Effects of low-level laser therapy and eccentric exercises in the treatment of recreational athletes with chronic achilles tendinopathy

Effects of photobiomodulation therapy associated with motor control exercise for chronic non-specific low back pain: protocol for a randomised placebo-controlled trial

Photobiomodulation therapy (PBMT), as an adjunct therapy to exercise, can reduce pain in musculoskeletal disorders. In addition, PBMT associated with exercise decreases fatigue, accelerates muscle recovery and enhances performance and gain through different training protocols. Although it has not been investigated, the association of PBMT and exercise therapy could be an alternative to improve the positive effects of exercise in patients with non-specific low back pain (LBP). Therefore, we aim to evaluate the effects of PBMT associated with motor control exercise (MCE) versus placebo associated with MCE in patients with chronic non-specific LBP. This is a prospectively registered, two-arm, randomised, placebo-controlled, triple-blind trial. A total of 148 patients with chronic non-specific LBP will be randomised to either active PBMT associated with MCE or placebo PBMT associated with MCE. Treatment sessions will be provided twice a week for 6 weeks. The primary outcomes will be pain intensity and general disability measured at the end of the treatment. The secondary outcomes will be pain intensity and general disability measured 1 month after the end of the treatment, 3, 6 and 12 months after randomisation, in addition to levels of prostaglandin E2 measured at the end of the treatment. Medication intake, cointerventions and adverse events will be measured at all time points. This study was approved by the Research Ethics Committee of Irmandade de Santa Casa de Misericórdia de Porto Alegre. The results will be disseminated through scientific publications and presentations at scientific meetings. Trial registration number: NCT05487118.

Effectiveness of Low-Level Laser Therapy Combined With Eccentric Exercise in Treating Midportion Achilles Tendinopathy: A Randomized Controlled Trial

Background Achilles tendinopathy is a common overuse tendon injury, affecting athletes in running and similar sports. Repetitive overload of the Achilles tendon is the primary cause of inflammation, collagen degeneration, and tendon thickening. This study aims to investigate the efficacy of combining low-level laser therapy (LLLT) with eccentric exercises in treating midportion Achilles tendinopathy. Methods This prospective randomized controlled trial was conducted at the Sports Injury Centre, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, from 2019 to 2022. Sixty clinically diagnosed patients with midportion Achilles tendinopathy, aged 18 to 60, were randomly assigned to two groups: Group A received eccentric exercises with LLLT, and Group B received eccentric exercises with placebo LLLT. The Victorian Institute of Sport Assessment-Achilles (VISA-A) score and the visual analog scale (VAS) score were used to measure treatment effectiveness at baseline and three, six, 12, and 24 weeks. Results The study included 60 participants, with no dropouts observed. The mean age was 33.9 ± 8.3 years in Group A and 33.40 ± 8.64 years in Group B, with no significant difference between the groups (p = 0.821). Both groups showed significant improvement in VISA-A and VAS scores over time (p < 0.001), but there was no statistically significant difference between the groups at any time point (p > 0.05). Conclusion Adding LLLT to eccentric exercises did not provide significant additional benefits compared to eccentric exercises alone in treating midportion Achilles tendinopathy. Practitioners should prioritize evidence-based interventions, such as eccentric exercises, as the primary treatment modality while considering alternative therapies for adjunctive purposes. Further research is needed to explore additional modalities or combination therapies that may enhance outcomes for patients with Achilles tendinopathy.

Effects of Photobiomodulation on Pain and Return to Play of Injured Athletes: A Systematic Review and Meta-analysis

ABSTRACT

Morgan, RM, Wheeler, TD, Poolman, MA, Haugen, ENJ, LeMire, SD, and Fitzgerald, JS. Effects of photobiomodulation on pain and return to play of injured athletes: A systematic review and meta-analysis. J Strength Cond Res 38(6): e310-e319, 2024-The aims of this systematic review and meta-analysis were to evaluate the effect of photobiomodulation (PBM) on musculoskeletal pain in injured athletes and to determine if the effects of PBM allowed injured athletes to return to play faster. Electronic databases (MEDLINE Complete, CINAHL, and SPORTDiscus, PubMed, Web of Science, and Embase) were systematically searched (up to and including November 7, 2023) for peer-reviewed randomized controlled trials (RCTs) meeting criteria. Six RCTs, representing 205 competitive and recreational athletes with a mean age of 24 years, were included in the analysis. There were 6 intervention groups using standard physical therapy (n = 1), placebo PBM (n = 4), and aloe gel (n = 1) lasting between 10 minutes and 8 weeks in duration. The level of significance set for the study was p < 0.05. Overall, the use of PBM indicated a positive effect on pain reduction for PBM vs. control groups, standardized mean differences = 1.03, SE = 0.22, 95% confidence intervals = [0.43-1.63], p = 0.0089, but the 2 RCTs found evaluating the effect of PBM on time to return to play after injury in athletes do not support a benefit. Allied healthcare professionals may use PBM to reduce pain, thus allowing an athlete to return to their normal biomechanical movement faster; however, limited evidence suggests that PBM does not reduce time to return to play after an injury.

Photobiomodulation combination therapy as a new insight in neurological disorders: a comprehensive systematic review

Preclinical and clinical studies have indicated that combining photobiomodulation (PBM) therapy with other therapeutic approaches may influence the treatment process in a variety of disorders. The purpose of this systematic review was to determine whether PBM-combined therapy provides additional benefits over monotherapies in neurologic and neuropsychiatric disorders. In addition, the review describes the most commonly used methods and PBM parameters in these conjunctional approaches.To accomplish this, a systematic search was conducted in Google Scholar, PubMed, and Scopus databases through January 2024. 95 potentially eligible articles on PBM-combined treatment strategies for neurological and neuropsychological disorders were identified, including 29 preclinical studies and 66 clinical trials.According to the findings, seven major categories of studies were identified based on disease type: neuropsychiatric diseases, neurodegenerative diseases, ischemia, nerve injury, pain, paresis, and neuropathy. These studies looked at the effects of laser therapy in combination with other therapies like pharmacotherapies, physical therapies, exercises, stem cells, and experimental materials on neurological disorders in both animal models and humans. The findings suggested that most combination therapies could produce synergistic effects, leading to better outcomes for treating neurologic and psychiatric disorders and relieving symptoms.These findings indicate that the combination of PBM may be a useful adjunct to conventional and experimental treatments for a variety of neurological and psychological disorders.

Socioeconomic Status and Race Are Rarely Reported in Randomized Controlled Trials for Achilles Tendon Pathology in the Top 10 Orthopaedic Journals: A Systematic Review

Background

Randomized controlled trials (RCTs) are crucial in comparative research, and a careful approach to randomization methodology helps minimize bias. However, confounding variables like socioeconomic status (SES) and race are often underreported in orthopaedic RCTs, potentially affecting the generalizability of results. This study aimed to analyze the reporting trends of SES and race in RCTs pertaining to Achilles tendon pathology, considering 4 decades of data from top-tier orthopaedic journals.

Methods

This review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and used PubMed to search 10 high-impact factor orthopaedic journals for RCTs related to the management of Achilles tendon pathology. The search encompassed all articles from the inception of each journal until July 11, 2023. Data extraction included year of publication, study type, reporting of SES and race, primary study location, and intervention details.

Results

Of the 88 RCTs identified, 68 met the inclusion criteria. Based on decade of publication, 6 articles (8.8%) reported on SES, whereas only 2 articles (2.9%) reported on race. No RCTs reported SES in the pre-1999 period, but the frequency of reporting increased in subsequent decades. Meanwhile, all RCTs reporting race were published in the current decade (2020-2030), with a frequency of 20%. When considering the study location, RCTs conducted outside the United States were more likely to report SES compared with those within the USA.

Conclusion

This review revealed a concerning underreporting of SES and race in Achilles tendon pathology RCTs. The reporting percentage remains low for both SES and race, indicating a need for comprehensive reporting practices in orthopaedic research. Understanding the impact of SES and race on treatment outcomes is critical for informed clinical decision making and ensuring equitable patient care. Future studies should prioritize the inclusion of these variables to enhance the generalizability and validity of RCT results.

A pilot study exploring the use of hyaluronic acid in treating insertional achilles tendinopathy

PURPOSE

This study explores the use of ultrasound-guided Hyaluronic Acid (HA) injections for Insertional Achilles Tendinopathy (IAT).

METHODS

A cohort of 15 ankles diagnosed with IAT received three weekly ultrasound-guided HA injections. The Victorian Institute of Sport Assessment - Achilles (VISA-A) questionnaire scored the severity of symptoms and functional impairment before treatment, and at one and six months post-treatment.

RESULTS

Significant improvement was observed in VISA-A scores post-treatment, rising from an average baseline of 34.8 ± 15.2 (11-63) to 53.6 ± 20.9 (15-77) after one month, and then to 50.7 ± 18.6 (20-75) after six months. No adverse reactions were noted, underscoring the safety of the intervention.

CONCLUSION

The pilot study presents HA injections as a potentially effective treatment for IAT, while interpretation of these findings must take into account the variability in results, indicating a range of patient responses. It encourages further research to confirm these findings and to explore HA's full potential in managing IAT, despite the limitations of a small sample size and lack of control group.

Exercise therapy for tendinopathy: a mixed-methods evidence synthesis exploring feasibility, acceptability and effectiveness

Background

Tendinopathy is a common, painful and functionally limiting condition, primarily managed conservatively using exercise therapy.

Review questions

(i) What exercise interventions have been reported in the literature for which tendinopathies? (ii) What outcomes have been reported in studies investigating exercise interventions for tendinopathy? (iii) Which exercise interventions are most effective across all tendinopathies? (iv) Does type/location of tendinopathy or other specific covariates affect which are the most effective exercise therapies? (v) How feasible and acceptable are exercise interventions for tendinopathies?

Methods

A scoping review mapped exercise interventions for tendinopathies and outcomes reported to date (questions i and ii). Thereafter, two contingent systematic review workstreams were conducted. The first investigated a large number of studies and was split into three efficacy reviews that quantified and compared efficacy across different interventions (question iii), and investigated the influence of a range of potential moderators (question iv). The second was a convergent segregated mixed-method review (question v). Searches for studies published from 1998 were conducted in library databases (n = 9), trial registries (n = 6), grey literature databases (n = 5) and Google Scholar. Scoping review searches were completed on 28 April 2020 with efficacy and mixed-method search updates conducted on 19 January 2021 and 29 March 2021.

Results

Scoping review - 555 included studies identified a range of exercise interventions and outcomes across a range of tendinopathies, most commonly Achilles, patellar, lateral elbow and rotator cuff-related shoulder pain. Strengthening exercise was most common, with flexibility exercise used primarily in the upper limb. Disability was the most common outcome measured in Achilles, patellar and rotator cuff-related shoulder pain; physical function capacity was most common in lateral elbow tendinopathy. Efficacy reviews - 204 studies provided evidence that exercise therapy is safe and beneficial, and that patients are generally satisfied with treatment outcome and perceive the improvement to be substantial. In the context of generally low and very low-quality evidence, results identified that: (1) the shoulder may benefit more from flexibility (effect sizeResistance:Flexibility = 0.18 [95% CrI 0.07 to 0.29]) and proprioception (effect sizeResistance:Proprioception = 0.16 [95% CrI -1.8 to 0.32]); (2) when performing strengthening exercise it may be most beneficial to combine concentric and eccentric modes (effect sizeEccentricOnly:Concentric+Eccentric = 0.48 [95% CrI -0.13 to 1.1]; and (3) exercise may be most beneficial when combined with another conservative modality (e.g. injection or electro-therapy increasing effect size by ≈0.1 to 0.3). Mixed-method review - 94 studies (11 qualitative) provided evidence that exercise interventions for tendinopathy can largely be considered feasible and acceptable, and that several important factors should be considered when prescribing exercise for tendinopathy, including an awareness of potential barriers to and facilitators of engaging with exercise, patients' and providers' prior experience and beliefs, and the importance of patient education, self-management and the patient-healthcare professional relationship.

Limitations

Despite a large body of literature on exercise for tendinopathy, there are methodological and reporting limitations that influenced the recommendations that could be made.

Conclusion

The findings provide some support for the use of exercise combined with another conservative modality; flexibility and proprioception exercise for the shoulder; and a combination of eccentric and concentric strengthening exercise across tendinopathies. However, the findings must be interpreted within the context of the quality of the available evidence.

Future work

There is an urgent need for high-quality efficacy, effectiveness, cost-effectiveness and qualitative research that is adequately reported, using common terminology, definitions and outcomes.

Study registration

This project is registered as DOI: 10.11124/JBIES-20-00175 (scoping review); PROSPERO CRD 42020168187 (efficacy reviews); https://osf.io/preprints/sportrxiv/y7sk6/ (efficacy review 1); https://osf.io/preprints/sportrxiv/eyxgk/ (efficacy review 2); https://osf.io/preprints/sportrxiv/mx5pv/ (efficacy review 3); PROSPERO CRD42020164641 (mixed-method review).

Funding

This project was funded by the National Institute for Health and Care Research (NIHR) HTA programme and will be published in full in HTA Journal; Vol. 27, No. 24. See the NIHR Journals Library website for further project information.

Effects of exercise treatment on functional outcome parameters in mid-portion achilles tendinopathy: a systematic review

Exercise interventions are evident in the treatment of mid-portion Achilles tendinopathy (AT). However, there is still a lack of knowledge concerning the effect of different exercise treatments on improving a specific function (e.g., strength) in this population. Thus, this study aimed to systematically review the effect of exercise treatments on different functional outcomes in mid-portion AT. An electronic database of Pubmed, Web of Science, and Cochrane Central Register of Controlled Trials were searched from inception to 21 February 2023. Studies that investigated changes in plantar flexor function with exercise treatments were considered in mid-portion AT. Only randomized controlled trials (RCTs) and clinical controlled trials (CCTs) were included. Functional outcomes were classified by kinetic (e.g., strength), kinematic [e.g., ankle range of motion (ROM)], and sensorimotor (e.g., balance index) parameters. The types of exercise treatments were classified into eccentric, concentric, and combined (eccentric plus concentric) training modes. Quality assessment was appraised using the Physiotherapy Evidence Database scale for RCTs, and the Joanna Briggs Institute scale for CCTs. The search yielded 2,260 records, and a total of ten studies were included. Due to the heterogeneity of the included studies, a qualitative synthesis was performed. Eccentric training led to improvements in power outcomes (e.g., height of countermovement jump), and in strength outcomes (e.g., peak torque). Concentric training regimens showed moderate enhanced power outcomes. Moreover, one high-quality study showed an improvement in the balance index by eccentric training, whereas the application of concentric training did not. Combined training modalities did not lead to improvements in strength and power outcomes. Plantarflexion and dorsiflexion ROM measures did not show relevant changes by the exercise treatments. In conclusion, eccentric training is evident in improving strength outcomes in AT patients. Moreover, it shows moderate evidence improvements in power and the sensorimotor parameter "balance index". Concentric training presents moderate evidence in the power outcomes and can therefore be considered as an alternative to improve this function. Kinematic analysis of plantarflexion and dorsiflexion ROM might not be useful in AT people. This study expands the knowledge what types of exercise regimes should be considered to improve the functional outcomes in AT.

Physical modalities with eccentric exercise are no better than eccentric exercise alone in the treatment of chronic achilles tendinopathy: A systematic review and meta-analysis

BACKGROUND

To investigate the available evidence and conduct a systematic review with meta-analysis to determine the effectiveness of physical modalities combined with eccentric exercise (PMEE) with eccentric exercise (EE) alone for improvements in pain and function in individuals with chronic Achilles tendinopathy (AT) at short-term (4 weeks) and long-term (12-16 weeks) follow-ups.

MATERIALS AND METHODS

A systematic literature review identified 8 papers (from 6404 possible inclusions) that allowed the comparison of PMEE with EE alone, in the treatment of chronic AT. We extracted the mean and standard deviations for Victorian Institute of Sports Assessment Achilles Tendinopathy (VISA-A), Numerical Pain Rating Scale (NPRS), and load-induced pain (NRS). Standardized mean difference (SMD) of the included variables was presented, and all the studies had low risk of bias.

RESULTS

Non-significant results were achieved for short-term (pooled SMD = 0.03; 95% CI= -0.46 to 0.53, p = 0.89, I2 = 60%) and long- term follow-ups (pooled SMD =0.43; 95% CI= -0.05 to 0.92, p = 0.08, I2 = 82%) of VISA-A. Short-term (pooled SMD = -0.16; 95% CI= -0.72 to 0.40, p = 0.57, I2 = 40%) and long-term (pooled SMD = -0.39;95% CI= -1.11 to 0.32, p = 0.28, I2 = 62%) follow-up analysis of NPRS and long-term(pooled SMD = -0.46; 95% CI= -1.08 to 0.15, p = 0.14, I2 = 74%) follow-up of load induced pain also demonstrated non-significant improvements when comparing two groups.

CONCLUSION

Meta- analysis of the results published in the 8 papers that met theinclusion criteria showed no significant differences between PMEE and EE, in terms of load-induced pain (NRS) and numerical pain rating scales (NPRS) at 4 and 12-16 weeks. Thus, the meta-analysis reflects the other cited published work that PMEE shows no greater advantage than EE in the treatment of Chronic Achilles Tendinopathy.

Efficacy of low-level laser therapy in patients with lower extremity tendinopathy or plantar fasciitis: systematic review and meta-analysis of randomised controlled trials

OBJECTIVES

We investigated the effectiveness of low-level laser therapy (LLLT) in lower extremity tendinopathy and plantar fasciitis on patient-reported pain and disability.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

Eligible articles in any language were identified through PubMed, Embase and Physiotherapy Evidence Database (PEDro) on the 20 August 2020, references, citations and experts.

ELIGIBILITY CRITERIA FOR SELECTION OF STUDIES

Only randomised controlled trials involving participants with lower extremity tendinopathy or plantar fasciitis treated with LLLT were included.

DATA EXTRACTION AND SYNTHESIS

Random effects meta-analyses with dose subgroups based on the World Association for Laser Therapy treatment recommendations were conducted. Risk of bias was assessed with the PEDro scale.

RESULTS

LLLT was compared with placebo (10 trials), other interventions (5 trials) and as an add-on intervention (3 trials). The study quality was moderate to high.Overall, pain was significantly reduced by LLLT at completed therapy (13.15 mm Visual Analogue Scale (VAS; 95% CI 7.82 to 18.48)) and 4-12 weeks later (12.56 mm VAS (95% CI 5.69 to 19.42)). Overall, disability was significantly reduced by LLLT at completed therapy (Standardised Mean Difference (SMD)=0.39 (95% CI 0.09 to 0.7) and 4-9 weeks later (SMD=0.32 (95% CI 0.05 to 0.59)). Compared with placebo control, the recommended doses significantly reduced pain at completed therapy (14.98 mm VAS (95% CI 3.74 to 26.22)) and 4-8 weeks later (14.00 mm VAS (95% CI 2.81 to 25.19)). The recommended doses significantly reduced pain as an add-on to exercise therapy versus exercise therapy alone at completed therapy (18.15 mm VAS (95% CI 10.55 to 25.76)) and 4-9 weeks later (15.90 mm VAS (95% CI 2.3 to 29.51)). No adverse events were reported.

CONCLUSION

LLLT significantly reduces pain and disability in lower extremity tendinopathy and plantar fasciitis in the short and medium term. Long-term data were not available. Some uncertainty about the effect size remains due to wide CIs and lack of large trials.

PROSPERO REGISTRATION NUMBER

CRD42017077511.

Effectiveness of High Power Laser Therapy on Pain and Isokinetic Peak Torque in Athletes with Proximal Hamstring Tendinopathy: A Randomized Trial

Athletes such as long-distance runners, sprinters, hockey, and/or football players may have proximal hamstring tendinopathy (PHT). Laser therapy has been shown to be effective in tendinopathies. High power laser therapy (HPLT) is used for the treatment of several musculoskeletal conditions; however, its efficacy on PHT has not been investigated. This study is aimed at examining the effects of HPLT on pain and isokinetic peak torque (IPT) in athletes with PHT. The two-arm comparative pretest-posttest experimental design was used with random allocation of 36 athletes aged 18-35 years into two groups (experimental and conventional group). The experimental group included the application of HPLT for 3 weeks. The conventional group included treatment with a conventional physiotherapy program including ultrasound therapy, moist heat pack, and home exercises for a total of 3 weeks. Pain and IPT of the hamstring muscle were measured before and after the application of the intervention. Pain score decreased, and IPT increased significantly (p < 0.05) after application of HPLT, by 61.26% and 13.18%, respectively. In the conventional group, a significant difference (p < 0.05) was observed in pain scores only, which decreased by 41.14%. No significant difference (p > 0.05) was observed in IPT in the conventional group. When HPLT was compared with conventional physiotherapy, a significant difference was found in pain scores only. HPLT for 3 weeks was found to be effective in improving pain in athletes with PHT. However, no significant difference was found between HPLT and conventional physiotherapy (US, moist heat, and home exercises) in improving the IPT of the hamstring muscle.

Assessment of the reporting quality of resistance training interventions in randomised controlled trials for lower limb tendinopathy: A systematic review

OBJECTIVES

1. To describe what exercises and intervention variables are used in resistance training interventions in randomised controlled trials for lower limb tendinopathy 2. To assess completeness of reporting as assessed by the Consensus on Exercise Reporting Template (CERT) and the Toigo and Boutellier framework. 3. To assess the implementation of scientific resistance training principles. 4. To assess therapeutic quality of exercise interventions with the i-CONTENT tool.

DATA SOURCES

We searched MEDLINE, CINAHL, AMED, EMBase, SPORTDiscus, and the Cochrane library databases.

REVIEW METHODS

Systematic review of randomised controlled trials that reported using resistance exercises for lower limb tendinopathies.

RESULTS

We included 109 RCTs. Eccentric heel drops were the most common exercise (43 studies), followed by isotonic heel raises (21), and single leg eccentric decline squats (18). Reporting of exercise descriptor items from the Toigo and Boutellier framework ranged from 0-13, with an average score of 9/13, and only 7 studies achieved a full 13/13. Reporting of items from the CERT ranged from 0-18, with an average score of 14/19. No study achieved a full 19/19, however 5 achieved 18/19. Scoring for resistance training principles ranged from 1-10, with only 11 studies achieving 10/10. Reporting across studies for the i-CONTENT tool ranged from 2-7, with an average score of 5 across included studies. A total of 19 studies achieved a full 7/7 score. Less than 50% of studies achieved an overall low risk of bias, highlighting the methodological concerns throughout studies.

CONCLUSION

The reporting of exercise descriptors and intervention content was generally high across RCTs for lower limb tendinopathy, with most allowing exercise replication. However, reporting for some tendinopathies and content items such as adherence was poor, limiting optimal translation to clinical practice.

Resistance Training Interventions for Lower Limb Tendinopathies: A Scoping Review of Resistance Training Reporting Content, Quality, and Scientific Implementation

The objectives of this scoping review were as follows: (1) to describe what exercises and intervention variables are used in resistance training interventions for lower limb tendinopathy,  (2) to assess the completeness of reporting as assessed by the Consensus on Exercise Reporting Template (CERT) and the Toigo and Boutellier framework, and (3) to assess the implementation of scientific resistance training principles. We searched MEDLINE, CINAHL, AMED, Embase, SPORTDiscus, and Cochrane Library databases. Randomized controlled trials, cohort studies, case series, case reports, and observational studies that reported using resistance exercises for lower limb tendinopathies were considered for inclusion, with 194 studies meeting the inclusion criteria. Completeness of the reporting of exercise descriptors and programme variables was assessed by the CERT and the Toigo and Boutellier framework. Reporting of exercise descriptor items from the Toigo and Boutellier framework ranged from 0 to 13, with an average score of 9/13, with only 9 studies achieving a full 13/13. Reporting of items from the CERT ranged from 0 to 18, with an average score of 13/19. No study achieved a full 19/19; however, 8 achieved 18/19. Scoring for resistance training principles ranged from 1 to 10, with only 14 studies achieving 10/10. Eccentric heel-drops were the most common exercise (75 studies), followed by isotonic heel raises (38), and single-leg eccentric decline squats (27). The reporting of exercise descriptors and intervention content was high across studies, with most allowing exercise replication, particularly for Achilles and patellar tendinopathy. However, reporting for some tendinopathies and content items such as adherence was poor, limiting optimal translation to clinical practice.

ICON 2020-International Scientific Tendinopathy Symposium Consensus: A Systematic Review of Outcome Measures Reported in Clinical Trials of Achilles Tendinopathy

BACKGROUND

Nine core domains for tendinopathy have been identified. For Achilles tendinopathy there is large variation in outcome measures used, and how these fit into the core domains has not been investigated.

OBJECTIVE

To identify all available outcome measures outcome measures used to assess the clinical phenotype of Achilles tendinopathy in prospective studies and to map the outcomes measures into predefined health-related core domains.

DESIGN

Systematic review.

DATA SOURCES

Embase, MEDLINE (Ovid), Web of Science, CINAHL, The Cochrane Library, SPORTDiscus and Google Scholar.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Clinical diagnosis of Achilles tendinopathy, sample size ≥ ten participants, age ≥ 16 years, and the study design was a randomized or non-randomized clinical trial, observational cohort, single-arm intervention, or case series.

RESULTS

9376 studies were initially screened and 307 studies were finally included, totaling 13,248 participants. There were 233 (177 core domain) different outcome measures identified across all domains. For each core domain outcome measures were identified, with a range between 8 and 35 unique outcome measures utilized for each domain. The proportion of studies that included outcomes for predefined core domains ranged from 4% for the psychological factors domain to 72% for the disability domain.

CONCLUSION

233 unique outcome measures for Achilles tendinopathy were identified. Most frequently, outcome measures were used within the disability domain. Outcome measures assessing psychological factors were scarcely used. The next step in developing a core outcome set for Achilles tendinopathy is to engage patients, clinicians and researchers to reach consensus on key outcomes measures.

PROSPERO REGISTRATION

CRD42020156763.

Histological tissue healing following high-power laser treatment in a model of suspensory ligament branch injury

BACKGROUND

High-power laser therapy gained popularity recently as a regenerative treatment for tendinitis and desmitis in the horse. However, studies evaluating effects of laser therapy on tissue repair at histological level in large mammals are lacking.

OBJECTIVES

To evaluate effects of high-power laser therapy on suspensory desmitis healing, using a model of suspensory ligament branch injury.

STUDY DESIGN

In vivo experiments.

METHODS

Standardised lesions were surgically induced in all 4 lateral suspensory branches of twelve healthy Warmblood horses. Laser therapy (class 4, 15W) was applied daily on 2 of 4 induced lesions for 4 consecutive weeks. Horses were randomly assigned to either short-term study (horses were sacrificed after 4 weeks) or long-term study (6 months). Suspensory ligament samples were scored after staining with haematoxylin-eosin and immunostaining for collagen 1- collagen 3- and factor VIII.

RESULTS

In the short-term study, significantly better (lower) scores for variation in density (17% above cut-off score in treated lesions vs. 31% above cut-off score in controls, p=0.03), shape of nuclei (54% vs. 92%, p=0.02), fibre alignment (32% vs. 75%, p=0.003) and fibre structure (38% vs. 71%, p=0.02) were found in laser treated lesions when compared to controls. Collagen 3 expression was significantly higher (32% vs. 19%, p=0.006) in control lesions. In both short- and long-term studies combined, parameters lesion size (44% vs. 56%, p=0.02) and shape of nuclei (53% vs. 84%, p=0.05) scored significantly better in treated lesions. Long-term, significantly better (lower) scores were found in the laser-treated group for lesion size (15% vs. 45%, p=0.008) and a higher percentage above cut-off score for density of the nuclei (27% vs. 9%, p=0.02), compared to controls.

MAIN LIMITATIONS

The model of suspensory branch injury is not an exact representation of clinical overstrain lesions.

CONCLUSIONS

These results suggest that high-power laser therapy enables better lesion healing than conservative treatment.

Tendon Tissue Repair in Prospective of Drug Delivery, Regenerative Medicines, and Innovative Bioscaffolds

The natural healing capacity of the tendon tissue is limited due to the hypovascular and cellular nature of this tissue. So far, several conventional approaches have been tested for tendon repair to accelerate the healing process, but all these approaches have their own advantages and limitations. Regenerative medicine and tissue engineering are interdisciplinary fields that aspire to develop novel medical devices, innovative bioscaffold, and nanomedicine, by combining different cell sources, biodegradable materials, immune modulators, and nanoparticles for tendon tissue repair. Different studies supported the idea that bioscaffolds can provide an alternative for tendon augmentation with an enormous therapeutic potentiality. However, available data are lacking to allow definitive conclusion on the use of bioscaffolds for tendon regeneration and repairing. In this review, we provide an overview of the current basic understanding and material science in the field of bioscaffolds, nanomedicine, and tissue engineering for tendon repair.

Comparison of the effects of low level laser and insoles on pain, functioning, and muscle strength in subjects with stage 2 posterior tibial tendon dysfunction: A randomized study

BACKGROUND

Low level laser therapy (LLLT) is known to be effective in tendinopathies. No study yet investigated the effect of LLLT on posterior tibial tendon dysfunction (PTTD) in comparison to orthotic treatment.

OBJECTIVE

The aim was to compare the effects of LLLT and insole application on pain, function and muscle strength in subjects with stage 2 PTTD.

METHODS

Fifty-two subjects with stage 2 PTTD were randomly assigned to the LLLT and insole groups. The foot pain, function and strength of invertor and evertor muscles of the subjects was evaluated before and after treatment, and after 9 months.

RESULTS

Significant improvement was observed in the foot function and pain (p< 0.05) in both groups after treatment, but in the 9-month follow-up, the insole group had better values. The increase in 180∘.sec-1 concentric invertor muscle strength was found significant after the treatment and in month-9 as compared to the initial values (p< 0.05).

CONCLUSIONS

Both treatments are effective in reducing treating foot pain, as well as improving the function in subjects with stage 2 PTTD. However, at the end of the 9-month follow-up, it was seen that insoles were more effective. Neither method had a clinically important effect on muscle strength.

The clinical diagnosis of Achilles tendinopathy: a scoping review

Background

Achilles tendinopathy describes the clinical presentation of pain localised to the Achilles tendon and associated loss of function with tendon loading activities. However, clinicians display differing approaches to the diagnosis of Achilles tendinopathy due to inconsistency in the clinical terminology, an evolving understanding of the pathophysiology, and the lack of consensus on clinical tests which could be considered the gold standard for diagnosing Achilles tendinopathy. The primary aim of this scoping review is to provide a method for clinically diagnosing Achilles tendinopathy that aligns with the nine core health domains.

Methodology

A scoping review was conducted to synthesise available evidence on the clinical diagnosis and clinical outcome measures of Achilles tendinopathy. Extracted data included author, year of publication, participant characteristics, methods for diagnosing Achilles tendinopathy and outcome measures.

Results

A total of 159 articles were included in this scoping review. The most commonly used subjective measure was self-reported location of pain, while additional measures included pain with tendon loading activity, duration of symptoms and tendon stiffness. The most commonly identified objective clinical test for Achilles tendinopathy was tendon palpation (including pain on palpation, localised tendon thickening or localised swelling). Further objective tests used to assess Achilles tendinopathy included tendon pain during loading activities (single-leg heel raises and hopping) and the Royal London Hospital Test and the Painful Arc Sign. The VISA-A questionnaire as the most commonly used outcome measure to monitor Achilles tendinopathy. However, psychological factors (PES, TKS and PCS) and overall quality of life (SF-12, SF-36 and EQ-5D-5L) were less frequently measured.

Conclusions

There is significant variation in the methodology and outcome measures used to diagnose Achilles tendinopathy. A method for diagnosing Achilles tendinopathy is proposed, that includes both results from the scoping review and recent recommendations for reporting results in tendinopathy.

Autoregulation in Resistance Training for Lower Limb Tendinopathy: A Potential Method for Addressing Individual Factors, Intervention Issues, and Inadequate Outcomes

Musculoskeletal disorders, such as tendinopathy, are placing an increasing burden on society and health systems. Tendinopathy accounts for up to 30% of musculoskeletal disorders, with a high incidence in athletes and the general population. Although resistance training has shown short-term effectiveness in the treatment of lower limb tendinopathy, more comprehensive exercise protocols and progression methods are required due to poor long-term outcomes. The most common resistance training protocols are predetermined and standardized, which presents significant limitations. Current standardized protocols do not adhere to scientific resistance training principles, consider individual factors, or take the importance of individualized training into account. Resistance training programs in case of tendinopathy are currently not achieving the required intensity and dosage, leading to high recurrence rates. Therefore, better methods for individualizing and progressing resistance training are required to improve outcomes. One potential method is autoregulation, which allows individuals to progress training at their own rate, taking individual factors into account. Despite the finding of their effectiveness in increasing the strength of healthy athletes, autoregulation methods have not been investigated in case of tendinopathy. The purpose of this narrative review was 3-fold: firstly, to give an overview and a critical analysis of the individual factors involved in tendinopathy and current resistance training protocols and their limitations. Secondly, to give an overview of the history, methods, and application of autoregulation strategies both in sports performance and physiotherapy. Finally, a theoretical adaptation of a current tendinopathy resistance training protocol using autoregulation methods is presented, providing an example of how the method could be implemented in clinical practice or future research.

The effect of low-level red and near-infrared photobiomodulation on pain and function in tendinopathy: a systematic review and meta-analysis of randomized control trials

Background

Tendinopathy is a common clinical condition that can significantly affect a person’s physical function and quality of life. Despite exercise therapy being the mainstay of tendinopathy management, there are many potential adjunct therapies that remain under investigated, one of which is photobiomodulation (PBM). PBM uses varied wavelengths of light to create a biological effect. While PBM is used frequently in the management of tendinopathy, high quality evidence supporting its utility is lacking.

Methods

A systematic search of the Pubmed, CINAHL, SCOPUS, Cochrane Database, Web of Science and SPORTSDICUS databases was performed for eligible articles in August 2020. Randomized Control Trials that used red or near-infrared PBM to treat tendinopathy disorders that made comparisons with a sham or ‘other’ intervention were included. Pain and function data were extracted from the included studies. The data were synthesized using a random effects model. The meta-analysis was performed using the mean difference (MD) and standardized mean difference (SMD) statistics.

Results

A total of 17 trials were included (n = 835). When compared solely to other interventions PBM resulted in similar decreases in pain (MD -0.09; 95% CI − 0.79 to 0.61) and a smaller improvement in function (SMD -0.52; 95% CI − 0.81 to − 0.23). When PBM plus exercise was compared to sham treatment plus exercise, PBM demonstrated greater decreases in pain (MD 1.06; 95% CI 0.57 to 1.55) and improved function (MD 5.65; 95% CI 0.25 to 11.04). When PBM plus exercise was compared to other interventions plus exercise, no differences were noted in pain levels (MD 0.31; 95% CI − 0.07 to 0.70). Most studies were judged as low-risk of bias. The outcome measures were classified as very low to moderate evidence quality according to the Grading of Recommendation, Development and Evaluation tool.

Conclusion

There is very-low-to-moderate quality evidence demonstrating that PBM has utility as a standalone and/or adjunctive therapy for tendinopathy disorders.

Trial registration

PROPERO registration number: CRD42020202508.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13102-021-00306-z.

The implementation of resistance training principles in exercise interventions for lower limb tendinopathy: A systematic review

OBJECTIVES

The primary purpose of this systematic review is to examine the literature on resistance training interventions for lower limb tendinopathy to evaluate the proportion of interventions that implemented key resistance training principles (specificity, progression, overload, individualisation) and reported relevant prescription components (frequency, intensity, sets, repetitions) and reported intervention adherence.

METHODS

Two reviewers performed a systematic review after screening titles and abstracts based on eligibility criteria. Identified papers were obtained in full text, with data extracted regarding the implementation of resistance training principles. Included articles were evaluated by the Cochrane risk of bias tool, with a scoring tool out of 10 used for implementation and reporting of the 5 key principles. Scientific databases were searched in November 2020 and included Medline, CINAHL, AMED, and Sportsdiscus.

RESULTS

52 randomised controlled trials investigating resistance training in five different lower limb tendinopathies were included. Although most studies considered the principles of progression (92%) and individualisation (88%), only 19 studies (37%) appropriately described how this progression in resistance was achieved, and only 18 studies (35%) reported specific instruction on how individualisation was applied. Adherence was considered in 27 studies (52%), with only 17 studies (33%) reporting the levels of adherence. In the scoring criteria, only 5 studies (10%) achieved a total maximum score of 10, with 17 studies (33%) achieving a maximum score of 8 for implementing and reporting the principles of specificity, overload, progression and individualisation.

CONCLUSION

There is meaningful variability and methodological concerns regarding the application and reporting of resistance training principles, particularly progression and individualisation, along with intervention adherence throughout studies. Collectively, these findings have important implications for the prescription of current resistance training interventions, including the design and implementation of future interventions for populations with lower limb tendinopathies.

Achilles tendinopathy: Exploring injury characteristics and current treatment modalities

Achilles tendinopathy is a prevalent overuse injury to the Achilles tendon causing prominent pain and reduction in quality of life. Several biomechanical and anatomical properties govern the pathology of the Achilles tendinopathy, and as a result, choosing the optimal treatment option is challenging. The aim of this review is to study the anatomical and biomechanical characteristics of this injury and explore the available treatment options in order to extrapolate the most suitable option with the best prognosis. Treatment modalities for Achilles tendinopathy vary and include non-operative and operative options. Non-operative treatment modalities include physical therapy, extracorporeal shockwave therapy, injectable agents, and bracing and taping. Operative treatment modalities include surgical procedures, both percutaneous and open. Treatment should be catered to the individual patient. Further research is required in order to confirm the efficacy of the available treatment options, test the viability of novel techniques and approaches, and discover possible new therapeutic modalities.

Effects of the infrared laser on classical ballerinas' feet: Analysis of plantar foot and static balance

BACKGROUND AND PURPOSE

Overuse injuries and painful symptoms in athletes and dancers (especially classical ballerinas) may lead to reduced functional performance. However, laser application may reduce pain and increase physical conditioning. The aim of the current study was to evaluate the immediate and long-term effects of infrared laser on classical ballerinas' feet.

METHODS

Eight female adults who perform classical ballet training and feel pain in their foot, but report no injuries in the last 6 months participated in the study. Infrared laser (808 nm) was applied on ballerina's feet twice a week during three months. The laser parameters utilized were 100 mW average optical power and spot size of 0.04 cm² applied during 1 min, leading to 6 J and 125 J/cm² per point. Thermography, algometry and unipodal static standing balance test were performed.

RESULTS

There was a significant increase in plantar arch temperature (1.6 °C for center and 2.3 °C for border, p < 0.05) immediately after laser treatment for all ballerinas. The pressure pain thresholds (PPT) were significantly increased for 5 of 7 analyzed sites (p < 0.05). Regarding to the static standing balance, the time on one-foot showed a significant increases (from 23 ± 12 s to 34 ± 13 s, p < 0.05) only when the test was performed on the left foot (support foot).

CONCLUSION

Then, there were pain relief and improvement of functional performance in ballerinas. The possible mechanism of laser action in reducing pain and thus enhancing performance, like higher blood flow of foot due to an increase of cutaneous temperature, will be discussed.

Achilles Tendinosis Injuries-Tendinosis to Rupture (Getting the Athlete Back to Play)

Recreational athletes are susceptible to experiencing pain in the Achilles tendon, affecting their ability to complete daily activities. Achilles tendinosis is a degenerative process of the tendon without histologic or clinical signs of intratendinous inflammation, which can be categorized by location into insertional and noninsertional tendinosis. This condition is one that can be treated conservatively with great success or surgically for refractory cases. Currently, there is a lack of consensus regarding the best treatment options. This review aims to explore both conservative and operative treatment options for Achilles tendinopathy and Achilles tendon rupture.

Does photobiomodulation therapy combined to static magnetic field (PBMT-sMF) promote ergogenic effects even when the exercised muscle group is not irradiated? A randomized, triple-blind, placebo-controlled trial

Background

The direct application of photobiomodulation therapy (PBMT) using low-level laser therapy (LLLT) and light emitting diodes (LEDs) combined with a static magnetic field (sMF) (PBMT-sMF) to target tissues is shown to improve muscle performance and recovery. Studies have reported possible PBMT effects when a local distant to the target tissue is irradiated. Notably, the extent of these effects on musculoskeletal performance and the optimal site of irradiation remain unclear, although this information is clinically important since these aspects could directly affect the magnitude of the effect. Therefore, we investigated the effects of local and non-local PBMT-sMF irradiations on musculoskeletal performance and post-exercise recovery before an eccentric exercise protocol.

Methods

This randomized, triple-blind (participants, therapists and assessors), placebo-controlled trial included 30 healthy male volunteers randomly assigned to the placebo, local, and non-local groups. Active or placebo PBMT-sMF was applied to 6 sites of the quadriceps muscle of both legs. An eccentric exercise protocol was used to induce fatigue. The primary outcome was peak torque assessed by maximal voluntary contraction (MVC). The secondary outcomes were delayed onset muscle soreness (DOMS) measured by visual analogue scale (VAS), muscle injury assessed by serum creatine kinase activity (CK), and blood lactate levels. Evaluations were performed before the eccentric exercise protocol (baseline), as well as immediately after and 1, 24, 48, and 72 h upon protocol completion.

Results

Ten volunteers were randomized per group and analysed for all outcomes. Compared to the placebo and non-local groups, irradiation with PBMT-SMF led to statistically significant improvement (p < 0.05) with regard to all variables in the local group. The outcomes observed in the non-local group were similar to those in the placebo group with regard to all variables.The volunteers did not report any adverse effects.

Conclusion

Our results support the current evidence that local irradiation of all exercised muscles promotes ergogenic effects. PBMT-sMF improved performance and reduced muscle fatigue only when applied locally to muscles involved in physical activity.

Trial registration

NCT03695458. Registered October 04th 2018.

Photobiomodulation does not influence maturation and mildly improves functional healing of mouse achilles tendons

Tendon rupture can occur at any age and is commonly treated nonoperatively, yet can result in persisting symptoms. Thus, a need exists to improve nonoperative treatments of injured tendons. Photobiomodulation (PBM) therapy has shown promise in the clinic and is hypothesized to stimulate mitochondrial-related metabolism and improve healing. However, the effect of PBM therapy on mitochondrial function during tendon maturation and healing are unknown, and its effect on tendon structure and function remain unclear. In this study, near-infrared light (980:810 nm blend, 2.5 J/cm² ) was applied at low (30 mW/cm² ) or high (300 mW/cm² ) irradiance to unilateral Achilles tendons of CD-1 mice during postnatal growth (maturation) as well as adult mice with bilateral Achilles tenotomy (healing). The chronic effect of PBM therapy on tendon structure and function was determined using histology and mechanics, and the acute effect of PBM therapy on mitochondrial-related gene expression was assessed. During maturation and healing, collagen alignment, cell number, and nuclear shape were unaffected by chronic PBM therapy. We found a sex-dependent effect of PBM therapy during healing on mechanical outcomes (eg, increased stiffness and Young's modulus for PBM-treated females, and increased strain at ultimate stress for PBM-treated males). Mitochondria-related gene expression was marginally influenced by PBM therapy for both maturation and healing studies. This study was the first to implement PBM therapy during both growth and healing of the murine tendon. PBM therapy resulted in marginal and sex-dependent effects on the murine tendon. Clinical significance: PBM may be beneficial for tendon healing because functional remodeling improves without adverse effects.

Meta-analysis of Noninsertional Achilles Tendinopathy

BACKGROUND

Achilles tendinopathy is a common clinical problem that can be either insertional or noninsertional. A variety of treatment methods have been described, although little consensus exists on an optimal method or methods. We sought to investigate the current evidence on different treatment methods for noninsertional Achilles tendinopathy, with a focus on functional outcomes.

METHODS

We performed a review of the available literature in PubMed and the Cochrane Central Register of Controlled Trials. Data from included studies were categorized according to treatment method and analyzed with respect to functional outcome and complication rate.

RESULTS

In total, 1420 abstracts were reviewed, of which 72 articles containing 3523 patients met inclusion criteria. Within the 72 studies included, 6 operative techniques and 19 nonoperative treatments were evaluated.

CONCLUSION

A wide variety of treatments are available for noninsertional Achilles tendinopathy, although newer treatments and most operative methods lack high-level evidence. Eccentric exercise is the most thoroughly studied and supported nonoperative treatment, while tenotomy and debridement is the operative procedure with the most evidence of efficacy. Platelet-rich plasma injections and extracorporeal shockwave therapy have proven to be viable second-line nonoperative treatments. Gastrocnemius recession and flexor hallucis longus transfer have shown benefit in case series.

LEVEL OF EVIDENCE

Level II, systematic review.

Rehabilitation of Elbow Injuries: Nonoperative and Operative

Athletes are subject to traumatic and repetitive stress injuries at the elbow joint as a result of high levels of forces imparted across the elbow. Injuries can be acute to the point of tissue failure, or chronic as a result of repetitive overuse. Complete restoration of elbow function must be achieved to allow the athlete to return to their prior level of function. Systematic and progressive rehabilitation programs can help avoid overstressing healing tissues. Treatment programs are designed to restore full motion, muscular strength, endurance, and neuromuscular control. Multiphased rehabilitation programs are designed to restore function in the athlete's elbow.

Photobiomodulation with low-level laser therapy for treating Achilles tendinopathy: a systematic review and meta-analysis

Objective:

The purpose of this study was to determine the benefits and harms of low-level laser therapy for Achilles tendinopathy.

Data sources:

Search strategies were conducted (from inception to February 2020) in Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Literatura Latino Americana em Ciências da Saúde e do Caribe (LILACS), Physiotherapy Evidence Database (PEDro), SPORTDiscus, ClinicalTrials.gov, World Health Organization (WHO)-ICTRP and OpenGrey databases, to retrieve all randomized controlled trials that compared laser therapy with inactive/active interventions.

Review methods:

This study was reported following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. The risk of bias was assessed using the Cochrane Risk of bias table. Meta-analyses were performed on dependence of homogeneity, otherwise results were reported narratively. The certainty of evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach.

Results:

Four trials (119 participants) were analyzed. Laser therapy associated to eccentric exercises when compared to eccentric exercises and sham had very low to low certainty of evidence in pain and function assessment. Despite one trial favored laser therapy at two months (mean difference (MD) −2.55, 95% confidence interval (95% CI) −3.87 to −1.23), the CIs did not include important differences between groups at 3 and 13 months. The function assessment showed an improvement favoring the placebo group at one month (MD 9.19, 95% CI −16.16 to −2.23) and non-significant difference between groups at 3 and 13 months. Adverse events were poorly reported but restricted to minor events related to the exercises.

Conclusion:

The certainty of evidence was low to very low, and the results are insufficient to support the routine use laser therapy for Achilles tendinopathy.

904 nm Low-Level Laser Irradiation Decreases Expression of Catabolism-Related Genes in White Adipose Tissue of Wistar Rats: Possible Roles of Laser on Metabolism

Background: Adipose tissue is the main energy storage tissue in the body. Its catabolic and anabolic responses depend on several factors, such as nutritional status, metabolic profile, and hormonal signaling. There are few studies addressing the effects of laser photobiomodulation (PBM) on adipose tissue and results are controversial. Objective: Our purpose was to investigate the metabolic effects of PBM on adipose tissue from Wistar rats supplemented or not with caffeine. Materials and methods: Wistar rats were divided into four groups: control (CTL), laser-treated [CTL (L)], caffeine (CAF), and caffeine+PBM [CAF (L)]. Blood was extracted for quantification of triglyceride and cholesterol levels and white adipose tissues were collected for analysis. We evaluated gene expression in the adipose tissue for the leptin receptor, lipase-sensitive hormone, tumor necrosis factor alpha, and beta adrenergic receptor. Results: We demonstrated that the low-level laser irradiation was able to increase the feed intake of the animals and the relative mass of the adipose tissue in the CTL (L) group compared with CTL. Laser treatment also increases serum triglycerides [CTL = 46.99 ± 5.87; CTL (L) = 57.46 ± 14.38; CAF = 43.98 ± 5.17; and CAF (L) = 56.9 ± 6.12; p = 0.007] and total cholesterol (CTL = 70.62 ± 6.80; CTL (L) = 79.41 ± 13.07; CAF = 71.01 ± 5.52; and CAF (L) = 79.23 ± 6.881; p = 0.003). Conclusions: Laser PBM decreased gene expression of the studied genes in the adipose tissue, indicating that PBM is able to block the catabolic responses of this tissue. Interestingly, the CAF (L) and CAF animals presented the same CLT (L) phenotype, however, without increasing the feed intake and the relative weight of the adipose tissue. The description of these phenomena opens a new perspective for the study of the action of low-level laser in adipose tissue.

The light-oxygen effect in biological cells enhanced by highly localized surface plasmon-polaritons

Here at the first time we suggested that the surface plasmon-polariton phenomenon which it is well described in metallic nanostructures could also be used for explanation of the unexpectedly strong oxidative effects of the low-intensity laser irradiation in living matters (cells, tissues, organism). We demonstrated that the narrow-band laser emitting at 1265 nm could generate significant amount of the reactive oxygen species (ROS) in both HCT116 and CHO-K1 cell cultures. Such cellular ROS effects could be explained through the generation of highly localized plasmon-polaritons on the surface of mitochondrial crista. Our experimental conditions, the low-intensity irradiation, the narrow spectrum band (<4 nm) of the laser and comparably small size bio-structures (~10 μm) were shown to be sufficient for the plasmon-polariton generation and strong laser field confinement enabling the oxidative stress observed.

Acute effects of photobiomodulation therapy and magnetic field on functional mobility in stroke survivors: a randomized, sham-controlled, triple-blind, crossover, clinical trial

Identify the optimal energy delivered with a single application of the combination of photobiomodulation therapy (PBMT) combining different light sources (low-level laser therapy-LLLT and light emitting diode therapy-LEDT) and static magnetic field (sMF) in order to determine the acute effects on functional mobility of stroke survivors. Was conducted a randomized, placebo-controlled, crossover, triple-blind, clinical trial (RCT). Twelve patients were recruited, however ten concluded the study, they were randomly treated with four PBMT/sMF energies (sham-0 J, 10 J, 30 J, and 50 J per site irradiated), with 1-week interval washout between treatments. PBMT/sMF were administered after the pre-intervention (baseline) evaluation and the total energy delivered per site at each treatment was determined based on the results of the randomization procedure. PBMT/sMF were administered in direct contact with the skin and applied with slight pressure to nine sites on the knee extensors, six sites on the knee flexors, and two sites on the plantar flexors' muscles in both lower limbs (bilaterally). The primary outcome measure was the 6-min walk test (6MWT) and the secondary outcome was the Timed Up and Go (TUG) test. Significant improvements were found in the 6MWT test using a total energy of 30 J per site compared with sham (0 J) (p < 0.05) and compared with the baseline evaluation (p < 0.01). And in the TUG test significant improvements were also found using a total energy per site of 30 J per site compared to sham (0 J) and baseline (p < 0.05). PBMT with different light sources (laser and LEDs) and wavelengths in combination with sMF with a total energy per site of 30 J has positive acute effects on functional mobility in stroke survivors.

Photobiomodulation therapy (PBMT) in bone repair: A systematic review

BACKGROUND

Photobiomodulation therapy (PBMT) using low-level laser influences the release of several growth factors involved in the formation of epithelial cells, fibroblasts, collagen and vascular proliferation, besides accelerating the synthesis of bone matrix due to the increased vascularization and lower inflammatory response, with significant increase of osteocytes in the irradiated bone. Considering its properties, beneficial effects and clinical relevance, the aim of this review was to analyze the scientific literature regarding the use of PBMT in the process of bone defect repair.

METHODS

Electronic search was carried out in PubMed/MEDLINE^Ⓡ and Web of Science databases with combination of the descriptors low-level laser therapy AND bone repair, considering the period of publication until the year 2018.

RESULTS

The literature search identified 254 references in PubMed/MEDLINE and 204 in Web of Science, of which 33 and 4 were selected, respectively, in accordance with the eligibility requirements. The analysis of researches showed articles using PBMT in several places of experimentation in the subjects, different types of associated biomaterials, stimulatory effects on cell proliferation, besides variations in the parameters of use of laser therapy, mainly in relation to the wavelength and density of energy. Only four articles reported that the laser did not improve the osteogenic properties of a biomaterial.

CONCLUSIONS

Many studies have shown that PBMT has positive photobiostimulatory effects on bone regeneration, accelerating its process regardless of parameters and the use of biomaterials. However, standardization of its use is still imperfect and should be better studied to allow correct application concerning the utilization protocols.

Conservative treatment of Achilles tendon partial tear in a futsal player: A case report

Background and purpose: Achilles tendon is the most commonly injured part in the lower limb, especially in athletes. Treatment options for Achilles tendinopathy and total rupture are well described; however, there is a lack of information regarding treatment protocols for partial tears. Thus, the purpose of this case report was to describe the examination, intervention and outcomes of patient who suffered an acute Achilles tendon partial tear. Case description: A case is described here, in which the diagnosis of Achilles tendon partial tear was based on both magnetic resonance imaging and physical evaluation. Both the patient and the physical therapy team opted for non-surgical treatment. A 12-week course of conservative treatment including exercise, tendon loading, electrical stimulation, and photobiomodulation is described. Outcomes: Ankle dorsiflexion range of motion and hop tests. Discussion: This case report demonstrated that non-surgical treatment for Achilles tendon partial tear was effective for this patient and enabled the athlete to return to pre-injury levels of activity 6 months following the injury.

Effects of Pulsed 810 nm Al-Ga-As Diode Laser on Wound Healing Under Immunosuppression: A Molecular Insight

BACKGROUND AND OBJECTIVES

Dysregulated inflammation is one of the major contributing factors for the prevalence of non-healing chronic wound in immunosuppressed subjects. Photobiomodulation (PBM) has emerged as a potential non-thermal, light-based therapeutic healing intervention for the treatment of impaired wounds.

STUDY DESIGN/MATERIALS AND METHODS

The present study delineates the underlying molecular mechanisms of PBM 810 nm laser-induced full-thickness cutaneous wound repair in immunosuppressed rats at continuous and pulsed wave-mode with power-density of 40 mW/cm ² , fluence 22.6 J/cm ² for 10 minutes daily for 7 post-wounding days. Molecular markers were assessed using biochemical, enzyme-linked immunosorbent assay quantification, enzyme kinetics and immunoblots analyses pertaining to inflammation, oxidative stress, cell survival, calcium signaling, and proliferation cascades.

RESULTS

Results distinctly revealed that pulsed 810 nm (10 Hz) PBM potentially influenced the cell survival and proliferation signaling pathway by significantly upregulated phospho-protein kinase B(phospho-Akt), phospho-extracellular-signal-regulated kinase 1 (ERK1), transient receptor potential vanilloid-3 (TRPV3), Ca²⁺ , calmodulin, transforming growth factor-β1 (TGF-β1), TGF-βR3, and Na ⁺ /K ⁺ -ATPase pump levels. PBM treatment resulted in reduction of exaggerated inflammatory responses evident by significantly repressed levels of interleukin-1β (IL-1β), IL-6, cyclooxygenase 2 (COX-2), and substance-P receptor (SPR), as well as inhibited apoptotic cell death by decreasing p53, cytochrome C, and caspase 3 levels (P < 0.05), which, in turn, effectively augment the wound repair in immunosuppressed rats. PBM treatment also lowered 4-hydroxynoneal (HNE) adduct level and NADP/NADPH ratio and upregulated the GRP78 expression, which might culminate into reduced oxidative stress and maintained the redox homeostasis.

CONCLUSIONS

Taken together, these findings would be helpful in better understanding of the molecular aspects involved in pulsed 810 nm laser-mediated dermal wound healing in immunosuppressed rats through regulation of cell survival and proliferation via Ca²⁺ -calmodulin, Akt, ERK, and redox signaling. Lasers Surg. Med. © 2019 Wiley Periodicals, Inc.

Sex, but not skin tone affects penetration of red-light (660 nm) through sites susceptible to sports injury in lean live and cadaveric tissues

Red-light treatment is emerging as a novel therapy for promoting tissue recovery but data on red-light penetration through human tissues are lacking. We aimed to: (1) determine the effect of light irradiance, tissue thickness, skin tone, sex and bone/muscle content on 660 nm light penetration through common sites of sports injuries, and (2) establish if cadaver tissues serve as a useful model for predicting red-light penetration in live tissues. Live and cadaver human tissues were exposed to 660 nm light at locations across the skull, spinal cord and upper and lower limbs. Red-light was produced by a light emitting diode array of various irradiances (15-500 mW/cm² ) and measured by a light-probe positioned on the tissue surface opposite to the light emitting diodes. 100 mW/cm² successfully penetrated tissue <50 mm thick; a disproportionate irradiance increase was required to achieve deeper penetration. Penetration was unaffected by skin tone, increased with irradiance and relative bone/muscle composition, and decreased with greater tissue thickness and in males. Live and cadaveric tissue penetration did not differ statistically for tissues <50 mm but cadavers required more red-light to penetrate >50 mm. These results assist clinicians and researchers in determining red-light treatment intensities for penetrating human tissues.

Low-Level Laser Treatment Is Ineffective for Capsular Contracture: Results of the LaTCon Randomized Controlled Trial

BACKGROUND

Breast reconstruction with implants can be complicated by symptomatic capsular contracture, especially after radiotherapy. A phase I, nonrandomized clinical trial demonstrated improvement in capsular contracture and avoidance of revision surgery with low-level laser therapy. This phase II, double-blind, randomized controlled trial assessed the efficacy of low-level laser for treating capsular contracture in women with breast reconstruction following mastectomy for breast cancer.

METHODS

Participants had completed their definitive implant-based reconstruction a minimum of 6 months previously and were randomized to weekly treatments over 6 weeks with either an active or inactive low-level laser handpiece (Riancorp LTU-904). Pain, tightness, arm movement, and appearance were assessed by patient questionnaires. Breast symmetry, shape, naturalness, softness, and grade of contracture were assessed by clinician reports. Participants were assessed at 1 and 6 months after completion of the treatments.

RESULTS

A total of 42 patients (intervention arm, n = 20; placebo, n = 22) were assessed in the trial. Thirty-two had postmastectomy radiotherapy. There was no significant difference in the change in any patient-reported outcomes or clinician-reported outcomes of breast symmetry, shape, or naturalness for the two groups. There was a significantly greater improvement in clinician-reported breast softness (p < 0.05) and degree of contracture (p < 0.05) in the placebo group at both 1- and 6-month follow-up.

CONCLUSION

Low-level laser is not an effective therapy for breast implant capsular contracture in reconstruction patients.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, I.

Immediate effect of photobiomodulation therapy on Achilles tendon morphology and mechanical properties: an exploratory study

Objectives

Evaluate the immediate (within 4 hours) effects of laser-induced photobiomodulation (PBM) therapy on Achilles tendon morphology and mechanical properties in healthy and pathologic tendons.

Materials and Methods

Twenty people with healthy Achilles tendons and twelve people with Achilles tendinopathy participated. One Achilles tendon received PBM treatment following an established protocol and the contralateral side received a placebo treatment. Achilles tendon morphology and mechanical properties were evaluated bilaterally with ultrasound imaging and continuous shear wave elastography immediately before treatment, immediately after treatment, then 2- and 4-hours after treatment.

Results

There were no immediate effects of PBM on tendon morphology or mechanical properties when comparing the PBM-treated side and placebo-treated side within each cohort. Additionally, the effects of PBM did not differ between healthy and pathologic Achilles tendons.

Conclusion

When treated with a laser-induced PBM treatment, healthy and pathologic Achilles tendons do not have immediate (within 4 hours) changes in tendon morphology or mechanical properties. These findings suggest that PBM therapy can be administered before other clinical treatments or high-load activities.

[Low level laser therapy : A narrative literature review on the efficacy in the treatment of rheumatic orthopaedic conditions]

BACKGROUND

In low level laser therapy (LLLT) low wattage lasers are used to irradiate the affected skin areas, joints, nerves, muscles and tendons without any sensation or thermal damage. Although the exact mechanism of its effect is still unknown, it seems beyond dispute that LLLT induces a variety of stimulating processes at the cellular level affecting cell repair mechanisms, the vascular system and lymphatic system. LLLT has been popular among orthopaedic practitioners for many years, whereas university medicine has remained rather sceptical about it.

OBJECTIVES

Overview of studies on the efficacy of LLLT in the treatment of rheumatic orthopaedic conditions, i. e. muscle, tendon lesions and arthropathies.

MATERIALS AND METHODS

Narrative literature review (PubMed, Web of Science).

RESULTS

While earlier studies often failed to demonstrate the efficacy of LLLT, several recent studies of increasing quality proved the efficacy of LLLT in the treatment of multiple musculoskeletal pain syndromes like neck or lower back pain, tendinopathies (especially of the Achilles tendon) and epicondylolpathies, chronic inflammatory joint disorders like rheumatoid arthritis or chronic degenerative osteoarthritis of the large and small joints. In addition, there is recent evidence that LLLT can have a preventive capacity and can enhance muscle strength and accelerate muscle regeneration.

CONCLUSION

LLLT shows potential as an effective, noninvasive, safe and cost-efficient means to treat and prevent a variety of acute and chronic musculoskeletal conditions. Further randomized controlled studies, however, are required to confirm this positive assessment.