A Systematic Review on Low-Level Laser Therapy in the Management of Shoulder Impingement Syndrome
Round 1
Reviewer 1 Report
The work concerns a review of publications that deal with shoulder impingement syndrome, which is very important in physiotherapy.
It should be emphasized here that experiments aimed at increasing the effectiveness of physiotherapy methods are extremely useful in rehabilitation practice.
The authors of this study maintained the correctness of the methodological requirements for systematic review articles.
The weakness of the entire study is the fact that only 5 articles were included in the final review.
The description in the INTRODUCTION clearly shows that “shoulder impingement syndrome” does not have a homogeneous etiology. The symptoms are similar but the causes are different.
The above statement underlies the ambiguous effects of therapy in the 5 considered experiments.
In the description of the work of Alfredo et. Al. (2020) in column 2 there is no information on which LLLT was used (Table 2).
Personally, I always have an ethical problem when placebos are applied in experiments involving people with disabilities (Column 5, Table 2).
The DISCUSSION chapter is actually a description of the publications under consideration. Lack of deeper reflections of the authors of the "systematic review".
On the margin of the CONCLUSION chapter, it should be noted that in the cited experimental works there is a lack of basic research on individual reactions of healthy human tissue to LLLT.
After getting acquainted with the manuscript of this review, a final reflection arises that it is not yet time to propose a uniform recommendation for the use of LLLT in the process of rehabilitation of people with shoulder impingement syndrome.
Author Response
Date: December, 20th 2022
Dear Editor,
Please find enclosed our revised article entitled “Low-level laser therapy in the management of shoulder impingement syndrome: a systematic review”. We appreciated the careful and constructive reviewer’s comments. Based on them, we have made tracked changes over the manuscript in. The revised version of our manuscript accompanies this letter.
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Reviewer Comment |
Response |
Line # |
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Reviewer #1 |
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The work concerns a review of publications that deal with shoulder impingement syndrome, which is very important in physiotherapy.
It should be emphasized here that experiments aimed at increasing the effectiveness of physiotherapy methods are extremely useful in rehabilitation practice.
|
We enriched the conclusion paragraph to emphasize the concept: “Given the low number of experimental studies found in the literature, it was not easy to find an answer to the prefixed question. Literature shows that in rehabilitation practice more randomized clinical trials are needed, to better investigate the efficacy of physiotherapy methods and consequently offer quality therapies to patients. In this case, further studies are needed to determine the effectiveness of this type of treatment, but the data obtained are still very encouraging.” |
5-8 page 15 |
|
The authors of this study maintained the correctness of the methodological requirements for systematic review articles.
The weakness of the entire study is the fact that only 5 articles were included in the final review.
|
The included articles were only 5 because the others didn’t meet the inclusion criteria. |
|
|
In the description of the work of Alfredo et. Al. (2020) in column 2 there is no information on which LLLT was used (Table 2).
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In the corresponding space in the description of the work of Alfredoet Al. (2020) the missing information was specified. |
Table 2 column 2 |
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Personally, I always have an ethical problem when placebos are applied in experiments involving people with disabilities (Column 5, Table 2).
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This is a second level study, so no treatments were performed directly on patients and consequently no ethical committee approval was needed. |
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The DISCUSSION chapter is actually a description of the publications under consideration. Lack of deeper reflections of the authors of the "systematic review".
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In the discussion chapter further reflections were added: “In these included studies the results show an improvement in pain severity in groups treated with LLLT and LLLT added to exercise programs, but this aspect should be investigated also using other outcome measures evaluating both pain perception and quality of life of patients. Furthermore, only two studies included an assessment at follow up after 12 weeks and 2-3 months; this data should be investigated to understand if the effects of LLLT on pain is a short term effect or it lasts over time (Alfredo et Al. 2020, Bal et Al. 2009).” |
14-19 page 14 |
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On the margin of the CONCLUSION chapter, it should be noted that in the cited experimental works there is a lack of basic research on individual reactions of healthy human tissue to LLLT.
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The aspect of lack of basic research on individual reactions of healthy human tissue due to LLLT was cited in the conclusion chapter: “In addition, the included experimental works don’t show which are the individual reactions of healthy human tissue due to LLLT: a research about this aspect should be performed in future studies.” |
1-3 page 15 |
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After getting acquainted with the manuscript of this review, a final reflection arises that it is not yet time to propose a uniform recommendation for the use of LLLT in the process of rehabilitation of people with shoulder impingement syndrome.
|
In the conclusion chapter this concept is specified: “In conclusion, LLLT is used as a treatment for SIS along with therapeutic exercise. Given the low number of experimental studies found in the literature, it was not easy to find an answer to the prefixed question. Literature shows that in rehabilitation practice more randomized clinical trials are needed, to better investigate the efficacy of physiotherapy methods and consequently offer quality therapies to patients.”
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4-8 page 15 |
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Reviewer #2 |
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The section entitled “Discussion section” is a narrative analysis of the included studies. This section should be called “Narrative analysis”. This also means that there is no discussion section in the manuscript.
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In the Discussion chapter comparison with other studies were included in addition to the description of included studies, so it constitutes a “Discussion section”: This study is comparable to other reviews: also J. M. Bjordal concluded that LLLT and in general passive therapies are not more effective of placebo (22). In the systematic review of Kromer et Al. results show the effectiveness of surgery and home-based exercises in SIS, while passive terapies cannot be recommended as a valid treatment; however, the samples were small, and different diagnostic criteria were applied, which makes a firm conclusion difficult (23). Wei Dong et Al. conducted a Meta Analysis about different treatments for SIS and foud that LLLT is not recommended respect to exercise therapy (24).” |
7-13 page 14 |
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Please state the risk of bias assessment methods in the method section.
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In the method section the statement about risk of bias assessment was added. |
22-23 page 6 |
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Why was no meta-analysis conducted?
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Meta-analysis was not conducted because there aren’t comparable outcomes in the selected studies. |
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Why did pain have to be measured on the VAS? There are a lot of valid pain outcome measurement scales out there.
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This is a second level study, in fact outcome measures (and also VAS) were used by researchers that conducted the single experiments included in this review. |
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Please indicate how many independent reviewers that selected the trials, extracted the data, and scored the risk of bias.
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In this study three independent reviewers worked on trials selection, while two of them extracted the data and scored the risk of bias. |
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|
Please indicate whether an a priori protocol was published explaining the intended review methods.
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The methods are explained in Prisma Statement for reporting systematic reviews and meta-analyses of studies that evaluate healthcare interventions. (Liberati et Al. 2009) |
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Please write in past tense throughout the manuscript.
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The verbs were corrected with the appropriate tense. |
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We hope that the new version of our manuscript is now acceptable for publication.
Best regards,
Giovanni Galeoto
Reviewer 2 Report
The topic is interesting, but the review appears to be incomplete.
The section entitled “Discussion section” is a narrative analysis of the included studies. This section should be called “Narrative analysis”. This also means that there is no discussion section in the manuscript.
Please state the risk of bias assessment methods in the method section.
Why was no meta-analysis conducted?
Why did pain have to be measured on the VAS? There are a lot of valid pain outcome measurement scales out there.
Please indicate how many independent reviewers that selected the trials, extracted the data, and scored the risk of bias.
Please indicate whether an a priori protocol was published explaining the intended review methods.
Please write in past tense throughout the manuscript.
There is a lot of work to be done before this review can be considered for publication.
Author Response
Date: December, 20th 2022
Dear Editor,
Please find enclosed our revised article entitled “Low-level laser therapy in the management of shoulder impingement syndrome: a systematic review”. We appreciated the careful and constructive reviewer’s comments. Based on them, we have made tracked changes over the manuscript in. The revised version of our manuscript accompanies this letter.
|
Reviewer Comment |
Response |
Line # |
|
Reviewer #1 |
||
|
The work concerns a review of publications that deal with shoulder impingement syndrome, which is very important in physiotherapy.
It should be emphasized here that experiments aimed at increasing the effectiveness of physiotherapy methods are extremely useful in rehabilitation practice.
|
We enriched the conclusion paragraph to emphasize the concept: “Given the low number of experimental studies found in the literature, it was not easy to find an answer to the prefixed question. Literature shows that in rehabilitation practice more randomized clinical trials are needed, to better investigate the efficacy of physiotherapy methods and consequently offer quality therapies to patients. In this case, further studies are needed to determine the effectiveness of this type of treatment, but the data obtained are still very encouraging.” |
5-8 page 15 |
|
The authors of this study maintained the correctness of the methodological requirements for systematic review articles.
The weakness of the entire study is the fact that only 5 articles were included in the final review.
|
The included articles were only 5 because the others didn’t meet the inclusion criteria. |
|
|
In the description of the work of Alfredo et. Al. (2020) in column 2 there is no information on which LLLT was used (Table 2).
|
In the corresponding space in the description of the work of Alfredoet Al. (2020) the missing information was specified. |
Table 2 column 2 |
|
Personally, I always have an ethical problem when placebos are applied in experiments involving people with disabilities (Column 5, Table 2).
|
This is a second level study, so no treatments were performed directly on patients and consequently no ethical committee approval was needed. |
|
|
The DISCUSSION chapter is actually a description of the publications under consideration. Lack of deeper reflections of the authors of the "systematic review".
|
In the discussion chapter further reflections were added: “In these included studies the results show an improvement in pain severity in groups treated with LLLT and LLLT added to exercise programs, but this aspect should be investigated also using other outcome measures evaluating both pain perception and quality of life of patients. Furthermore, only two studies included an assessment at follow up after 12 weeks and 2-3 months; this data should be investigated to understand if the effects of LLLT on pain is a short term effect or it lasts over time (Alfredo et Al. 2020, Bal et Al. 2009).” |
14-19 page 14 |
|
On the margin of the CONCLUSION chapter, it should be noted that in the cited experimental works there is a lack of basic research on individual reactions of healthy human tissue to LLLT.
|
The aspect of lack of basic research on individual reactions of healthy human tissue due to LLLT was cited in the conclusion chapter: “In addition, the included experimental works don’t show which are the individual reactions of healthy human tissue due to LLLT: a research about this aspect should be performed in future studies.” |
1-3 page 15 |
|
After getting acquainted with the manuscript of this review, a final reflection arises that it is not yet time to propose a uniform recommendation for the use of LLLT in the process of rehabilitation of people with shoulder impingement syndrome.
|
In the conclusion chapter this concept is specified: “In conclusion, LLLT is used as a treatment for SIS along with therapeutic exercise. Given the low number of experimental studies found in the literature, it was not easy to find an answer to the prefixed question. Literature shows that in rehabilitation practice more randomized clinical trials are needed, to better investigate the efficacy of physiotherapy methods and consequently offer quality therapies to patients.”
|
4-8 page 15 |
|
Reviewer #2 |
||
|
The section entitled “Discussion section” is a narrative analysis of the included studies. This section should be called “Narrative analysis”. This also means that there is no discussion section in the manuscript.
|
In the Discussion chapter comparison with other studies were included in addition to the description of included studies, so it constitutes a “Discussion section”: This study is comparable to other reviews: also J. M. Bjordal concluded that LLLT and in general passive therapies are not more effective of placebo (22). In the systematic review of Kromer et Al. results show the effectiveness of surgery and home-based exercises in SIS, while passive terapies cannot be recommended as a valid treatment; however, the samples were small, and different diagnostic criteria were applied, which makes a firm conclusion difficult (23). Wei Dong et Al. conducted a Meta Analysis about different treatments for SIS and foud that LLLT is not recommended respect to exercise therapy (24).” |
7-13 page 14 |
|
Please state the risk of bias assessment methods in the method section.
|
In the method section the statement about risk of bias assessment was added. |
22-23 page 6 |
|
Why was no meta-analysis conducted?
|
Meta-analysis was not conducted because there aren’t comparable outcomes in the selected studies. |
|
|
Why did pain have to be measured on the VAS? There are a lot of valid pain outcome measurement scales out there.
|
This is a second level study, in fact outcome measures (and also VAS) were used by researchers that conducted the single experiments included in this review. |
|
|
Please indicate how many independent reviewers that selected the trials, extracted the data, and scored the risk of bias.
|
In this study three independent reviewers worked on trials selection, while two of them extracted the data and scored the risk of bias. |
|
|
Please indicate whether an a priori protocol was published explaining the intended review methods.
|
The methods are explained in Prisma Statement for reporting systematic reviews and meta-analyses of studies that evaluate healthcare interventions. (Liberati et Al. 2009) |
|
|
Please write in past tense throughout the manuscript.
|
The verbs were corrected with the appropriate tense. |
|
We hope that the new version of our manuscript is now acceptable for publication.
Best regards,
Giovanni Galeoto
Round 2
Reviewer 2 Report
- The abstract lacks a results section.
- In the section "Inclusion criteria", the following text is not required "Reviews, case reports, letters, editorials, and studies that did not respect these criteria were excluded.".
- Only 98 publications were identified in the initial search, which is a strikingly low number, and it makes me wonder whether the literature search was comprehensive. Please state the full search string for at least one database, preferably the PubMed search string, in the manuscript or in a supplementary file. The references of the included trials and prior systematic reviews should be included in the literature search as well.
- In the previous review round, the authors informed me that multiple reviewers extracted the data and scored the risk of bias. Please explain this to the readers in the method section.
- The conclusion of the main text is too long, in my opinion.
- Please add a limitations section in the discussion section. Here it should be written that no a priori protocol was published. Please consider additional limitations as well. Any limitations in the literature search should also be included, such as a lack of reference screening.
- The pathology is often referred to as shoulder impingement syndrome (SIS), however, recent studies show that it is not associated with impingement of tissues, and thus SAPS seems to be a better term (1).
1. Park SW, Chen YT, Thompson L, et al. No relationship between the acromiohumeral distance and pain in adults with subacromial pain syndrome: a systematic review and meta-analysis. Scientific reports 2020;10(1):20611. doi: 10.1038/s41598-020-76704-z
Author Response
Date: February 02nd, 2023
Dear Editor,
Please find enclosed our revised article entitled “A systematic review on low-level laser therapy in the management of shoulder impingement syndrome”. We appreciated the careful and constructive reviewer’s comments. Based on them, we have made tracked changes over the manuscript in. The revised version of our manuscript accompanies this letter.
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Reviewer Comment |
Response |
Line # |
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Reviewer #1 |
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The abstract lacks a results section. |
A result section was added in the abstract. |
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n the section "Inclusion criteria", the following text is not required "Reviews, case reports, letters, editorials, and studies that did not respect these criteria were excluded.". |
The indicated sentence was removed. |
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Only 98 publications were identified in the initial search, which is a strikingly low number, and it makes me wonder whether the literature search was comprehensive. Please state the full search string for at least one database, preferably the PubMed search string, in the manuscript or in a supplementary file. The references of the included trials and prior systematic reviews should be included in the literature search as well. |
The search string used on PubMed was added. The included trials references were included in the literature search paragraph. |
14-15 7 |
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In the previous review round, the authors informed me that multiple reviewers extracted the data and scored the risk of bias. Please explain this to the readers in the method section. |
The sentence to explain the process of data extraction and risk of bias assessment has been included in the method section. |
16-17 |
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The conclusion of the main text is too long, in my opinion. |
The conclusion paragraph has been reduced. |
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Please add a limitations section in the discussion section. Here it should be written that no a priori protocol was published. Please consider additional limitations as well. Any limitations in the literature search should also be included, such as a lack of reference screening. |
A limitation section has been added.
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14-18 |
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The pathology is often referred to as shoulder impingement syndrome (SIS), however, recent studies show that it is not associated with impingement of tissues, and thus SAPS seems to be a better term (1). 1.Park SW, Chen YT, Thompson L, et al. No relationship between the acromiohumeral distance and pain in adults with subacromial pain syndrome: a systematic review and meta-analysis. Scientific reports 2020;10(1):20611. doi: 10.1038/s41598-020-76704-z |
The reference (1) has been added in the introduction explaining the recent findings about SAPS. However, it has not been used in the main text because the systematic review includes studies about SIS. |
14-17 |
We hope that the new version of our manuscript is now acceptable for publication.
Best regards,
Giovanni Galeoto
Author Response File: 
Author Response.docx
Round 3
Reviewer 2 Report
The number of reviewers that scored the risk of bias and extracted the data has been stated in the section "Information sources and Search strategy". Please state this information in the relevant sections.
The section "Data collection and analysis" in the method section should be renamed as no info regarding an analysis is stated here. Here the procedures for extracting the data should be stated, , including how many reviewers that extracted the data, how it was done (eg. using Excel) and how disagreements were handled.
The risk of bias section in the method section should also contain information regarding the risk of bias process, including how many reviewers that scored the risk of bias and what was done in case of disagreement.
In the previous review round I asked the authors to state the database search strings since I was concerned about the literature search had not been comprehensive enough. The authors now state that "For PubMed database the search string "Shoulder Impingement Syndrome" AND “low level laser therapy” was used.". This search should have included synonyms, abbreviations and MeSH terms as well. The PubMed search string only identified 22 records. Similar search strategies were used in the other databases (table 1) and they are simply not acceptable. Here is an example of a comprehensive PubMed search string:
("Shoulder Impingement Syndrome"[Title/Abstract] OR "Subacromial"[Title/Abstract] OR "Shoulder Pain"[Title/Abstract] OR "Shoulder"[Mesh] OR "Shoulder Pain"[Mesh] OR "Shoulder Joint"[Mesh]) AND ("Low-Level Light Therapy"[Mesh] OR "LLLT"[Title/Abstract] OR “low level”[Title/Abstract] OR “low power”[Title/Abstract] OR laser therap*[Title/Abstract] OR “laser acupuncture”[Title/Abstract] OR “HeNe”[Title/Abstract] OR “632 nm”[Title/Abstract] OR “Ga-Al-As”[Title/Abstract] OR “820 nm”[Title/Abstract] OR “830 nm”[Title/Abstract] OR “850 nm”[Title/Abstract] OR “GaAs”[Title/Abstract] OR “904 nm”[Title/Abstract])
The conclusion contains too much general discussion.
Author Response
Date: February 12th, 2023
Dear Editor,
Please find enclosed our revised article entitled “A systematic review on low-level laser therapy in the management of shoulder impingement syndrome”. We appreciated the careful and constructive reviewer’s comments. Based on them, we have made tracked changes over the manuscript in. The revised version of our manuscript accompanies this letter.
|
Reviewer Comment |
Response |
Line # |
|
Reviewer #1 |
||
|
The number of reviewers that scored the risk of bias and extracted the data has been stated in the section "Information sources and Search strategy". Please state this information in the relevant sections. |
The number of reviewers that scored the risk of bias and extracted the data has been stated in the sections “Selection process” and “Risk of bias assessment”. |
120-21 9-11 |
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The section "Data collection and analysis" in the method section should be renamed as no info regarding an analysis is stated here. Here the procedures for extracting the data should be stated, including how many reviewers that extracted the data, how it was done (eg. using Excel) and how disagreements were handled. |
The section was renamed. Procedures about data extraction were stated in the same section. |
5-7 |
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The risk of bias section in the method section should also contain information regarding the risk of bias process, including how many reviewers that scored the risk of bias and what was done in case of disagreement. |
The required information was added. |
9-11 |
|
In the previous review round I asked the authors to state the database search strings since I was concerned about the literature search had not been comprehensive enough. The authors now state that "For PubMed database the search string "Shoulder Impingement Syndrome" AND “low level laser therapy” was used.". This search should have included synonyms, abbreviations and MeSH terms as well. The PubMed search string only identified 22 records. Similar search strategies were used in the other databases (table 1) and they are simply not acceptable. Here is an example of a comprehensive PubMed search string: |
PubMed search string was indicated in “Information sources and Search strategy” paragraph. |
14-16 |
We hope that the new version of our manuscript is now acceptable for publication.
Best regards,
Giovanni Galeoto
Author Response File: Author Response.docx
