Investigation of the Supplementary Effect of GaAs Laser Therapy on the Rehabilitation of Human Digital Flexor Tendons

Effect of Low-Level Laser Therapy on Knee Range of Motion and Functional Abilities After Total Knee Arthroplasty

OBJECTIVE

The aim of this study was to determine the effectiveness of combined low-level laser therapy (LLL) and rehabilitation in patients following recent total knee replacement (TKR).

METHODS

A double-blind randomized controlled study was conducted at the Orthopedic Department of Mansoura University Hospital. Forty-four patients were chosen from a total of 58 patients who met the inclusion criteria and were assigned randomly into control and experimental groups of equal size. Ultimately, 40 patients completed the study (20 from each group). Both groups participated in an intensive functional rehabilitation program, and the experimental group also received LLL therapy around the knee at the incisional line, the medial and lateral intra-articular space, above and below the patella, and at the popliteal fossa at low fluence (6 J/cm2, 650 nm continuous wave) and 60 s per point with a total dose of 48 J per session over 12 treatment sessions for six weeks. Knee range of motion (ROM) was measured with a digital goniometer, and functional abilities were assessed with the Arabic version of the Western Ontario and McMaster Universities Osteoarthritis (WOMAC) index.

RESULTS

There were significant differences in all variables pre- and post-treatment within each group. Before treatment, there was no significant difference in any of the measured variables between the groups (P>0.05). After treatment, there were significant differences in knee flexion ROM and WOMAC index (P<0.05) but no significant difference in knee extension ROM between the groups (P>0.05).

CONCLUSION

The addition of low-level laser therapy to a rehabilitation program post-TKR resulted in substantial enhancements in knee flexion range of motion and the WOMAC index.

Rehabilitation following surgery for flexor tendon injuries of the hand

BACKGROUND

Various rehabilitation treatments may be offered following surgery for flexor tendon injuries of the hand. Rehabilitation often includes a combination of an exercise regimen and an orthosis, plus other rehabilitation treatments, usually delivered together. The effectiveness of these interventions remains unclear.

OBJECTIVES

To assess the effects (benefits and harms) of different rehabilitation interventions after surgery for flexor tendon injuries of the hand.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials, the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register, MEDLINE, Embase, two additional databases and two international trials registries, unrestricted by language. The last date of searches was 11 August 2020. We checked the reference lists of included studies and relevant systematic reviews.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and quasi-RCTs that compared any postoperative rehabilitation intervention with no intervention, control, placebo, or another postoperative rehabilitation intervention in individuals who have had surgery for flexor tendon injuries of the hand. Trials comparing different mobilisation regimens either with another mobilisation regimen or with a control were the main comparisons of interest. Our main outcomes of interest were patient-reported function, active range of motion of the fingers, and number of participants experiencing an adverse event.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected trials for inclusion, extracted data, assessed risk of bias and assessed the quality of the body of evidence for primary outcomes using the GRADE approach, according to standard Cochrane methodology.

MAIN RESULTS

We included 16 RCTs and one quasi-RCT, with a total of 1108 participants, mainly adults. Overall, the participants were aged between 7 and 72 years, and 74% were male. Studies mainly focused on flexor tendon injuries in zone II. The 17 studies were heterogeneous with respect to the types of rehabilitation treatments provided, intensity, duration of treatment and the treatment setting. Each trial tested one of 14 comparisons, eight of which were of different exercise regimens. The other trials examined the timing of return to unrestricted functional activities after surgery (one study); the use of external devices applied to the participant to facilitate mobilisation, such as an exoskeleton (one study) or continuous passive motion device (one study); modalities such as laser therapy (two studies) or ultrasound therapy (one study); and a motor imagery treatment (one study). No trials tested different types of orthoses; different orthosis wearing regimens, including duration; different timings for commencing mobilisation; different types of scar management; or different timings for commencing strengthening. Trials were generally at high risk of bias for one or more domains, including lack of blinding, incomplete outcome data and selective outcome reporting. Data pooling was limited to tendon rupture data in a three trial comparison. We rated the evidence available for all reported outcomes of all comparisons as very low-certainty evidence, which means that we have very little confidence in the estimates of effect. We present the findings from three exercise regimen comparisons, as these are commonly used in clinical current practice. Early active flexion plus controlled passive exercise regimen versus early controlled passive exercise regimen (modified Kleinert protocol) was compared in one trial of 53 participants with mainly zone II flexor tendon repairs. There is very low-certainty evidence of no clinically important difference between the two groups in patient-rated function or active finger range of motion at 6 or 12 months follow-up. There is very low-certainty evidence of little between-group difference in adverse events: there were 15 overall. All three tendon ruptures underwent secondary surgery. An active exercise regimen versus an immobilisation regimen for three weeks was compared in one trial reporting data for 84 participants with zone II flexor tendon repairs. The trial did not report on self-rated function, on range of movement during three to six months or numbers of participants experiencing adverse events. The very low-certainty evidence for poor (under one-quarter that of normal) range of finger movement at one to three years follow-up means we are uncertain of the finding of zero cases in the active group versus seven cases in the immobilisation regimen. The same uncertainty applies to the finding of little difference between the two groups in adverse events (5 tendon ruptures in the active group versus 10 probable scar adhesion in the immobilisation group) indicated for surgery. Place and hold exercise regimen performed within an orthosis versus a controlled passive regimen using rubber band traction was compared in three heterogeneous trials, which reported data for a maximum of 194 participants, with mainly zone II flexor tendon repairs. The trials did not report on range of movement during three to six months, or numbers of participants experiencing adverse events. There was very low-certainty evidence of no difference in self-rated function using the Disability of the Arm, Shoulder and Hand (DASH) functional assessment between the two groups at six months (one trial) or at 12 months (one trial). There is very low-certainty evidence from one trial of greater active finger range of motion at 12 months after place and hold. Secondary surgery data were not available; however, all seven recorded tendon ruptures would have required surgery. All the evidence for the other five exercise comparisons as well as those of the other six comparisons made by the included studies was incomplete and, where available, of very low-certainty.

AUTHORS' CONCLUSIONS

There is a lack of evidence from RCTs on most of the rehabilitation interventions used following surgery for flexor tendon injuries of the hand. The limited and very low-certainty evidence for all 14 comparisons examined in the 17 included studies means that we have very little confidence in the estimates of effect for all outcomes for which data were available for these comparisons. The dearth of evidence identified in this review points to the urgent need for sufficiently powered RCTs that examine key questions relating to the rehabilitation of these injuries. A consensus approach identifying these and establishing minimum study conduct and reporting criteria will be valuable. Our suggestions for future research are detailed in the review.

Comparison of Photobiomodulation and Anti-Inflammatory Drugs on Tissue Repair on Collagenase-Induced Achilles Tendon Inflammation in Rats

BACKGROUND

Tendinopathy is characterized by pain, edema, and structural changes in tendon tissue.

OBJECTIVE

In this animal study we decided to compare the short- and medium-term effects of low-level laser therapy (LLLT), dexamethasone, and diclofenac on inflammation and tendon tissue repair in collagenase-induced tendinitis.

MATERIALS AND METHODS

Two hundred five female Wistar rats were randomly divided into five groups. Animals in the control group were given a saline injection and the experimental groups received a collagenase injection (100 μg/tendon) in the peritendinous Achilles and received no treatment, LLLT (3 J, 810 nm, 100 mW), diclofenac (1.1 mg/kg), or dexamethasone (0.02 mg/kg). Histological analyses were performed at 10 time points up to 60 days (n = 5/group each time point), and included an assessment of the severity of inflammation, collagen fiber content, and organization.

RESULTS

Collagenase injection induced a severe inflammatory reaction with significant reduction in collagen content for 48 h, and disorientation of collagen fibers lasting between 14 and 21 days. Diclofenac and dexamethasone reduced inflammatory signs during the first 2 days, although there was prolongation of the inflammatory phase and slower normalization of tendon quality, particularly in the dexamethasone group. LLLT prevented hemorrhage, reduced inflammation severity, and preserved tendon morphology compared with the other groups.

CONCLUSIONS

LLLT showed a significant superiority over commonly used anti-inflammatory pharmaceutical agents in acute collagenase-induced tendinitis.

Achilles Tendinopathy: Current Concepts about the Basic Science and Clinical Treatments

Achilles tendinopathy is one of the most frequently ankle and foot overuse injuries, which is a clinical syndrome characterized by the combination of pain, swelling, and impaired performance. The two main categories of Achilles tendinopathy are classified according to anatomical location and broadly include insertional and noninsertional tendinopathy. The etiology of Achilles tendinopathy is multifactorial including both intrinsic and extrinsic factors. Failed healing response and degenerative changes were found in the tendon. The failed healing response includes three different and continuous stages (reactive tendinopathy, tendon disrepair, and degenerative tendinopathy). The histological studies have demonstrated an increased number of tenocytes and concentration of glycosaminoglycans in the ground substance, disorganization and fragmentation of the collagen, and neovascularization. There are variable conservative and surgical treatment options for Achilles tendinopathy. However, there has not been a gold standard of these treatments because of the controversial clinical results between various studies. In the future, new level I researches will be needed to prove the effect of these treatment options.

Low level laser therapy (lllt) for chronic joint pain of the elbow, wrist and fingers

BACKGROUND AND AIMS

In previous studies, we successfully applied Low Level Laser Therapy (LLLT) in patients with non-specific chronic pain of the shoulder joint and lower back. The purpose of the present study was to assess the effectiveness of LLLT for chronic joint pain of the elbow, wrist, and fingers.

SUBJECTS AND METHODS

Nine male and 15 female patients with chronic joint pain of the elbow, wrist, or fingers, who were treated at the rehabilitation outpatient clinic at our hospital from April, 2007 to March, 2009 were enrolled in the study. We used a 1000 mW semiconductor laser device. Each tender point and three points around it were irradiated with laser energy. Each point was irradiated twice for 20 s per treatment, giving a total of three minutes for all 4 points. Patients visited the clinic twice a week, and were evaluated after four weeks of treatment. Pain was evaluated with a Visual Analogue Scale (VAS). Statistical analysis of the VAS scores after laser irradiation was performed with Wilcoxon's signed rank sum test, using SPSS Ver.17.

RESULTS

All VAS scores were totaled and statistically analyzed. The average VAS score before irradiation was 59.2±12.9, and 33.1±12.2 after the irradiation, showing a significant improvement in VAS score (p<0.001) after treatment. The treatment effect lasted for about one and a half days in the case of wrist pain, epicondylitis lateralis (tennis elbow), and carpal tunnel syndrome. In other pain entities, it lasted for about three to fifteen hours. No change in the range of motion (ROM) was seen in any of the 24 subjects.

CONCLUSION

We concluded that LLLT at the wavelength and parameters used in the present study was effective for chronic pain of the elbow, wrist, and fingers.

Skin-derived fibroblasts for the treatment of refractory Achilles tendinosis: preliminary short-term results

BACKGROUND

Chronic Achilles tendinosis is a common musculoskeletal disorder often refractory to conservative management. Our study aimed to assess the safety and efficacy of the use of autologous skin-derived collagen-producing cells in the treatment of refractory Achilles tendinosis.

METHODS

We conducted a randomized, double-blind study on forty Achilles tendons in thirty-two patients (eight with bilateral involvement) who had a clinical and radiographic diagnosis of Achilles tendinosis. The patients ranged from twenty-two to sixty-seven years old and had a mean age of 45.2 years. The patients with unilateral involvement were randomized into the treatment group (twelve patients) and control group (twelve patients). The eight patients with bilateral involvement were individually randomized into treatment and control groups, with eight Achilles tendons in each group. Achilles tendons in the treatment group were injected under ultrasound guidance with laboratory-expanded, skin-derived fibroblasts suspended in autologous plasma. The control group received ultrasound-guided injection of a local anesthetic and physiotherapy. The Victorian Institute of Sport Assessment (VISA) questionnaire and visual analog scale (VAS) scores were used as the main outcome measures for both groups.

RESULTS

Significant differences in the mean VISA and VAS scores were detected between the treatment and the control groups for the patients with unilateral involvement at six months (p < 0.001 for both). With use of the Mann-Whitney U Test, significant differences in the VISA score were observed at the second visit and at the three-month and six-month visits (p = 0.02, p = 0.007, and p < 0.001 respectively). The VAS scores also showed significant differences at the second visit and at the six-month evaluation (p = 0.014 and p < 0.001, respectively). The eight patients with bilateral involvement were analyzed separately; with the number of patients studied, no significant differences in the VISA or VAS scores were observed between the treatment group and the control group.

CONCLUSIONS

These preliminary short-term results demonstrate that the injection of skin-derived fibroblasts for the treatment of Achilles tendinosis is safe. However, larger studies with a longer duration of follow-up are required to determine the long-term effectiveness before wider clinical application is considered.

An in-vivo experimental evaluation of He-Ne laser photostimulation in healing Achilles tendons

There is no method of treatment that has been proven to accelerate the rate of tendon healing or to improve the quality of the regenerating tendon. Low level laser photostimulation has gained a considerable attention for enhancing tissue repair in a wide spectrum of applications. However, there is controversy regarding the effectiveness of laser photostimulation for improvement of the healing process of surgically repaired tendons. Accordingly, the present study was conducted to evaluate the role of helium-neon (He-Ne) laser photostimulation on the process of healing of surgically repaired Achilles tendons. Thirty unilateral Achilles tendons of 30 Raex rabbits were transected and immediately repaired. Operated Achilles tendons were randomly divided into two equal groups. Tendons at group A were subjected to He-Ne laser (632.8 nm) photostimulation, while tendons at group B served as a control group. Two weeks later, the repaired Achilles tendons were histopathologically and biomechanically evaluated. The histopathological findings suggest the favorable qualitative pattern of the newly synthesized collagen of the regenerating tendons after He-Ne laser photostimulation. The biomechanical results support the same favorable findings from the functional point of view as denoted by the better biomechanical properties of the regenerating tendons after He-Ne laser photostimulation with statistical significance (p <or= 0.01) at most of the biomechanical parameters. He-Ne laser photostimulation reported a great value after surgical repair of ruptured and injured tendons for a better functional outcome. It could be applied safely and effectively in humans, especially with respect to the proposed long-term clinical outcome.

Biomechanical basis for tendinopathy

Tendinopathy affects millions of people in athletic and occupational settings and is a nemesis for patients and physicians. Mechanical loading is a major causative factor for tendinopathy; however, the exact mechanical loading conditions (magnitude, frequency, duration, loading history, or some combinations) that cause tendinopathy are poorly defined. Exercise animal model studies indicate that repetitive mechanical loading induces inflammatory and degenerative changes in tendons, but the cellular and molecular mechanisms responsible for such changes are not known. Injection animal model studies show that collagenase and inflammatory agents (inflammatory cytokines and prostaglandin E1 and E2) may be involved in tendon inflammation and degeneration; however, whether these molecules are involved in the development of tendinopathy because of mechanical loading remains to be verified. Finally, despite improved treatment modalities, the clinical outcome of treatment of tendinopathy is unpredictable, as it is not clear whether a specific modality treats the symptoms or the causes. Research is required to better understand the mechanisms of tendinopathy at the tissue, cellular, and molecular levels and to develop new scientifically based modalities to treat tendinopathy more effectively.

The future: rehabilitation, gene therapy, optimization of healing

Tendon disorders can be debilitating for patients and are difficult to manage. Current management strategies offer symptomatic relief, but may not result in definitive disease resolution. Despite remodeling, the biochemical and mechanical properties of healed tendon tissue never match those of intact tendon. This article outlines the stages of tendon healing, and reviews the possible strategies for optimizing tendon healing and repair, such as cytokine therapy, gene therapy, and tissue engineering.

Tendon injury and tendinopathy: healing and repair

Tendon disorders are frequent and are responsible for substantial morbidity both in sports and in the workplace. Tendinopathy, as opposed to tendinitis or tendinosis, is the best generic descriptive term for the clinical conditions in and around tendons arising from overuse. Tendinopathy is a difficult problem requiring lengthy management, and patients often respond poorly to treatment. Preexisting degeneration has been implicated as a risk factor for acute tendon rupture. Several physical modalities have been developed to treat tendinopathy. There is limited and mixed high-level evidence to support the, albeit common, clinical use of these modalities. Further research and scientific evaluation are required before biological solutions become realistic options.