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Effect of Low Level Laser Therapy in Type II Diabetes Mellitus Complicated With
Tarsal Tunnel Syndrome.

Article  in  International Journal of Health and Rehabilitation Sciences (IJHRS) · January 2017

DOI: 10.5455/ijhrs.0000000125

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 ORIGINAL RESEARCH
LOW LEVEL LASER THERAPY IN TYPE II DIABETES MELLITUS

Effect of Low Level Laser Therapy in Type II

Diabetes Mellitus Complicated With Tarsal
Tunnel Syndrome.
Hala Mohamed Ezz El Dein, Marriam E.M,Abd El Aal. Mohei Eldin
Tharwat Mohamed, Asmaa Embaby Ameen Swelim.

Hala Mohamed Ezz El

Dein, Prof. Department of
ABSTRACT
Physical Therapy for Diabetic neuropathies are a family of nerve disorders either subclinical or
Cardiopulmonary Disorders and clinically evident that occurs in both peripheral nervous systems with Type II
Geriatrics. Faculty of Physical
Therapy, Cairo University, Egypt diabetes. Currently, Physical therapy treatment by Low Level Laser Therapy
(LLLT) effective in decreasing symptoms or even reversing the progress of
Marriam E.M, AbdEl
Aal. Prof., Department of Tarsal Tunnel Syndrome (TTS). The purpose of this study was to investigate
Physical Therapy for the influence of the LLLT on the symptoms, Neurophysiological study and
Cardiopulmonary Disorders and
Geriatrics, Faculty of Physical visual analog scale (VAS) in Diabetic Type II patients with TTS. Thirty
Therapy, Cairo University, Egypt. diabetic patients had TTS aged 40-60 years were received LLLT program.
Faculty of medicine, Al Azhar
University. Egypt Neurophysiological study and VAS measured before, and after 12 weeks of
LLLT and analyzed motor and sensory (latency and amplitude). Distal latency
Mohei Eldin Tharwat
Mohamed, Dr. Egypt. Faculty
was significantly decreased, amplitude increased and VAS improved after
of medicine –Al Azhar LLLT sessions. It was concluded that LLLT influences the symptoms of TTS
University. New Cairo hospital.
Egypt
as a complications of type II diabetes mellitus.
Asmaa Embaby Ameen Key Words: Low Level Laser Therapy, Neurophysiological study, Visual Analog
Swelim. scale, Diabetes mellitus type II, Tarsal Tunnel syndrome.
Department of Physical Therapy for
Cardiopulmonary Disorders
Corresponding Author:
Asma Embaby Ameen Swelim.
E-mail:
ahmedesmat81@yahoo.com

DOI:
10.5455/ijhrs.0000000125

91 Jun 2017 International Journal of Health and Rehabilitation Sciences Volume 6 Issue 2
 LOW LEVEL LASER THERAPY IN TYPE II DIABETES MELLITUS

diffuse symmetrical nature of the

INTRODUCTION common forms of neuropathy implies
Diabetes mellitus (DM)
a metabolic cause since hyperglycemia
commonly referred to one of the most
leads to increase formation of sorbitol
common endocrine diseases with high 4
.
1
costs worldwide . Type II diabetes is
Nerve compression syndrome or
typically a chronic disease associated
compression neuropathy, also known
with a ten-year-shorter life expectancy
as entrapment neuropathy, is a medical
2
. Diabetes affects different
condition caused by direct pressure on
components of the peripheral nervous
a single nerve. It is known colloquially
system. Isolated involvement of the
as a trapped nerve, though this may
peripheral nerves of the limbs occurs
also refer to nerve root compression
in diabetic patient and it is difficult to
(by a herniated disc) 5.
know whether this is a manifestation of
Tarsal tunnel syndrome (TTS),
increase liability to pressure palsy in
known as posterior tibial neuralgia, is
common sites of nerve entrapment in
a compression neuropathy and painful
these patient or a specific diabetic
foot condition in which tibial nerve
3
neuropathy .
and its brunches as well as the extrinsic
Diabetes can damage peripheral
flexor tendons of foot and ankle is
nervous tissue in number of ways,
compressed as it travels through the
vascular hypothesis postulate
tarsal tunnel between the medial
occlusion of the vasa nervorum as the
malleolus and the calcaneus 6.
prime cause this seems likely in
isolated mono-neuropathies, but the Affected individuals may describe a

radiating pain that cannot be localized to one

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 LOW LEVEL LASER THERAPY IN TYPE II DIABETES MELLITUS

spot. In addition to or instead of pain, affected Radiation), Low Level Laser is a form of

individuals may experience(asleep) laser medicine that uses low-power lasers

numbness of the affected area (dead feeling) less than 60 mw or light-emitting diodes used

in the feet (the most common complaints) or in physical therapy to alter cellular function
10
a burning( deep aching ) or tingling pricking .

sensation (paresthesia), which is often Low-level laser therapy is perfect simple

described as similar to “pins and needles” 7. and non-invasive treatment to help nerves to heal

Symptoms of tarsal tunnel syndrome are quickly and function better in TTS. It promotes

often worsened by activity such as prolonged microcirculation in the irradiated area, increases

standing or walking. Consequently, pain may nerve functional activity and rate of axon

worsen throughout an active day and relieved growth myelination, improves regeneration

by rest. However, as the disorder progresses, of injured nerve and increase release of

some affected individuals have reported pain endorphins 11.

that occurs during rest or at night when Therefore, this study aimed to investigate

attempting to sleep 8. efficacy of LLLT on neurophysiological

A specific finding that can detect an measures, symptoms and pain in type II

irritated nerve is Tinel’s sign. During a diabetic with TTS.

Tinel’s sign test, a doctor will tap or apply

Method and Materials
Subjects characteristics and general
pressure to the tibial nerve. If this causes a
experimental design
tingling or a “pins and needles” sensation in
Study subjects: Thirty patients had type
the foot or toes, it is considered positive and
II diabetes for at least 5 years prior this study,
is indicative of tarsal tunnel syndrome 9.
complained with TTS were selected
Laser is abbreviation of (Light randomly from physical therapy outpatient
Amplification by Stimulation Emission of clinic in New Cairo hospital and assigned to

93 Jun 2017 International Journal of Health and Rehabilitation Sciences Volume 6 Issue 2
 LOW LEVEL LASER THERAPY IN TYPE II DIABETES MELLITUS
pre-post experimental group. Blood glucose
level was around (fasting above 120 mg/dl –
postprandial above 180mg/dl), rated their
pain at 30 or more on a 100-point pain VAS.
Participants were diagnosed as TTS, failed
one month of medical treatment, free from
(malignant lesion, unstable glycemic control,
renal or hepatic disease, thyroid disease,
Epileptic seizures). Non-pregnant, non-
alcoholic or history of drug abuse had no any
photosensitive medication or active
hemorrhage and wound healing. Their age
ranged from 40 to 60 years and did not
received any physical therapy program
before they participate in the study.
Evaluated parameters
Visual Analog Scale (VAS) all
measurements were conducted
before and after 12 weeks of therapy by
LLLT. The patient was given a 10-cm line
and asked to draw on the line (intensity of
pain he was feeling). The left end of the line
represented “no pain at all,” and the right end
of the line represented the “worst pain you
can imagine.” The patient’s mark on the line
was measured (in centimeters) with a ruler 12.
94 Jun 2017 International Journal of Health and Rehabilitation Sciences
Measurements of
neurophysiological parameters are
tested for both sensory and motor nerves at
different locations. Electrical impulses are
sent through nerve, speed and intensity at
which they travel were measured. If there is
compression in the tunnel, this can be
confirmed and pinpointed with this test 13.
Sensory conduction velocity of the
medial and lateral plantar nerves were best
done by recording from the tibial nerve just
above the flexor retinaculum and stimulated
14.
nerves at vault of the foot Motor
conduction velocity was recorded of distal
motor latency at the abductor halluces brevis
muscle. Active electrode (A) placed over the
medial foot, anterior and inferior to the
navicular tubercle. Reference electrode (R) is
slightly distal to the 1stmetatarsophalangeal
joint, on the medial surface of the joint.
Ground electrode (G) is over the dorsum of
the foot 15.
All participants were received sessions under
supervision and assessed before and after
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 LOW LEVEL LASER THERAPY IN TYPE II DIABETES MELLITUS
study. The study procedures were carried out
at outpatient Clinic of the New Cairo
Hospital, Cairo. All subjects were free to
withdraw from the study at any time. All
participants signed an informed consent after
receiving a detailed explanation of the study.
The ethics committee of research in Faculty
of Physical Therapy, Cairo University
approved the study. The data of all the
participants were available for analysis.
Detailed Low Level Laser protocol was as
follow:
Low Level Laser Therapy protocol:
For the entire LLLT session, all participants
had to adhere to identical LLLT protocol.
Laser probe was applied along its course
which started from the proximal border of the
flexor retinaculum in the midline for 3 points
proximally, then passed distally for another 2
points across the retinaculum with lateral
division of the tibial nerve behind medial
malleolus (1 cm between each successive two
points) the application was 5 points each
95 Jun 2017 International Journal of Health and Rehabilitation Sciences
point received 120 second, time of all session
10 minutes.
Statistical Analysis
Descriptive statistics was conducted for age,
weight, height, BMI, and duration of
diabetes. Paired t test was conducted for
comparison between pre and post treatment
mean values of VAS, motor and sensory
conduction velocity (distal latency and
amplitude). Level of significance for all
statistical tests was set at p < 0.05.
RESULT
Thirty patients participated in this pre –post
experimental group. Their mean ± SD age,
weight, height, and BMI were 51.5 ± 6.63 years,
86.9 ± 13.12 kg, 171.76 ± 5.69 cm, and 29.41 ±
3.79 kg/m² respectively. The mean duration of
diabetes was 17.9 ± 5.39 years. (Table 1). The
study involved thirty patients had type II diabetes
complained with TTS. As shown in (Table 2)
mean values of VAS showed significant decrease
in VAS post treatment compared with that
pretreatment (p = 0.0001) the mean difference
between pre and post treatment was 3.83 and the
percent of change was 45.27%. Also as in (Table
2) there was a significant decrease in the motor
distal latency post treatment compared with that
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 LOW LEVEL LASER THERAPY IN TYPE II DIABETES MELLITUS

pretreatment (p = 0.0001), the mean difference Table 2: mean difference between pre and post
treatment and the percent of change
between pre and post treatment was 1.57 msec
 ±SD
%of t-value p-value
and the percent of change was 23.39% change
respectively shown in (Table 2). While there was Pre Post
treatment treatment
a significant decrease in the sensory peak distal 8.46 ±
VAS 4.63 ± 1.73 45.27 12.62 0.0001**
1.19
latency post treatment compared with that
Motor
pretreatment (p = 0.0001), the mean difference distal
6.71 ± 0.87 5.14 ± 0.9 23.39 7.24 0.0001**
latency
between pre and post treatment was 1.35 msec (msec)
and the percent of change was 29.67 %.( Table 2). Sensory
peak distal
4.55 ± 0.5 3.2 ± 0.29 29.67 11.24 0.0001**
latency
Table 1. Descriptive statistics of the mean age, (msec)
Motor
weight, height, BMI, and duration of diabetes of the amplitude 2.55 ± 0.6 4.05 ± 0.46 58.82 -9.74 0.0001**
experimental group. (mV)
Minim Maximu Rang Medial
 ±SD um m e
planter
6.05 ± 3.23 15.13 ± 3.54
150.0
-13.13 0.0001**
amplitude 8
Age 51.5 ± (mV)
(years) 6.63 40 63 23 Lateral
planter 194.1
Weight 86.9 ± amplitude
4.26 ± 1.98 12.53 ± 1.63
3
-15.36 0.0001**
(kg) 13.12 68 120 52
(mV)
Height 171.76
(cm) ± 5.69 160 180 20
DISCUTION
BMI 29.41 ± 13.5
(kg/m²) 3.79 23.53 37.04 This study was conducted to investigate
1
Duratio effect of low-level laser therapy in the
n of treatment of TTS as a complication of type II
17.9 ±
diabete 10 30 20
5.39 diabetes.
s
(years) Patients with type II diabetes mellitus had
various types of neuropathic complication
x̄: Mean SD: Standard deviation
P value: Probability value and tarsal tunnel syndrome is one of them 16.
S: Significant Current study found a significant decrease in
t value : Paired t value
the VAS, decrease in the motor distal latency
and decrease in the sensory peak distal

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latency post treatment compared with that
pretreatment .There was a significant
increase in motor amplitude and increase in
(lateral planter, the medial
planter) sensory amplitude post treatment
compared with that pretreatment . The Low-
level laser therapy is a useful way for treating
the injuries of nerves and when use the LLLT
at the early stage so it will helps in the
minimizing of the loss of nerve functions 16 ,
It causes vasodilation of the small arteries,
which allows the arteries to open up , bring
more nutrients are brought. Body will use
these nutrients for repair along with increased
ATP or energy production that was
stimulated by the laser. The combination of
increased blood flow and increased ATP
leads to more repair in a shorter period of
time 17.
The pain relief effect of LLLT
scientifically based on stimulation of nerves:
on peripheral nerves by stimulation of pain
(depolarization) and stabilizes
(polarization) suppressing the generation of
pain impulses. On central nerve through
trigger point making to emit pain relief
substances such as B-endorphins
catecholamine. Stimulation of sympathetic
nerves relive the strain of the blood vessels
and improve the blood circulation. Improve
the blood circulation and leads to release of
18 19
chemical mediators . Shashi et al.,
concluded that, result analysis showed
significant reduction in Pain using VAS
scale. Possible explanatory factor for
reduction in pain could be due to increased
microcirculation to the periphery; they
suggested that low-level laser therapy
stimulates release of cytokines and growth
factors into the circulation, which are
responsible for vasodilatation of the vessels
and formation of new capillaries.
20
In study of shawqi et al., . LLLT showed
significant pain reduction (70.9%) and
improved latency and amplitude studies for
sensory (16.7% and 29%, respectively) and
motor (18% and 26%, respectively). (Nerve
is recovery after irradiated with 904 nm LLLT
increase the total number of large diameter
axons and enhances regenerative processes of
them peripheral nerves)
The result of this study also come in
21
agreement again with that of Bakhtiary,
who concluded that there was significant
and increase in group A in motor amplitude from
12.9 to 19.19 and sensory amplitude from

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 LOW LEVEL LASER THERAPY IN TYPE II DIABETES MELLITUS

11.97 to 24.9 . Improvement could be Conclusion

explained as follows; laser has a bio
Type 2 DM is associated with high
stimulation effect on the nervous system,
incidence of peripheral entrapment nerves as
enhance reinnervation of target tissues
a severe chronic complication that has effects
subsequent to nerve injury, and induces
on patients quality of life and considered
Schwann cell proliferation.
22 greatest source of morbidity and mortality .
In The study of yamany and sayed.,
LLLT has good effect on decreasing
findings indicate that LLLT could be an
symptoms or even reversing the progress of
effective therapeutic modality in the
TTS so, resulted in improved complaint of
treatment of painful diabetic neuropathy in
the patients. The improvement due to
that it is able to modify pain, foot skin
stimulation of nerves (peripheral and
microcirculation and some
central), stimulation of pain (depolarization)
electrophysiological parameters of peripheral
and stabilizes them (polarization)
nerve function by increase myelination axon
suppressing the generation of pain impulses
regeneration, increase microcirculation to
and through trigger point resulting in release
the periphery and stimulate the release of
pain relief substances such as B-endorphins
cytokines and growth factors into the
and catecholamine's. Stimulate sympathetic
circulation which are responsible for the
nerves making improve the blood circulation
vasodilatation of the vessels and formation of
leads to release of chemical mediators.
new capillaries .
Favorable to all physical therapists in
In contrast with current study Viera et al., 23.
outpatients clinics and hospitals to use Low
reported that there was no significant changes
Level Laser (904 nm) as an ingredient in the
in electrophysiological parameters with
program when dealing with adult patients
exposure to laser radiation with wavelength
suffering from tarsal tunnel syndrome as a
of 904 nm on median nerve, this may be due
complication of type II diabetes mellitus.
to different therapeutic parameters, which
have been applied in their study.

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