials and methods: This was a single-blinded, randomized, placebo-controlled trial. This 106
41 107
study was performed in a university-affiliated medical center. One hundred participants
42 108
Keywords: with cervical myofascial pain syndrome were randomly allocated to four treatment groups,
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Laser therapy including (1) acupoint therapy, (2) acupoint control, (3) trigger point therapy, and (4) trigger
44 110
45 Low level laser therapy point control groups. Low-level laser (810-nm) therapy was used in both therapy groups,
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46 Myofascial pain syndrome while the same procedure was performed without laser in the control groups. The patients
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47 Acupoint were evaluated based on visual analogue scale pain score, pressure pain threshold, and
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48 Q2 Trigger point cervical range of motion before and after the therapy.
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49 Range of motion Results: Immediate pain relief was observed in the trigger point therapy group (p < 0.01). 115
50 The trigger point therapy group showed improved cervical range-of-motion in ipsilateral 116
51 bending (p < 0.01), while the acupoint therapy group did not. 117
52 Conclusions: Low-level laser therapy applied to trigger points could significantly relieve 118
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myofascial pain and was effective in relieving cervical range-of-motion limitations.
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Abbreviations: LLLT, low-level laser therapy; MPS, myofascial pain syndrome; Ga-Al-As, gallium aluminum arsenide; VAS, visual analogue scale;
58 ROM, range of motion; AcuT, acupoint therapy; AcuC, acupoint control; TriT, trigger point therapy; TriC, trigger point control. 124
59 * Corresponding author. Chang Gung Memorial Hospital at Taoyuan, No. 123, Din-Hu Rd, Chio-Lu Tswen, Kwei-Shan Shan, Taoyuan 125
60 County 333, Taiwan. 126
61 E-mail addresses: walice@adm.cgmh.org.tw, yspeii@gmail.com (A.MK. Wong). 127
62 Peer review under responsibility of Chang Gung University. 128
63 https://doi.org/10.1016/j.bj.2020.05.020 129
64 2319-4170/© 2020 Chang Gung University. Publishing services by Elsevier B.V. This is an open access article under the CC BY-NC-ND
license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Please cite this article as: Chang W-H et al., Comparison of the effects between lasers applied to myofascial trigger points and to
classical acupoints for patients with cervical myofascial pain syndrome, Biomedical Journal, https://doi.org/10.1016/j.bj.2020.05.020
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1 Considering the risk of pneumothorax, laser therapy at trigger points for patients with 66
2 cervical MPS may be a choice when acupuncture therapy is unavailable. 67
3 Trial registration: ClinicalTrials.gov ID: NCT01516502. 68
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9 Many people continue to suffer from myofascial pain syn- was calculated based on a previous article [6] with equal 74
10 drome (MPS) with regional painful muscle spasm as well as sample size in the treatment and placebo groups (n ¼ 31), 75
11 particular referred pain pattern. Focal palpable taut bands and mean ¼ 3.11/5.79 and an overall standard deviation ¼ 3.05. 76
12 tender spots with local twitch responses (called myofascial The estimated sample size was 22 in each group. Considering 77
13 trigger points (MTrPs)), are the two main clinical signs of MPS the 10% dropout rate, each group would have approximately 78
14 [1e3]. Other symptoms of MPS include range of motion (ROM) 25 subjects. The study was conducted from February 2011 to 79
15 limitation, rapid exhaustion, and referred pain [4,5]. Patients February 2012. The primary diagnosis of cervical MPS was 80
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with MPS begin with one active MTrP (called the primary based on the following criteria: (1) complaints of regional
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MTrP) in the affected muscles due to chronic repetitive minor pain in the neck, (2) presence of a palpable taut band, (3)
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muscle strain, poor posture, systemic diseases, or neuro- presence of a tender spot along the length of the taut band,
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20 musculoskeletal lesions. When not treated correctly, expan- and (4) reproduction of the clinical symptoms by compres- 85
21 sion of the pain region and additional active MTrPs (called sion of the active trigger points [3]. Patients with significant 86
22 secondary or satellite MTrPs) will develop [3,6]. If they are not clinical conditions other than MPS such as (1) cervical spine 87
23 treated effectively, the pain often recurs later [7]. lesions, radiculopathy, or myelopathy, (2) fractures or cer- 88
24 Traditional treatments for MPS include medication, vical spinal surgery, (3) cervical spinal instability, and (4) 89
25 stretching therapy, thermal treatment, electrical stimulation, cognitive deficits or psychiatric illness were excluded. The 90
26 massage, manipulation, and trigger point injection [3,7]. Hsieh study was approved by the Human Studies Research Com- 91
27 et al. [8] have demonstrated the remote effect of MTrP mittee (approval number: 200900569B0D001). The clinical 92
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needling on the referred pain and local twitch response eli- trial was registered on ClinicalTrials.gov (ID number:
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cited in the referred zone of the needling site. Ilbuldu et al. [9] NCT01516502). Written informed consent was obtained from
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applied HeeNe laser to three MTrPs in the upper trapezius each participant.
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32 muscles on both sides at 632.8 nm. They reported a significant 97
33 decrease in pain at rest and with activity, as well as an in- Equipment 98
34 crease in pain threshold in the laser group compared to dry 99
35 needling and placebo laser groups. An infrared (low-level laser, class IIIb) gallium aluminum 100
36 Low-level laser therapy (LLLT) has the benefit of being a arsenide (Ga-Al-As) diode laser device with a wavelength of 101
37 noninvasive, easy, and short-term procedure. LLLT has been 810 nm (LaserPen Expert, RJ-LASER; Reimers & Janssen GmbH, 102
38 used since the 1960s to treat neurological, musculoskeletal, Germany) and a maximum power output of 150 mW in the 103
39 and soft tissue disorders [10]. LLLT has also been used for the continuous wave mode was used for LLLT in the present 104
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treatment of neck pain since 1981 [11], and has demonstrated study. The diameter of the laser probe is 0.5 cm and its
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significant reduction of pain intensity and improvement of maximum power density is 0.76 W/cm2. The device auto-
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43 cervical ROM in patients with cervical MPS [9,12e14]. How- matically generates the frequencies and energy of a laser 108
44 ever, Chou et al. [15] report that acupuncture needling to distal beam according to the pre-determined settings of Reininger 109
45 acupuncture points could also influence the subjective pain Meridian from RL-Laser Pen of Germany (ISO 110
46 intensity and change endplate noise (EPN) amplitude in the 13485:2012 þ AC2012). The probe of the laser device was held 111
47 MTrP region of the upper trapezius muscle. In addition, some perpendicularly to and slightly contacting the skin of partici- 112
48 studies suggest that the use of LLLT on acupoints has a similar pants during the treatment process. The same device and 113
49 effect to that induced by needle acupuncture on acupoints procedure were used for all participants but no laser beam 114
50 [16e18]. In this study, we investigated the immediate effec- was emitted for the placebo treatment (control groups). 115
51 116
tiveness of LLLT application to the local MTrP and distal
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classical acupoints in patients with cervical MPS. Experimental design
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54 119
55 The study used a parallel design, in which participants were 120
56 equally allocated between the four groups. Participants were 121
57 Materials and methods randomly assigned to one of the four groups: the acupoint 122
58 therapy (AcuT) group, the acupoint control (AcuC) group, the 123
59 Subjects trigger point therapy (TriT) group, and the trigger point control 124
60 (TriC) group. We used a sequence generated by a computer 125
61 We (rehabilitation doctors) enrolled participants who were randomization program (from another core laboratory) to 126
62 diagnosed with cervical MPS of the upper trapezius muscles. ensure a balanced group assignment. A single-blinded design 127
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The sample size was estimated by the software, G-power. We was used in which the allocation was blinded to the partici-
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selected the one-way ANOVA test and gave an alpha pant and physician, but not to the therapist and statistician.
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error ¼ 0.05 and a statistical power ¼ 0.8. The effect size (0.51) Allocation concealment was achieved using sealed envelopes.

Please cite this article as: Chang W-H et al., Comparison of the effects between lasers applied to myofascial trigger points and to
classical acupoints for patients with cervical myofascial pain syndrome, Biomedical Journal, https://doi.org/10.1016/j.bj.2020.05.020
 BJ310_proof ■ 18 June 2020 ■ 3/9

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33 Fig. 1 Acupoint and trigger point. The application of low-level laser therapy on acupoints (A, B, C, D) used in acupoint therapy 98
34 group and proximal (E) or distal (F) trigger points used in trigger point therapy group. 99
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39 All participants eligible to participate were assessed by the For the TriT and TriC groups, participants were asked to 104
40 same physician and treated by the same therapist. The indicate the point of maximal pain in the affected posterior- 105
41 physician conducted the processes of participant enrollment, neck and upper-back regions. The most reliable and the 106
42 allocation, and assessments. Before the treatment, partici- minimal diagnostic criteria for myofascial trigger points of 107
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pants' health information and baseline measurements upper trapezius muscles include: (1) spot tenderness; (2) taut
44 109
including demographic data, affected side, and pain charac- band; and (3) pain recognition. Confirmatory criteria include:
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teristics were recorded by the physician. The therapist, (1) referred pain; and (2) local twitch response [21]. The
46 111
47 licensed to practice acupuncture and operating the low-level physician checked the point according to the diagnostic 112
48 laser machine, was responsible for the localization of acu- criteria and then marked it with a pen. The major locations of 113
49 points in the AcuT and AcuC groups and the application of the trigger point were illustrated in Fig. 1 (E and F). In the TriT 114
50 LLLT in all four groups. group, the laser frequency for the trigger point was 583 Hz (the 115
51 For the AcuT and AcuC groups, we selected the following same frequency to the Gb meridian). LLLT was applied to the 116
52 four acupoints on the affected side: Shousanli (Large Intestine trigger point for 160 s so that the total energy density was 8 J/ 117
53 Meridians, LI 10), Hegu (Large Intestine Meridians, LI 4), Wai- cm2. The study design reflected our attempt to make the total 118
54 guan (Sanjiao Meridians, TE 5), and Houxi (Small Intestine dosages for the AcuT and TriT groups equal (8 J/cm2), even 119
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Meridians, SI 3), which are commonly used in the treatment of though no evidence yet indicates that the effect of LLLT is
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cervical MPS [19,20] [Fig. 1. A, B, C, D]. Note that the four proportional to its total energy.
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58 acupoints are distal and distant from the cervical region. In 123
59 the AcuT group, LLLT was applied to the four aforementioned Outcome measurements 124
60 acupoints ipsilateral to the point of maximal pain. The laser 125
61 frequencies for each acupoint were 553 Hz in LI Meridians, We examined the immediate effects of LLLT using a before- 126
62 791 Hz in SI3 and 731 Hz in TE5. At each acupoint, the laser after design in which the clinically relevant measurements 127
63 was applied for 40 s, so that the energy density applied to each 128
were evaluated before and 15-min after laser application. The
64 acupoint was 2 J/cm2 (the total energy density of the four 129
outcome measurements, which included objective pain
65 acupoints: 8 J/cm2). 130
scores using the visual analogue scale (VAS), pressure pain

Please cite this article as: Chang W-H et al., Comparison of the effects between lasers applied to myofascial trigger points and to
classical acupoints for patients with cervical myofascial pain syndrome, Biomedical Journal, https://doi.org/10.1016/j.bj.2020.05.020
 BJ310_proof ■ 18 June 2020 ■ 4/9

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36 Fig. 2 Flow diagram of this study. Flow diagram for participant enrollment, allocation, follow-up, and analysis (following the 101
37 CONSORT guideline). AcuT, acupoint therapy group; AcuC, acupoint control group; TriT, trigger point therapy group; TriC, 102
38 trigger point control group. 103
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43 threshold at the trigger point, and cervical ROM, were per- the following formula: (before treatment value e after treat- 108
44 formed by the same physician. ment value)/before treatment value. The median change ra- 109
45 We evaluated the pressure pain threshold of the trigger tios among the groups were compared using the 110
46 point using an algometer (Wagner Instruments, USA), KruskaleWallis test; post-hoc pair-wise comparisons were 111
47 112
following the procedure of pressure pain threshold measure- performed using the Dunn's test. Statistical significance was
48 113
ment proposed by Fischer [22]. The threshold was determined defined as p < 0.05.
49 114
50 as the mean of the two last values out of three consecutive 115
51 measurements, with a 10 s pause in between. 116
52 Active cervical ROM for three motion planes, including 117
Results
53 flexion-extension, bending, and rotation, were measured 118
54 with the MicroFET3 electrogoniometer (Hoggan Health In- 119
55 We enrolled 121 participants and twenty-one participants 120
dustries, USA).
56 were excluded due to the lack of a palpable taut band despite 121
57 the tenderness of their upper trapezius muscles. One hundred 122
58 participants were analyzed in total (25 participants in each 123
59 Calculation group) and all participants completed the entire study [Fig. 2]. 124
60 (Consolidated Standards for Reporting Trials, CONSORT) Their 125
61 The statistical analysis was conducted by a statistician using ages ranged from 20 to 65 years (median, 25th~75th percen- 126
62 intention-to-treat analysis. The baseline and demographic tiles: 32.0, 27.3e40.0 years). No adverse side effects were noted 127
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characteristics were analyzed with the chi-square test for in the process of laser therapy. There was no difference be-
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categorical data, and with the KruskaleWallis test for non- tween the four groups in terms of their demographic data
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parametric data. The change ratios were calculated using [Table 1]. Comparisons of the baseline ROM between the four

Please cite this article as: Chang W-H et al., Comparison of the effects between lasers applied to myofascial trigger points and to
classical acupoints for patients with cervical myofascial pain syndrome, Biomedical Journal, https://doi.org/10.1016/j.bj.2020.05.020
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Table 1 The demographic data and baseline evaluation〈number or median (25th-75th percentiles)〉for the four groups.
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3 Data AcuT (n ¼ 25) AcuC (n ¼ 25) TriT (n ¼ 25) TriC (n ¼ 25) p value 68
4 Gender (female/male) 23/2 22/3 21/4 22/3 0.59 69
5 Age (year) 31.0 (26.5e40.0) 35.0 (26.5e40.5) 33.0 (27.0e42.0) 32.0 (28.0e35.5) 0.90 70
6 Body height (cm) 159.0 (156.0e163.0) 159.0 (157.0e164.0) 159.0 (156.0e163.5) 161.0 (153.0e164.0) 0.75 71
7 Body weight (kg) 56.0 (50.0e63.0) 56.0 (52.5e66.0) 57.0 (54.5e68.0) 55.0 (50.0e61.0) 0.55 72
8 Disease Duration (month) 2/2/21 5/1/19 2/3/20 5/3/17 0.64 73
9 (1/2/>3 months) 74
10 Painful side (right/left/bilateral) 8/2/15 3/7/15 4/6/15 9/4/12 0.25 75
11 Pain VAS 5.8 (3.6e6.8) 5.0 (3.3e6.7) 6.0 (4.8e7.2) 5.7 (3.8e6.9) 0.72 76
12 Pressure pain threshold (kg/cm2) 1.3 (1.2e2.1) 1.5 (1.2e2.2) 1.5 (1.3e2.3) 1.4 (1.0e2.0) 0.50 77
13 Flexion ROM ( ) 54.0 (40.5e60.0) 48.0 (39.0e63.5) 50.0 (38.5e57.5) 48.0 (43.0e58.5) 0.95 78
14 Extension ROM ( ) 60.0 (48.5e70.0) 55.0 (48.0e65.0) 50.0 (43.5e59.0) 60.0 (50.0e68.0) 0.14 79
15 Ipsilateral bending ROM ( ) 42.0 (37.5e46.0) 38.0 (31.5e48.0) 36.0 (29.0e41.5) 42.0 (37.0e46.0) 0.03* 80
16 Contralateral bending ROM ( ) 42.0 (36.0e45.0) 38.0 (30.5e46.5) 37.0 (28.0e42.0) 40.0 (36.5e45.5) 0.13 81
17 Ipsilateral rotation ROM ( ) 80.0 (64.5e86.0) 80.0 (70.0e85.0) 75.0 (58.5e82.0) 78.0 (70.5e83.0) 0.47 82
Contralateral rotation ROM ( ) 79.0 (66.5e88.5) 79.0 (71.5e86.0) 78.0 (62.0e87.5) 78.0 (69.5e85.5) 0.98
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19 All data are presented as number or median (25th-75th percentiles). Abbreviations: F, female; M, male. AcuT, acupoint therapy group; AcuC, 84
20 acupoint control group; TriT, trigger point therapy group; TriC, trigger point control group; VAS, visual analogue scale; ROM, range of motion. 85
21 * p < 0.05. 86
22 87
23 88
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groups showed that ROM was comparable across the groups
25 Discussion 90
26 for most types of contralateral bending, extending, flexing, 91
27 and bilateral rotating. However, we noticed differences in 92
baseline ROM for ipsilateral bending (p ¼ 0.03) between the In this randomized, single-blind, placebo-controlled study, we
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29 four groups, and the post-hoc test showed a significant dif- evaluated the use of LLLT (using an 810-nm, 150-mW laser) 94
30 ference (p ¼ 0.04) between the AcuT (42.0, 37.5e46.0) and TriT applied to acupoints and trigger points for the management of 95
31 (36.0, 29.0e41.5) groups. cervical MPS. The pain VAS and some types of cervical ROM 96
32 The KruskaleWallis test showed that the relative change immediately improved in the trigger point group. Moreover, 97
33 in VAS (p < 0.01) and ROM (p < 0.01) scores for ipsilateral trigger point therapy was also effective for improving ipsilat- 98
34 eral cervical bending ROM and rotation ROM. In most of the 99
bending and ipsilateral rotation induced by LLLT differed
35 studies on LLLT and cervical MPS, trigger points were chosen 100
significantly across the four groups, while changes in the
36 as the application area for LLLT [13,14,23]. Some studies 101
37 other measurements, including pressure pain threshold, 102
ROM in cervical flexion, extension, contralateral bending and evaluated the application of laser therapy to acupoints [24] or
38 103
contralateral rotation, did not differ significantly among the to both trigger points and acupoints [25] for cervical MPS. To
39 104
four groups (p > 0.05) [Table 2]. We then performed post-hoc the best of our knowledge, there is no existing work that
40 105
41 analysis to compare the relative change in VAS between compares the effectiveness of LLLT on trigger points and 106
42 groups using the Dunn's test [Fig. 3]. For pain relief after LLLT traditional acupoints. This study is the first to compare the 107
43 of acupoint and trigger point, results showed that the change effects between LLLT application to trigger points and to 108
44 in VAS differed significantly between the TriT (0.40, acupoints with the same total laser dosage. The rationales for 109
45 choosing distal acupoints rather than local acupoints are as 110
0.25e0.56) and the AcuC (0.13, 0.00e0.38) groups (p ¼ 0.03), as
46 follows: (1) The distal acupuncture has been proven effective 111
well as between the TriT (0.40, 0.25e0.56) and TriC (0.17,
47 for relieving cervical myofascial pain [15,26,27]. (2) Local acu- 112
0.06e0.32) groups (p ¼ 0.04) [Table 2]. There was a possible
48 points such as SI15 and GB21 may be near to the trigger points 113
49 trend toward significance in the change in VAS between 114
AcuT and AcuC groups (p ¼ 0.08). There was no significant of the posterior-neck and upper-back regions, which may
50 115
confound the comparison of the treatment outcome between
51 difference in VAS between AcuT and TriT group pairs 116
52 (p > 0.05), indicating the comparable effectiveness of pain acupoint and trigger point groups. 117
53 relief from applying LLLT to trigger points. The efficacy of LLLT for pain reduction had been demon- 118
54 Post-hoc analysis for ROM in ipsilateral bending showed strated by meta-analysis and systemic reviews [28,29]. The 119
55 significant differences (p < 0.01) between the TriT (0.16, systemic effects of laser, including altering the endogenous 120
56 0.25~0.04) and TriC (0.05, 0.08e0.01) groups, indicating analgesic mediators [30,31] and reducing afferent nociceptive 121
57 input to the central nervous system (CNS) [16,17], have been 122
that only LLLT to trigger points improved ipsilateral bending.
58 reported. The systemic analgesic effect of LLLT does not fully 123
Post-hoc analysis for ROM in ipsilateral rotation showed sig-
59 account for the effect of specific distal acupoint on pain relief 124
60 nificant differences (p < 0.01) between the TriT (0.08, 125
0.12~0.03) and AcuC (0.02, 0.04e0.04) groups, implying for MPS. Laser acupuncture is assumed to share similar effects
61 126
that LLLT to trigger points was possible superior for improving with needle acupuncture [32], as proven by some studies
62 127
reporting that laser acupuncture generates comparable
63 ipsilateral rotation. 128
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Please cite this article as: Chang W-H et al., Comparison of the effects between lasers applied to myofascial trigger points and to
classical acupoints for patients with cervical myofascial pain syndrome, Biomedical Journal, https://doi.org/10.1016/j.bj.2020.05.020
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1 effects in modulation of CNS activation to needle acupuncture 66

p value post hoc

Change ratio ¼ (before e after)/before. Abbreviations: AcuT, acupoint therapy group; AcuC, acupoint control group; TriT, trigger point therapy group; TriC, trigger point control group; VAS, visual
bc*,cd*
2 [18,33]. Moreover, Litscher et al. found that laser irradiation of 67

cd**

bc**
3 four visual-associated acupoints on limbs (LI4, ST36, Bl60 and 68
4 Bl67) induced an increase signal in the visual cortex when 69
5 70

<0.01**

<0.01**

0.03 (0.07e0.01) <0.01**

visualized with functional magnetic resonance imaging [18];
6 71

0.19

0.19
0.76

0.37

0.02 (0.04e0.01) 0.39

Lorenzini et al. revealed that laser irradiation to acupoints
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associated to pain and inflammation (ST36 and TE5) reduced
8 73

(0.11e0.03)
(0.07e0.00)
(0.08e0.01)
(0.11e0.02)
Change ratioa

0.00 (0.15e0.10)
9 edema, hyperalgesia and spontaneous pain [34]; Erthal et al. 74
0.17 (0.06e0.32)

10 reported that laser irradiation to ST36 elicited the anti- 75

11 nociceptive effect mediated by activation of the opioidergic 76
12 and serotonergic systems [35] and produced an anti- 77
0.05
0.04
0.05
0.05
13 inflammatory effect by reduction of inflammatory mediators 78
TriC

14 [36]. LLLT may actually stimulate the acupoints and thus 79

After treatment

52.0 (45.5e60.0)
62.0 (52.0e70.0)
44.0 (38.0e48.0)
44.0 (38.0e48.0)

80.0 (74.5e86.0)
80.0 (72.5e85.0)
15 induce the therapeutic effects of the specific acupoints. Taken 80
16 81
4.7 (2.6e6.2)
1.4 (1.1e1.7)

together, these studies suggest the possible mechanism of

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LLLT on distal acupoints for treatment of MPS.
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Many studies have demonstrated positive effects from
19 84
20 LLLT application to trigger points in terms of reduction of 85
(0.13e0.00)
(0.14e0.01)
(0.25e0.04)
(0.24e0.03)

0.08 (0.12e0.03)
0.03 (0.08e0.00)

21 pain intensity, alleviation of muscle stiffness, and 86

Change ratioa

0.05 (0.13e0.19)
0.40 (0.25e0.56)

22 improvement of disability scale [9,12e14]. Moreover, a 87

Table 2 Comparison of treatment results〈change ratios, median (25th-75th percentile)〉between the four groups.

23 double-blind placebo-controlled trial in which a pulsed 88

24 infrared beam was applied to the four most painful muscular 89
0.09
0.06
0.16
0.11

25 trigger points and five bilateral homometameric acupoints 90

26 91
TriT

for treatment of cervical MPS showed significant pain

27 92
After treatment

attenuation in the treated group both at the end of therapy

52.0 (42.5e61.0)
53.0 (47.0e65.5)
40.0 (34.5e44.5)
38.0 (34.5e43.5)

80.0 (67.5e85.0)
82.0 (66.0e92.0)

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and in the 3-month follow-up examination [25]. According to
3.3 (2.4e4.6)
1.5 (1.2e2.3)

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our results, the effect of LLLT trigger point application
30 95
seemed similar to acupoint application for pain reduction
31 96
32 and improvement of cervical ROM in patients with cervical 97
33 MPS, but only LLLT trigger point application significantly 98
0.07 (0.28e0.03)

(0.20e0.02)
(0.10e0.01)
(0.25e0.02)
(0.21e0.00)

0.02 (0.04e0.04)
0.02 (0.04e0.02)
Change ratioa

34 improved pain and cervical ROM compared to the control 99

0.13 (0.00e0.38)

35 group. Local effects on the affected muscle might account for 100
36 the superiority of LLLT trigger point application. A study for 101
37 chronic myofascial pain syndrome stated that LLLT inhibi- 102
0.06
0.03
0.11
0.11

38 ted vasodilation and thus improved local circulation and 103

AcuC

39 reduced edema [13]. Another possible mechanism of LLLT on 104

After treatment

40 105
50.0 (45.5e68.0)

80.0 (70.0e84.5)
62.0 (49.0e65.0)
40.0 (36.5e48.5)
42.0 (36.5e49.0)

77.0 (74.0e85.5)

local muscle tissue is the reduction of oxidative stress and

analogue scale; ROM, range of motion; bc: AcuC vs. TriT; cd: TriT vs. TriC.

41 106
3.3 (2.5e5.6)
1.6 (1.3e2.3)

skeletal muscle fatigue. Studies have shown that laser irra-

42 107
43 diation before exercise can delay the onset of muscle fatigue 108
44 and accelerate muscle recovery because LLLT inhibited the 109
45 exercise-induced increase in creatine kinase and acceler- 110
46 ated the removal of lactate [37,38]. The local effects of LLLT, 111
0.08 (0.26e0.05)

(0.23e0.03)

0.03 (0.06e0.01)
(0.01e0.02)
(0.15e0.03)
(0.20e0.05)

0.03 (0.07e0.02)
Change ratioa

47 including the improvement of local circulation and reduc- 112

0.38 (0.20e0.56)

48 tion of muscle fatigue, may enhance the flexibility and 113

49 contraction of the affected upper trapezius muscle. These 114
50 mechanisms could explain the improvement of cervical 115
0.13
0.03
0.08
0.08

51 116
AcuT

ROM in patient with trigger point LLLT.

52 117
Numerous articles have reported conflicting results for
After treatment

53 118
57.0 (54.0e66.0)
62.0 (53.0e69.0)
44.0 (41.0e50.0)
46.0 (41.5e51.0)

78.0 (74.5e86.5)
81.0 (69.0e90.5)

LLLT application to acupoints to reduce pain in treatment of

54 119
3.1 (1.7e5.4)
1.5 (1.2e2.0)

55 temporomandibular joint disorder, lateral epicondylitis, low 120

56 back pain, knee osteoarthritis, and MPS [39e47]. The incon- 121
57 sistent effectiveness may be caused by variation in patient 122
58 groups, treatment protocols, laser therapy parameters, and 123
* p < 0.05; ** p < 0.01.
Ipsilateral bending

Ipsilateral rotation

59 duration of follow-up [48,49]. Among these studies, only one 124

60 article actually applied LLLT to acupoints to treat MPS and 125
Pressure pain

Contralateral

Contralateral

61 126
threshold

compare the effectiveness between treatment and placebo

bending

rotation
Extension

62 127
Pain scale

[24]. The researchers found no significant difference between

Flexion

63 128
groups. The result seemed to be analogous to our study but
VAS

64 129
ROM

further studies are needed to determine the effectiveness of

65 130
a

LLLT on acupoints for pain reduction in MPS.

Please cite this article as: Chang W-H et al., Comparison of the effects between lasers applied to myofascial trigger points and to
classical acupoints for patients with cervical myofascial pain syndrome, Biomedical Journal, https://doi.org/10.1016/j.bj.2020.05.020
 BJ310_proof ■ 18 June 2020 ■ 7/9

biomedical journal xxx (xxxx) xxx 7

1 66
2 67
3 68
4 69
5 70
6 71
7 72
8 73
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10 75
11 76
12 77
13 78
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17 82
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22 87
23 88
24 Fig. 3 Boxplot. The boxplots of change ratios between different groups for each outcome measurement. The median, 25th and 89
25 75th percentiles, and the significance of the post-hoc analysis in outcome measurement is shown for each of the four groups. 90
26 AcuT, acupoint therapy group; AcuC, acupoint control group; TriT, trigger point therapy group; TriC, trigger point control group. 91
27 * p < 0.05; ** p < 0.01. Q7 92
28 93
29 94
30 95
31 96
32 Acupuncture therapy has been widely used to treat pa- relief from cervical MPS, while the sham laser did not have 97
33 tients for more than 2500 years. In addition to classical and this effect. Significant pain improvement was noted only after 98
34 extraordinary acupoints, Ashi point was described by an LLLT was applied to MTrP. Pain relief occurred 15 min after a 99
35 ancient Chinese physician, Dr. SM Sun (AC 584e682). When single treatment and relieved cervical ROM limitations for 100
36 patients feel a strong withdrawal response (the jump sign) to ipsilateral bending. Considering the risk of pneumothorax, 101
37 palpation of such a hyperirritable point, they respond by laser therapy at MTrP for patients with cervical MPS may be a 102
38 103
saying “Ashi yes, this is the trigger point.” Ashi points have the choice when acupuncture therapy is unavailable.
39 104
extremely similar characteristics and locations that as the
40 105
trigger points associated with myofascial pain syndrome
41 106
42 (MTrP) [6,50,51], but were discovered independently and Authors' contributions Q3 107
43 labeled differently [6,52]. Kawakita & Okada [53] found that 108
44 polymodal receptors are the key to pain control when LW Tu conducted the experiment, WH Chang, LW Tu, YC Pei, 109
45 acupuncture and moxibustion are applied to the acupoint/ and CK Chen performed analysis, WH Chang, YC Pei and AMK 110
46 trigger points. Wong designed the experiment, WH Chang, LW Tu, Tzu-Ling 111
47 Our study has some limitations. We excluded participants 112
Chang and AMK Wong wrote the manuscript.
48 with cervical spine lesions, radiculopathy, or myelopathy. 113
49 Imaging data was not obtained to confirm the diagnosis. The 114
50 115
present study did not focus on the long-term effects of LLLT
51 Formatting of funding sources 116
and therefore the results can only be applied to the immediate
52 117
53 effects of LLLT. Also, the dosage effect of LLLT to distal acu- 118
This research was supported in part by the Chang Gung
54 points needs to be addressed in future researches. 119
Medical Foundation (Grant Numbers CMRPG5E0081~83), and
55 by Healthy Aging Research Center and the Taiwan Ministry of 120
56 Education's Higher Education Deep Plowing Program (Grant 121
57 122
Conclusion Numbers EMRPD1K0391 and EMRPD1K0481). Grants provide
58 123
personnel and consumables and the support for data analysis.
59 124
60 This study demonstrates that the Ga-Al-As laser (with a The funders had no role in study design, data collection and 125
61 wavelength of 810 nm and a maximum power output of analysis, decision to publish, or preparation of the 126
62 150 mW) is an effective therapeutic option for immediately manuscript. 127
63 128
64 129
65 130

Please cite this article as: Chang W-H et al., Comparison of the effects between lasers applied to myofascial trigger points and to
classical acupoints for patients with cervical myofascial pain syndrome, Biomedical Journal, https://doi.org/10.1016/j.bj.2020.05.020
 BJ310_proof ■ 18 June 2020 ■ 8/9

8 biomedical journal xxx (xxxx) xxx

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6 [17] Tsuchiya K, Kawatani M, Takeshige C, Sato T, Matsumoto I. 71
benefit on us or on any organization with which we are
7 Diode laser irradiation selectively diminishes slow 72
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8 component of axonal volleys to dorsal roots from the 73
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classical acupoints for patients with cervical myofascial pain syndrome, Biomedical Journal, https://doi.org/10.1016/j.bj.2020.05.020
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Please cite this article as: Chang W-H et al., Comparison of the effects between lasers applied to myofascial trigger points and to
classical acupoints for patients with cervical myofascial pain syndrome, Biomedical Journal, https://doi.org/10.1016/j.bj.2020.05.020