A systematic review with procedural assessments and meta-analysis of low level laser therapy in lateral elbow tendinopathy (tennis elbow)

Developments in low level light therapy (LLLT) for dentistry

OBJECTIVES

Low level light/laser therapy (LLLT) is the direct application of light to stimulate cell responses (photobiomodulation) in order to promote tissue healing, reduce inflammation and induce analgesia. There have been significant studies demonstrating its application and efficacy at many sites within the body and for treatment of a range of musculoskeletal injuries, degenerative diseases and dysfunction, however, its use on oral tissues has, to date, been limited. The purpose of this review is to consider the potential for LLLT in dental and oral applications by providing background information on its mechanism of action and delivery parameters and by drawing parallels with its treatment use in analogous cells and tissues from other sites of the body.

METHODS

A literature search on Medline was performed on laser and light treatments in a range of dental/orofacial applications from 2010 to March 2013. The search results were filtered for LLLT relevance. The clinical papers were then arranged to eight broad dental/orofacial categories and reviewed.

RESULTS

The initial search returned 2778 results, when filtered this was reduced to 153. 41 were review papers or editorials, 65 clinical and 47 laboratory studies. Of all the publications, 130 reported a positive effect in terms of pain relief, fast healing or other improvement in symptoms or appearance and 23 reported inconclusive or negative outcomes. Direct application of light as a therapeutic intervention within the oral cavity (rather than photodynamic therapies, which utilize photosensitizing solutions) has thus far received minimal attention. Data from the limited studies that have been performed which relate to the oral cavity indicate that LLLT may be a reliable, safe and novel approach to treating a range of oral and dental disorders and in particular for those which there is an unmet clinical need.

SIGNIFICANCE

The potential benefits of LLLT that have been demonstrated in many healthcare fields and include improved healing, reduced inflammation and pain control, which suggest considerable potential for its use in oral tissues.

Low-level laser irradiation stimulates tenocyte proliferation in association with increased NO synthesis and upregulation of PCNA and cyclins

Low-level laser therapy is commonly used to treat tendinopathy or tendon injury. Tendon healing requires tenocyte migration to the repair site, followed by proliferation and synthesis of the extracellular matrix. There are few evidence to elucidate that low-level laser promote tenocyte proliferation. This study was designed to determine the effect of laser on tenocyte proliferation. Furthermore, the association of this effect with secretion of nitric oxide (NO) and the expressions of proliferating cell nuclear antigen (PCNA) and cyclins D1, E, A, and B1 was investigated. Tenocytes intrinsic to rat Achilles tendon were treated with low-level laser (660 nm). Tenocyte proliferation was evaluated by MTT assay and immunocytochemistry with Ki-67 stain. NO in the conditioned medium was measured by ELISA. Western blot analysis was used to evaluate the protein expressions of PCNA and cyclins D1, E, A, and B1. The results revealed that tenocytes proliferation was enhanced dose dependently by laser. NO secretion was increased after laser treatment. PCNA and cyclins E, A, and B1 were upregulated by laser. In conclusion, low-level laser irradiation stimulates tenocyte proliferation in a process that is mediated by upregulation of NO, PCNA, and cyclins E, A, and B1.

Tendinopathy: a review of the pathophysiology and evidence for treatment

The understanding of tendinopathy has evolved over the past several decades. Initially thought to be a primarily inflammatory process, histologic evaluation has revealed that there is an absence of inflammatory cells, and rather, tendinopathy is more of a degenerative process. Various types of medications, rehabilitation, modalities, injections, and minimally invasive procedures have been described as treatment for this condition. The purpose of our article is to describe the pathophysiology of tendinopathy as currently understood and the evidence for the various available treatments. We performed a literature search to determine the types of reviews that have been performed previously regarding treatment for tendinopathy, and summarized these reviews. We then performed a systematic review of randomized controlled trials for treating patients with tendinopathy. It is our hope that our review of trial data will help providers to determine optimal management for their patients with tendinopathy.

Lateral epicondylitis

Lateral epicondylitis, or ’tennis elbow’, is a common condition that usually affects patients between 35 and 55 years of age. It is generally self-limiting, but in some patients it may continue to cause persistent symptoms, which can be refractory to treatment. This review discusses the mechanism of disease, symptoms and signs, investigations, current management protocols and potential new treatments.

Cite this article: Bone Joint J 2013;95-B:1158–64.

532 nm low-power laser irradiation recovers γ-secretase inhibitor-mediated cell growth suppression and promotes cell proliferation via Akt signaling

Background and Objective

The γ-secretase inhibitor (GSI) has been shown to inhibit expression of amyloid beta (Aβ), but GSI also has a side effect of reducing cell survival. Since low-power laser irradiation (LLI) has been known to promote cell survival, we examined whether 532 nm LLI can rescue the GSI side effect or not.

Study Design/Materials and Methods

The human-derived glioblastoma cells (A-172) were cultured in 35 mm culture dishes or 96-well plate. The center of dish or selected wells was irradiated with 532 nm laser (Nd:YVO4, CW, 60 mW) for 20, 40 and 60 min, respectively. The irradiated cells were photographed at immediately after, 24 and 48 h later and counted. GSI was supplemented in medium 3 h before LLI. The MTT assay was also used to estimate viable cells at 48 h after irradiation. The expression of phosphorylated Akt (p-Akt) or phosphorylated PTEN (p-PTEN) was examined by immunofluorescent staining and measured by fluorescence intensity using the software (BZ-9000, KEYENCE, Japan).

Results

GSI application depressed cell proliferation as well as cell survival compared to control. GSI down-regulated Aβ but up-regulated p-PTEN and suppressed p-Akt. Application of 532 nm LLI in the presence of GSI significantly recovered the GSI-mediated effects, i.e., LLI could decrease elevated p-PTEN, while increased p-Akt expression with keeping Aβ suppression. The LLI effects had a dose-dependency.

Conclusion

We confirmed that GSI potently suppressed intracellular Aβ and decreased cell survival. We conclude that a combination of GSI application and 532 nm LLI can increase cell proliferation via Akt activation while keeping PTEN and Aβ suppressed.

Acupuncture for lateral epicondylitis (tennis elbow): study protocol for a randomized, practitioner-assessor blinded, controlled pilot clinical trial

BACKGROUND

Lateral epicondylitis is the most frequent cause of pain around the elbow joint. It causes pain in the region of the elbow joint and results in dysfunction of the elbow and deterioration of the quality of life. The purpose of this study is to compare the effects of ipsilateral acupuncture, contralateral acupuncture and sham acupuncture on lateral epicondylitis.

METHODS/DESIGN

Forty-five subjects with lateral epicondylitis will be randomized into three groups: the ipsilateral acupuncture group, contralateral acupuncture group and the sham acupuncture group. The inclusion criteria will be as follows: (1) age between 19 and 65 years with pain due to one-sided lateral epicondylitis that persisted for at least four weeks, (2) with tenderness on pressure limited to regions around the elbow joint, (3) complaining of pain during resistive extension of the middle finger or the wrist, (4) with average pain of NRS 4 or higher during the last one week at a screening visit and (5) voluntarily agree to this study and sign a written consent. Acupuncture treatment will be given 10 times in total for 4 weeks to all groups. Follow up observations will be conducted after the completion of the treatment, 8 weeks and 12 weeks after the random assignment. Ipsilateral acupuncture group and contralateral acupuncture group will receive acupuncture on LI4, TE5, LI10, LI11, LU5, LI12 and two Ashi points. The sham acupuncture group will receive treatment on acupuncture points not related to the lateral epicondylitis using a non-invasive method. The needles will be maintained for 20 minutes. The primary outcome will be differences in the visual analogue scale (VAS) for elbow pain between the groups. The secondary outcome will be differences in patient-rated tennis elbow evaluation (PRTEE), pain-free/maximum grip strength (Dynamometer), pressure pain threshold, clinically relevant improvement, patient global assessment, and the EQ-5D. The data will be analyzed with the paired t-test and ANCOVA (P <0.05).

DISCUSSION

The results of this study will allow evaluation of contralateral acupuncture from two aspects. First, if the contralateral acupuncture shows the effects similar to ipsilateral acupuncture, this will establish clinical basis for contralateral acupuncture. Second, if the effects of contralateral acupuncture are not comparable to the effects of ipsilateral acupuncture, but are shown to be similar to the effects of the sham acupuncture, we can establish the basis for using the same acupoints of the unaffected side as a control in acupuncture clinical studies.

TRIAL REGISTRATION

This trial has been registered with the 'Clinical Research Information Service (CRIS)', Republic of Korea: KCT0000628.

Management of tennis elbow by Agnikarma

Tennis elbow is a painful condition and causes restricted movement of forearm which requires treatment for long period. Till date only symptomatic treatments are available like use of anti-inflammatory analgesic drugs, steroids injection, physiotherapy, exercise etc. But none of these provide satisfactory result. Long term use of anti-inflammatory, analgesic drugs and steroids injection is also not free from the adverse effects. Usually, ‘wait-and-see policy’ of treatment guideline is recommended in most of medical texts. According to Ayurveda, snayugata vata can be correlated with the condition of tennis elbow. Sushruta has advised Agnikarma for disorders of snayu (ligaments and tendons), asthi (bone), siddhi (joints) etc. Hence, in this study a case of tennis elbow (snayugata vata) was treated by Agnikarma, along with administration of powder of Ashwagandha and Navajivana Rasa orally, for a period of 03 weeks. This combination therapy provided considerable relief in pain and movement of the elbow joint.

Evidence for the effectiveness of electrophysical modalities for treatment of medial and lateral epicondylitis: a systematic review

BACKGROUND

Several treatments are available to treat epicondylitis. Among these are instrumental electrophysical modalities, ranging from ultrasound, extracorporeal shock wave therapy (ESWT), transcutaneous electrical nerve stimulation (TENS) to laser therapy, commonly used to treat epicondylitis.

OBJECTIVES

To present an evidence-based overview of the effectiveness of electrophysical modality treatments for both medial and lateral epicondylitis (LE).

METHODS

Searches in PubMed, EMBASE, CINAHL and Pedro were performed to identify relevant randomised clinical trials (RCTs) and systematic reviews. Two reviewers independently extracted data and assessed the methodological quality. A best-evidence synthesis was used to summarise the results.

RESULTS

A total of 2 reviews and 20 RCTs were included, all of which concerned LE. Different electrophysical regimes were evaluated: ultrasound, laser, electrotherapy, ESWT, TENS and pulsed electromagnetic field therapy. Moderate evidence was found for the effectiveness of ultrasound versus placebo on mid-term follow-up. Ultrasound plus friction massage showed moderate evidence of effectiveness versus laser therapy on short-term follow-up. On the contrary, moderate evidence was found in favour of laser therapy over plyometric exercises on short-term follow-up. For all other modalities only limited/conflicting evidence for effectiveness or evidence of no difference in effect was found.

CONCLUSIONS

Potential effectiveness of ultrasound and laser for the management of LE was found. To draw more definite conclusions high-quality RCTs examining different intensities are needed as well as studies focusing on long-term follow-up results.

Skin penetration time-profiles for continuous 810 nm and Superpulsed 904 nm lasers in a rat model

OBJECTIVE

The purpose of this study was to investigate the rat skin penetration abilities of two commercially available low-level laser therapy (LLLT) devices during 150 sec of irradiation.

BACKGROUND DATA

Effective LLLT irradiation typically lasts from 20 sec up to a few minutes, but the LLLT time-profiles for skin penetration of light energy have not yet been investigated.

MATERIALS AND METHODS

Sixty-two skin flaps overlaying rat's gastrocnemius muscles were harvested and immediately irradiated with LLLT devices. Irradiation was performed either with a 810 nm, 200 mW continuous wave laser, or with a 904 nm, 60 mW superpulsed laser, and the amount of penetrating light energy was measured by an optical power meter and registered at seven time points (range, 1-150 sec).

RESULTS

With the continuous wave 810 nm laser probe in skin contact, the amount of penetrating light energy was stable at ∼20% (SEM±0.6) of the initial optical output during 150 sec irradiation. However, irradiation with the superpulsed 904 nm, 60 mW laser showed a linear increase in penetrating energy from 38% (SEM±1.4) to 58% (SEM±3.5) during 150 sec of exposure. The skin penetration abilities were significantly different (p<0.01) between the two lasers at all measured time points.

CONCLUSIONS

LLLT irradiation through rat skin leaves sufficient subdermal light energy to influence pathological processes and tissue repair. The finding that superpulsed 904 nm LLLT light energy penetrates 2-3 easier through the rat skin barrier than 810 nm continuous wave LLLT, corresponds well with results of LLLT dose analyses in systematic reviews of LLLT in musculoskeletal disorders. This may explain why the differentiation between these laser types has been needed in the clinical dosage recommendations of World Association for Laser Therapy.

Tendinopathies of the elbow, wrist, and hand: histopathology and clinical considerations

This article reviews the current opinion of the histopathological findings of common elbow, wrist, and hand tendinopathies. Implications for client management including examination, diagnosis, prognosis, intervention, and outcomes are addressed. Concepts for further research regarding common therapeutic interventions are discussed.

Low-level laser irradiation stimulates tenocyte migration with up-regulation of dynamin II expression

Low-level laser therapy (LLLT) is commonly used to treat sports-related tendinopathy or tendon injury. Tendon healing requires tenocyte migration to the repair site, followed by proliferation and synthesis of the extracellular matrix. This study was designed to determine the effect of laser on tenocyte migration. Furthermore, the correlation between this effect and expression of dynamin 2, a positive regulator of cell motility, was also investigated. Tenocytes intrinsic to rat Achilles tendon were treated with low-level laser (660 nm with energy density at 1.0, 1.5, and 2.0 J/cm²). Tenocyte migration was evaluated by an in vitro wound healing model and by transwell filter migration assay. The messenger RNA (mRNA) and protein expressions of dynamin 2 were determined by reverse transcription/real-time polymerase chain reaction (real-time PCR) and Western blot analysis respectively. Immunofluorescence staining was used to evaluate the dynamin 2 expression in tenocytes. Tenocytes with or without laser irradiation was treated with dynasore, a dynamin competitor and then underwent transwell filter migration assay. In vitro wound model revealed that more tenocytes with laser irradiation migrated across the wound border to the cell-free zone. Transwell filter migration assay confirmed that tenocyte migration was enhanced dose-dependently by laser. Real-time PCR and Western-blot analysis demonstrated that mRNA and protein expressions of dynamin 2 were up-regulated by laser irradiation dose-dependently. Confocal microscopy showed that laser enhanced the expression of dynamin 2 in cytoplasm of tenocytes. The stimulation effect of laser on tenocytes migration was suppressed by dynasore. In conclusion, low-level laser irradiation stimulates tenocyte migration in a process that is mediated by up-regulation of dynamin 2, which can be suppressed by dynasore.

Light-induced vasodilation of coronary arteries and its possible clinical implication

BACKGROUND

Low-level laser therapy and light-emitting diodes (LED) are increasingly used in phototherapy. Their therapeutic effects are at least partly mediated by light-induced vasodilation. The aim of this study was to determine the effect of different light sources on coronary arteries.

METHODS

Porcine left coronary arteries were cut into 4-mm rings that were irradiated either by a semiconductor nonthermal gallium-arsenide diode laser or a noncoherent athermic red light source both with the same energy density up to 16 J/cm(2). After precontraction with 9, 11-dideoxy-11α, 9α-epoxymethano-prostaglandin F(2)α, respective relaxation responses were evaluated. The role of endothelium as well as intracellular pathways was investigated.

RESULTS

Maximum vasodilation after exposure to laser was observed at 10 J/cm(2) (56.8% ± 1.2%) and decreased to 43.9% ± 2.8% at 16 J/cm(2) (p < 0.003). After adjusting exposure time to achieve equivalent energy densities in the LED group, vessel segments revealed photorelaxation of 52.9% ± 6.5% and 47.5% ± 0.6%, respectively. Vasodilations achieved by either light source were comparable at 10 J/cm(2) (p < 0.574) and 16 J/cm(2) (p < 0.322). Furthermore, vasodilation could be inhibited by administration of 2-(4-carboxyphenyl)-4,4,5,5-tetramethylimidazoline-1-oxyl-3-oxide (nitric oxide scavenger) and 1H-[1,2,4]oxadiazolo[4,3-a]quinoxalin-1-one (guanocyclase inhibitor) but not with L-nitro-arginine methyl ester or deendothelialization.

CONCLUSIONS

Vessels exposed to either light source showed a remarkable as well as comparable photorelaxation at definite energy densities. This effect is mediated by an intracellular nitric oxide-dependent mechanism. As LED sources are of small size, simple, and inexpensive build-up, they may be used during routine coronary artery bypass surgery to ease suturing of anastomosis by target vessel vasodilation.

Infrared (810 nm) low-level laser therapy in rat achilles tendinitis: a consistent alternative to drugs

Nonsteroidal anti-inflammatory drugs (NSAIDs) are widely used and can reduce musculoskeletal pain in spite of the cost of adverse reactions like gastrointestinal ulcers or cardiovascular events. The current study investigates if a safer treatment such as low-level laser therapy (LLLT) could reduce tendinitis inflammation, and whether a possible pathway could be through inhibition of either of the two-cyclooxygenase (COX) isoforms in inflammation. Wistar rats (six animals per group) were injected with saline (control) or collagenase in their Achilles tendons. Then, we treated them with three different doses of IR LLLT (810 nm; 100 mW; 10 s, 30 s and 60 s; 3.57 W cm(-2); 1 J, 3 J, 6 J) at the sites of the injections, or intramuscular diclofenac, a nonselective COX inhibitor/NSAID. We found that LLLT dose of 3 J significantly reduced inflammation through less COX-2-derived gene expression and PGE(2) production, and less edema formation compared to nonirradiated controls. Diclofenac controls exhibited significantly lower PGE(2) cytokine levels at 6 h than collagenase control, but COX isoform 1-derived gene expression and cytokine PGE(2) levels were not affected by treatments. As LLLT seems to act on inflammation through a selective inhibition of the COX-2 isoform in collagenase-induced tendinitis, LLLT may have potential to become a new and safer nondrug alternative to coxibs.

Tennis elbow

INTRODUCTION

Lateral pain in the elbow affects up to 3% of the population, and is considered an overload injury of the extensor tendons of the forearm where they attach at the lateral epicondyle. Although usually self-limiting, symptoms may persist for over 1 year in up to 20% of people.

METHODS AND OUTCOMES

We conducted a systematic review and aimed to answer the following clinical question: What are the effects of treatments for tennis elbow? We searched: Medline, Embase, The Cochrane Library, and other important databases up to November 2009 (Clinical Evidence reviews are updated periodically, please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA).

RESULTS

We found 80 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions.

CONCLUSIONS

In this systematic review we present information relating to the effectiveness and safety of the following interventions: acupuncture, autologous whole blood injections, corticosteroid injections, combination physical therapies, exercise, extracorporeal shock wave therapy, iontophoresis, low-level laser therapy, manipulation, non-steroidal anti-inflammatory drugs (oral and topical), orthoses (bracing), platelet-rich plasma injections, pulsed electromagnetic field treatment, surgery, and ultrasound.

Management of tennis elbow

CLINICAL QUESTION

What is the best treatment for tennis elbow?

RESULTS

Despite a wealth of research, there is no true consensus on the most efficacious management of tennis elbow especially for effective long-term outcomes. Corticosteroid injections do show large pain-relieving effects in the short term but are associated with risks of adverse events and long-term reoccurrence. Advice with a "wait and see" approach is recommended as the first-line treatment in primary care for most cases. In the medium term physiotherapy and or low-level laser therapy may be effective.

IMPLEMENTATION

Rule out alternative diagnosis. Onward referral may be indicated if the condition does not resolve after 12 months.

An experimental study of low-level laser therapy in rat Achilles tendon injury

The aim of this controlled animal study was to investigate the effect of low-level laser therapy (LLLT) administered 30 min after injury to the Achilles tendon. The study animals comprised 16 Sprague Dawley male rats divided in two groups. The right Achilles tendons were injured by blunt trauma using a mini guillotine, and were treated with LLLT or placebo LLLT 30 min later. The injury and LLLT procedures were then repeated 15 hours later on the same tendon. One group received active LLLT (λ = 904 nm, 60 mW mean output power, 0.158 W/cm² for 50 s, energy 3 J) and the other group received placebo LLLT 23 hours after LLLT. Ultrasonographic images were taken to measure the thickness of the right and left Achilles tendons. Animals were then killed, and all Achilles tendons were tested for ultimate tensile strength (UTS). All analyses were performed by blinded observers. There was a significant increase in tendon thickness in the active LLLT group when compared with the placebo group (p < 0.05) and there were no significant differences between the placebo and uninjured left tendons. There were no significant differences in UTS between laser-treated, placebo-treated and uninjured tendons. Laser irradiation of the Achilles tendon at 0.158 W/cm² for 50 s (3 J) administered within the first 30 min after blunt trauma, and repeated after 15 h, appears to lead to edema of the tendon measured 23 hours after LLLT. The guillotine blunt trauma model seems suitable for inflicting tendon injury and measuring the effects of treatment on edema by ultrasonography and UTS. More studies are needed to further refine this model.

Could acupuncture needle sensation be a predictor of analgesic response?

During acupuncture some patients experience distinct sensations which are often referred to as needle sensation. Needle sensation may be related to treatment outcome, although what constitutes adequate acupuncture needle sensation is not known. In this paper, we debate the possibility of using the self-report of the overall intensity of needle sensation as a predictor of analgesic outcome to acupuncture. We describe how our approach to establish criteria to determine adequacy of transcutaneous electrical nerve stimulation interventions in clinical trials has been used to inform our search for markers of adequacy of procedural technique for acupuncture. We describe previous research which has focused on developing tools to capture the nature of the descriptors used by patients when they self-report needle sensation and reveal that little attention has been given to its role in outcome. We demonstrate that needle sensation is a complex phenomenon with subjects using multiple descriptors to report their experience. We argue that the intensity of the overall experience of needle sensation may prove useful as a gross marker of the adequacy of acupuncture. We briefly describe our research which isolates individual components of needling technique, such as depth of needle penetration and bidirectional needle rotation, in order to assess their contribution to overall needle sensation intensity.

Surgery for lateral elbow pain

BACKGROUND

Surgery is sometimes recommended for persistent lateral elbow pain where other less invasive interventions have failed.

OBJECTIVES

To determine the benefits and safety of surgery for lateral elbow pain.

SEARCH STRATEGY

We searched CENTRAL (The Cochrane Library), MEDLINE, EMBASE, CINAHL and Web of Science unrestricted by date or language (to 15 December 2010).

SELECTION CRITERIA

Randomised and controlled clinical trials assessing a surgical intervention compared with no treatment or another intervention including an alternate surgical intervention, in adults with lateral elbow pain.

DATA COLLECTION AND ANALYSIS

Two authors independently selected trials for inclusion, assessed risk of bias and extracted data.

MAIN RESULTS

We included five trials involving 191 participants with persistent symptoms of at least five months duration and failed conservative treatment. Three trials compared two different surgical procedures and two trials compared surgery to a non-surgical treatment. All trials were highly susceptible to bias. Meta-analysis was precluded due to differing comparator groups and outcome measures. One trial (24 participants) reported no difference between open extensor carpi radialis brevis (ECRB) surgery and radiofrequency microtenotomy, although reanalysis found that pain was significantly lower in the latter group at three weeks (MD -2.80 points on 10 point scale, 95% CI -5.07 to -0.53). One trial (26 participants) reported no difference between open ECRB surgery and decompression of the posterior interosseous nerve in terms of the number of participants with improvement in pain pain on activity, or tenderness on palpation after an average of 31 months following surgery. One trial (45 participants) found that compared with open release of the ERCB muscle, percutaneous release resulted in slightly better function. One trial (40 participants) found comparable results between open surgical release of the ECRB and botulinum toxin injection at two years, although we could not extract any data for this review. One trial (56 participants) found that extracorporeal shock wave therapy (ESWT) improved pain at night compared with percutaneous tenotomy at 12 months (MD 5 points on 100 point VAS, 95% CI 1.12 to 8.88), but there were no differences in pain at rest or pain on applying pressure.

AUTHORS' CONCLUSIONS

Due to a small number of studies, large heterogeneity in interventions across trials, small sample sizes and poor reporting of outcomes, there was insufficient evidence to support or refute the effectiveness of surgery for lateral elbow pain. Further well-designed randomised controlled trials and development of standard outcome measures are needed.

Deciphering the pathogenesis of tendinopathy: a three-stages process

Our understanding of the pathogenesis of "tendinopathy" is based on fragmented evidences like pieces of a jigsaw puzzle. We propose a "failed healing theory" to knit these fragments together, which can explain previous observations. We also propose that albeit "overuse injury" and other insidious "micro trauma" may well be primary triggers of the process, "tendinopathy" is not an "overuse injury" per se. The typical clinical, histological and biochemical presentation relates to a localized chronic pain condition which may lead to tendon rupture, the latter attributed to mechanical weakness. Characterization of pathological "tendinotic" tissues revealed coexistence of collagenolytic injuries and an active healing process, focal hypervascularity and tissue metaplasia. These observations suggest a failed healing process as response to a triggering injury. The pathogenesis of tendinopathy can be described as a three stage process: injury, failed healing and clinical presentation. It is likely that some of these "initial injuries" heal well and we speculate that predisposing intrinsic or extrinsic factors may be involved. The injury stage involves a progressive collagenolytic tendon injury. The failed healing stage mainly refers to prolonged activation and failed resolution of the normal healing process. Finally, the matrix disturbances, increased focal vascularity and abnormal cytokine profiles contribute to the clinical presentations of chronic tendon pain or rupture. With this integrative pathogenesis theory, we can relate the known manifestations of tendinopathy and point to the "missing links". This model may guide future research on tendinopathy, until we could ultimately decipher the complete pathogenesis process and provide better treatments.

Effect of pulsing in low-level light therapy

BACKGROUND AND OBJECTIVE

Low level light (or laser) therapy (LLLT) is a rapidly growing modality used in physical therapy, chiropractic, sports medicine and increasingly in mainstream medicine. LLLT is used to increase wound healing and tissue regeneration, to relieve pain and inflammation, to prevent tissue death, to mitigate degeneration in many neurological indications. While some agreement has emerged on the best wavelengths of light and a range of acceptable dosages to be used (irradiance and fluence), there is no agreement on whether continuous wave or pulsed light is best and on what factors govern the pulse parameters to be chosen.

STUDY DESIGN/MATERIALS AND METHODS

The published peer-reviewed literature was reviewed between 1970 and 2010.

RESULTS

The basic molecular and cellular mechanisms of LLLT are discussed. The type of pulsed light sources available and the parameters that govern their pulse structure are outlined. Studies that have compared continuous wave and pulsed light in both animals and patients are reviewed. Frequencies used in other pulsed modalities used in physical therapy and biomedicine are compared to those used in LLLT.

CONCLUSION

There is some evidence that pulsed light does have effects that are different from those of continuous wave light. However further work is needed to define these effects for different disease conditions and pulse structures.

Low-level laser therapy (LLLT; 780 nm) acts differently on mRNA expression of anti- and pro-inflammatory mediators in an experimental model of collagenase-induced tendinitis in rat

Low-level laser therapy (LLLT) has been found to produce anti-inflammatory effects in a variety of disorders. Tendinopathies are directly related to unbalance in expression of pro- and anti-inflammatory cytokines which are responsible by degeneration process of tendinocytes. In the current study, we decided to investigate if LLLT could reduce mRNA expression for TNF-α, IL-1β, IL-6, TGF-β cytokines, and COX-2 enzyme. Forty-two male Wistar rats were divided randomly in seven groups, and tendinitis was induced with a collagenase intratendinea injection. The mRNA expression was evaluated by real-time PCR in 7th and 14th days after tendinitis. LLLT irradiation with wavelength of 780 nm required for 75 s with a dose of 7.7 J/cm(2) was administered in distinct moments: 12 h and 7 days post tendinitis. At the 12 h after tendinitis, the animals were irradiated once in intercalate days until the 7th or 14th day in and them the animals were killed, respectively. In other series, 7 days after tendinitis, the animals were irradiated once in intercalated days until the 14th day and then the animals were killed. LLLT in both acute and chronic phases decreased IL-6, COX-2, and TGF-β expression after tendinitis, respectively, when compared to tendinitis groups: IL-6, COX-2, and TGF-β. The LLLT not altered IL-1β expression in any time, but reduced the TNF-α expression; however, only at chronic phase. We conclude that LLLT administered with this protocol reduces one of features of tendinopathies that is mRNA expression for pro-inflammatory mediators.

Effect of pulsing in low-level light therapy

BACKGROUND AND OBJECTIVE

Low level light (or laser) therapy (LLLT) is a rapidly growing modality used in physical therapy, chiropractic, sports medicine and increasingly in mainstream medicine. LLLT is used to increase wound healing and tissue regeneration, to relieve pain and inflammation, to prevent tissue death, to mitigate degeneration in many neurological indications. While some agreement has emerged on the best wavelengths of light and a range of acceptable dosages to be used (irradiance and fluence), there is no agreement on whether continuous wave or pulsed light is best and on what factors govern the pulse parameters to be chosen.

STUDY DESIGN/MATERIALS AND METHODS

The published peer-reviewed literature was reviewed between 1970 and 2010.

RESULTS

The basic molecular and cellular mechanisms of LLLT are discussed. The type of pulsed light sources available and the parameters that govern their pulse structure are outlined. Studies that have compared continuous wave and pulsed light in both animals and patients are reviewed. Frequencies used in other pulsed modalities used in physical therapy and biomedicine are compared to those used in LLLT.

CONCLUSION

There is some evidence that pulsed light does have effects that are different from those of continuous wave light. However further work is needed to define these effects for different disease conditions and pulse structures.

Hand therapist management of the lateral epicondylosis: a survey of expert opinion and practice patterns

Lateral epicondylosis (LE) is a common condition. Knowledge on practice patterns underlies identification of knowledge to practice gaps. The purpose was to determine the practice patterns and beliefs of hand therapists in managing LE. The study design used was a descriptive survey. A survey of Certified Hand Therapists and members of the American Society of Hand Therapists was conducted (n=693). Questions were framed around frequency and perceived effectiveness of interventions, examination techniques, outcome measures, and prognostic factors. More than 80% of therapists use education/activity modification, home exercise, LE orthoses, and stretching for both the acute and chronic LE. Therapists perceive education, orthoses and home exercise are the most effective for acute cases, whereas in chronic cases, orthoses dropped to ninth in ranked perceived effectiveness. Grip strength (80%) and numeric pain rating (71%) were the most commonly used outcome measures. Most (>70%) therapists perceived occupation and duration of symptoms are prognostic in terms of resolution of symptoms, whereas compliance with exercise (78%) and work factors are important for return to work. Therapists rely on impairment measures to evaluate hand therapy outcomes in patients with LE. Hand therapists are aligned with a number of recommendations from the available systematic reviews, although the use of outcome measures and optimal definition of education and exercise exhibit evidence to practice gaps.

LEVEL OF EVIDENCE

Level 5.

Effectiveness of manual therapies: the UK evidence report

BACKGROUND

The purpose of this report is to provide a succinct but comprehensive summary of the scientific evidence regarding the effectiveness of manual treatment for the management of a variety of musculoskeletal and non-musculoskeletal conditions.

METHODS

The conclusions are based on the results of systematic reviews of randomized clinical trials (RCTs), widely accepted and primarily UK and United States evidence-based clinical guidelines, plus the results of all RCTs not yet included in the first three categories. The strength/quality of the evidence regarding effectiveness was based on an adapted version of the grading system developed by the US Preventive Services Task Force and a study risk of bias assessment tool for the recent RCTs.

RESULTS

By September 2009, 26 categories of conditions were located containing RCT evidence for the use of manual therapy: 13 musculoskeletal conditions, four types of chronic headache and nine non-musculoskeletal conditions. We identified 49 recent relevant systematic reviews and 16 evidence-based clinical guidelines plus an additional 46 RCTs not yet included in systematic reviews and guidelines.Additionally, brief references are made to other effective non-pharmacological, non-invasive physical treatments.

CONCLUSIONS

Spinal manipulation/mobilization is effective in adults for: acute, subacute, and chronic low back pain; migraine and cervicogenic headache; cervicogenic dizziness; manipulation/mobilization is effective for several extremity joint conditions; and thoracic manipulation/mobilization is effective for acute/subacute neck pain. The evidence is inconclusive for cervical manipulation/mobilization alone for neck pain of any duration, and for manipulation/mobilization for mid back pain, sciatica, tension-type headache, coccydynia, temporomandibular joint disorders, fibromyalgia, premenstrual syndrome, and pneumonia in older adults. Spinal manipulation is not effective for asthma and dysmenorrhea when compared to sham manipulation, or for Stage 1 hypertension when added to an antihypertensive diet. In children, the evidence is inconclusive regarding the effectiveness for otitis media and enuresis, and it is not effective for infantile colic and asthma when compared to sham manipulation.Massage is effective in adults for chronic low back pain and chronic neck pain. The evidence is inconclusive for knee osteoarthritis, fibromyalgia, myofascial pain syndrome, migraine headache, and premenstrual syndrome. In children, the evidence is inconclusive for asthma and infantile colic.

Effect of low-level laser therapy (GaAs 904 nm) in skeletal muscle fatigue and biochemical markers of muscle damage in rats

We wanted to test if pre-exercise muscle irradiation with 904 nm laser affects the development of fatigue, blood lactate levels and creatine kinase (CK) activity in a rat model with tetanic contractions. Thirty male Wistar rats were divided into five groups receiving either one of four different laser doses (0.1, 0.3, 1.0 and 3.0 J) or a no-treatment control group. Laser irradiation was performed immediately before the first contraction for treated groups. Electrical stimulation was used to induce six tetanic tibial anterior muscle contractions with 10 min intervals between them. Contractions were stopped when the muscle force fell to 50% of the peak value for each contraction; blood samples were taken before the first and immediately after the sixth contraction. The relative peak forces for the sixth contraction were significantly better (P < 0.05) in the two laser groups irradiated with highest doses [151.27% (SD +/- 18.82) for 1.0 J, 144.84% (SD +/- 34.47) for 3.0 J and 82.25% (SD +/- 11.69) for the control group]. Similar significant (P < 0.05) increases in mean performed work during the sixth contraction for the 1.0 and 3.0 J groups were also observed. Blood lactate levels were significantly lower (P < 0.05) than the control group in all irradiated groups. All irradiated groups except the 3.0 J group had significantly lower post-exercise CK activity than the control group. We conclude that pre-exercise irradiation with a laser dose of 1.0 J and 904 nm wavelength significantly delays muscle fatigue and decreases post-exercise blood lactate and CK in this rat model.

Efficacy of low-level laser therapy in the management of neck pain: a systematic review and meta-analysis of randomised placebo or active-treatment controlled trials

BACKGROUND

Neck pain is a common and costly condition for which pharmacological management has limited evidence of efficacy and side-effects. Low-level laser therapy (LLLT) is a relatively uncommon, non-invasive treatment for neck pain, in which non-thermal laser irradiation is applied to sites of pain. We did a systematic review and meta-analysis of randomised controlled trials to assess the efficacy of LLLT in neck pain.

METHODS

We searched computerised databases comparing efficacy of LLLT using any wavelength with placebo or with active control in acute or chronic neck pain. Effect size for the primary outcome, pain intensity, was defined as a pooled estimate of mean difference in change in mm on 100 mm visual analogue scale.

FINDINGS

We identified 16 randomised controlled trials including a total of 820 patients. In acute neck pain, results of two trials showed a relative risk (RR) of 1.69 (95% CI 1.22-2.33) for pain improvement of LLLT versus placebo. Five trials of chronic neck pain reporting categorical data showed an RR for pain improvement of 4.05 (2.74-5.98) of LLLT. Patients in 11 trials reporting changes in visual analogue scale had pain intensity reduced by 19.86 mm (10.04-29.68). Seven trials provided follow-up data for 1-22 weeks after completion of treatment, with short-term pain relief persisting in the medium term with a reduction of 22.07 mm (17.42-26.72). Side-effects from LLLT were mild and not different from those of placebo.

INTERPRETATION

We show that LLLT reduces pain immediately after treatment in acute neck pain and up to 22 weeks after completion of treatment in patients with chronic neck pain.

FUNDING

None.

Conservative management of posterior interosseous neuropathy in an elite baseball pitcher's return to play: a case report and review of the literature

This report documents retrospectively a case of Posterior Interosseous Neuropathy (PIN) occurring in an elite baseball pitcher experiencing a deep ache in the radial aspect of the forearm and altered sensation in the dorsum of the hand on the throwing arm during his pitching motion. The initial clinical goal was to control for inflammation to the nerve and muscle with active rest, microcurrent therapy, low-level laser therapy, and cessation of throwing. Minimizing mechanosensitivity at the common extensor region of the right elbow and PIN, was achieved by employing the use of myofascial release and augmented soft tissue mobilization techniques. Neurodynamic mobilization technique was also administered to improve neural function. Implementation of a sport specific protocol for the purposes of maintaining throwing mechanics and overall conditioning was utilized. Successful resolution of symptomatology and return to pre-injury status was achieved in 5 weeks. A review of literature and an evidence-based discussion for the differential diagnoses, clinical examination, diagnosis, management and rehabilitation of PIN is presented.

From mini-invasive to non-invasive treatment using monopolar radiofrequency: the next orthopaedic frontier

Tendinopathy arises from a failed tendon healing process. Current non-invasive therapeutic alternatives are anti-inflammatory in nature, and outcomes are unpredictable. The benefit of invasive alternatives resides in the induction of the healing response. A new technology that uses non-invasive monopolar capacitive coupled radiofrequency has demonstrated the ability to raise temperatures in tendons and ligaments above 50 degrees C, the threshold for collagen modulation, tissue shrinkage and recruitment of macrophages, fibroblasts, and heat shock protein factors, without damaging the overlying structures, resulting in activation of the wound healing response. Monopolar capacitive-coupled radiofrequency offers a new non-invasive choice for tendinopathies and sprained ligaments. It does not interfere with subsequent surgical procedures should they become necessary.

Low-energy laser irradiation promotes synovial fibroblast proliferation by modulating p15 subcellular localization

BACKGROUND AND OBJECTIVE

Low-energy laser irradiation (low-level laser therapy) (LELI/LLLT/photobiomodulation) has been found to modulate various biological effects, especially those involved in promoting cell proliferation. Synovial fibroblasts are important in maintaining the homeostasis of articular joints and have strong chondrogenetic capacity. Here, we investigated the effect and molecular basis of LELI on synovial fibroblast proliferation.

STUDY DESIGN/MATERIALS AND METHODS

HIG-82 rabbit synovial fibroblasts were cultured, and laser irradiation (660 nm) was applied at the power density of 40 mW/cm(2) for 2 minutes, corresponding to laser fluence of 4.8 J/cm(2). The effect of LELI on cell proliferation, cell cycle progression, and expression of cyclin-dependent kinase inhibitors (CKIs) were investigated. We also examined whether the effects of LELI on HIG-82 cell proliferation were affected by cAMP content, which is known to influence the cell cycle via inducing CKIs.

RESULTS

LELI promoted HIG-82 synovial fibroblast proliferation and induced cytoplasmic localization of cyclin-dependent kinase inhibitor p15 (INK4B/CDKN2B). Moreover, the proliferation of HIG-82 synovial fibroblasts was reduced by cAMP, while cAMP inhibitor, SQ22536, induced p15 cytoplasmic localization and as a result, elevated synovial fibroblast proliferation was observed. In addition, the promotive effect of LELI-induced HIG-82 synovial fibroblast proliferation was abolished by cAMP treatment. Our findings suggest that cAMP may be involved in the effect of LELI on synovial fibroblast proliferation.

CONCLUSION

We revealed the effect and molecular link involved in synovial fibroblast proliferation induced by 660-nm LELI. Our study provides new insights into the mechanisms by which LELI has biological effects on synovial fibroblast proliferation. These insights may contribute to further investigation on biological effects and application of LELI in regenerative medicine.

Effect of laser acupoint treatment on blood pressure and body weight-a pilot study

OBJECTIVE

This study reports on the effects of laser acupuncture on blood pressure, body weight, and heart rate variability by stimulating acupuncture points and meridians on college students and faculty members.

METHODS

Forty-five students and faculty members from a chiropractic college were recruited in the study. All subjects signed a written informed consent before their participation in the study. This study was a randomized controlled pilot study with subjects divided into control and experimental groups. The control group received a sham low-level laser therapy treatment with no power output to the laser during their "treatment." The experimental group was treated with an activated laser. The acupuncture points used in this study were LI 4 and LI 11 for body weight and blood pressure. The treatment groups received 16 J of laser energy output for a total treatment time of 8 minutes (4 minutes for each of the 2 points).

RESULTS

After using the laser treatment for 90 days (at least 12 treatments per subject), both the systolic and diastolic blood pressures decreased significantly (P < .01). The mean systolic blood pressure was 129.6 +/- 14.7 mm Hg before the treatment and was reduced to 122.5 +/- 17.2 mm Hg (P < .001). The mean diastolic blood pressure was 85.6 +/- 8.0 mm Hg before treatment and was reduced to 77.2 +/- 8.7 mm Hg (P < .001). Subject's body weight was reduced in the active acupoint group, but the weight reduction did not reach a significant level. There were no significant changes in the heart rate variability.

CONCLUSION

It was concluded that low-level laser treatment of acupoint resulted in lower blood pressure by stimulating the LI 11 and LI 4. No significant difference was observed in both the body weight and heart rate variability after the laser acupoint treatment.