Analysis of pain relief and functional recovery in patients with rotator cuff tendinopathy through therapeutic ultrasound and photobiomodulation therapy: a comparative study.

This study aimed to compare shoulder tendinopathy treatment with therapeutic ultrasound combined with LED photobiomodulation therapy using LED-infrared (850 nm) or LED-red (640 nm). The study assessed 75 patients, aged 45 to 70 years, distributed into five experimental groups (15 patients each): therapeutic ultrasound (US), infrared light irradiation (IR), visible red light irradiation (VR), infrared light and ultrasound combined (IR-US), and red light in conjunction with ultrasound (VR-US). The ultrasound parameters are 1 MHz, 0.5 W/cm2 (SATA), and 100 Hz repetition rate, applied for 4 min each session. LED irradiation protocols were as follows: 3 points, 7.5 J per point, IR-LED 750 mW, 10 s, VR-LED 250 mW, 30 s. LED irradiation is followed by ultrasound in the combined therapies. The efficiency of the five therapies was evaluated assessing 12 parameters: quality of life (Health Assessment Questionnaire, HAQ), pain intensity (Visual Analog Scale, VAS), articular amplitude of shoulder movement (flexion, extension, abduction, adduction, medial rotation, lateral rotation), muscle strength (abduction, lateral rotation), and electromyography (lateral rotation, abduction). Treatments comprised 12 sessions for 4 weeks. Intra-group analysis showed that the five therapies significantly improved the recovery of all parameters after treatment. Regarding the comparison of irradiated therapies and ultrasound, statistical analysis showed that IR-US was a better treatment than US for all 12 parameters. IR treatment exceeded US on 9 items, whereas that VR and VR-US therapies exceeded US in 7 and 10 parameters, respectively (p < 0.05). Because of that, IR-US shows to be the best treatment for rotator cuff tendinopathy. In conclusion, improvements in quality of life, pain intensity relief, shoulder amplitude motion, and muscle strength force obtained with ultrasound therapy are enhanced by adding infrared LED irradiation to ultrasound for patients suffering from rotator cuff tendinopathy. This study was registered with the Brazilian Registry of Clinical Trials (ReBEC) under Universal Trial Number (UTN) U1111-1219-3594 (2018/22/08).

Photobiomodulation therapy on expression of HSP70 protein and tissue repair in experimental acute Achilles tendinitis.

The aim of the present study was to investigate the effects of photobiomodulation (PBM) therapy on the expression of heat shock protein 70 (HSP70) and tissue repair in an experimental model of collagenase-induced Achilles tendinitis. Thirty Wistar rats (aged 12 weeks) were randomly distributed among control group (n = 8), tendinitis group (n = 11), and LED group (n = 11). Tendinitis was induced in the tendinitis and LED groups through a peritendinous injection of collagenase (100 µl). The LED group animals received the first irradiation 1 h after injury. A 630 ± 20 nm, 300-mW continuous wave light-emitting diode (LED), spot size 1 cm2, was placed in contact with the skin. One point over the tendon was irradiated for 30 s, delivering 9 J (9 J/cm2). LED irradiation was performed once daily for 7 days, with the total energy delivered being 63 J. The tendons were surgically removed and expression of the HSP70 protein was calculated using semi-quantitative analyses of immunohistochemistry (HSCORE). Number of fibroblasts and amount of collagen were measured using histological and histochemical analyses. An increase in the mean HSCORE for HSP70, in the number of fibroblasts, and in the amount of collagen were found in the LED group compared with those in the tendinitis and control group (P ≤ 0.05). PBM therapy increased the expression of the HSP70, number of fibroblasts, and amount of collagen in the acute Achilles tendinitis in rats.

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.

Effect of light-emitting diodes, platelet-rich plasma, and their combination on the activity of sheep tenocytes.

Healthy tendons play an important role in joint movements and subjected to a group of pathologies called tendinopathy due to multiple factors. Tendons have a slowly repairing process due to the low vascularity and cellularity. Treatment options aimed at potentiating the healing response and relieving symptoms. Phototherapy and platelet-rich plasma were novel treatment modalities in tendons based on photobiomodulation and growth factors during healing, and the results were encouraging suggesting calibrating treatment parameters. This study utilizes cell culture to explore the potential effect of light-emitting diode and/or growth factors in the form of platelet-rich plasma (PRP) on the activity of tenocytes isolated from sheep Achilles tendons by measuring the cell metabolism and cell mobility using cell viability and migration assays to proof safety and confirm activity. Results showed that sheep tenocyte-cultured groups treated with 5% platelet-rich plasma alone or combined with 4 J/cm2 light-emitting diode have increased viability significantly when compared to control group after a 48 h, while light-emitting diode treatment has not decreased cell migration significantly when compared with control. Result suggests that using platelet-rich plasma alone or combined with light-emitting diode might have potential to enhance healing response at the conditions applied. PRP could enhance proliferation while LED could enhance migration and proliferation. Further research is needed at longer durations.

[Low level laser therapy : A narrative literature review on the efficacy in the treatment of rheumatic orthopaedic conditions]. / Low-Level-Lasertherapie : Eine narrative Literaturübersicht zur Wirksamkeit bei der Behandlung rheumatologisch-orthopädischer Krankheitsbilder.

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.

Photobiomodulation and eccentric exercise for Achilles tendinopathy: a randomized controlled trial.

BACKGROUND: The common regime of eccentric exercise in use for Achilles tendinopathy is somewhat arduous and compliance issues can arise. This is the first study to investigate the effectiveness of a regime of fewer exercise sessions combined with photobiomodulation for the treatment of Achilles tendinopathy. METHODS: A double blind randomized controlled trial and intention-to-treat analysis were performed. Eighty participants, 18-65 years with Achilles tendinopathy and symptoms for longer than 3 months, were included in the trial. Participants randomized into one of four groups; 1 (Placebo + Ex Regime 1) or 2 (Laser + Ex Regime 1) or 3 (Placebo + Ex Regime 2) or 4 (Laser + Ex Regime 2). The primary outcome measure was the Victorian Institute of Sports Assessment-Achilles (VISA-A) questionnaire. Outcomes were collected at baseline, week 4 and week 12. RESULTS: Sixteen participants were lost to follow-up at 12 weeks, 4 of which due to adverse reactions. As per intention to treat, missing data were imputed, 80 participants were included in the final analysis. For VISA-A at 12 weeks, group 4 achieved significant gains over the other 3 groups: group 1 (18.5 [9.1, 27.9]), group 2 (10.4 [1.5, 19.2]), group 3 (11.3 [3.0, 19.6]). There was a moderate effect size in favour of exercise twice per week (7.2 [-1.8, 16.2], ES .7). CONCLUSIONS: Twice-daily exercise sessions are not necessary as equivalent results can be obtained with two exercise sessions per week. The addition of photobiomodulation as adjunct to exercise can bring added benefit.

Photobiomodulation therapy on collagen type I and III, vascular endothelial growth factor, and metalloproteinase in experimentally induced tendinopathy in aged rats.

This study investigates the effect of photobiomodulation therapy (PBMT) on collagen type I and III, matrix metalloproteinase (MMP), and vascular endothelial growth factor (VEGF) in experimentally induced tendinopathy in female aged rats. Tendinopathy was induced by the Achilles tendoncollagenase peritendinous. Forty-two Wistar rats (Norvegicus albinus) were used; groups consisted of 36 aged animals (18 months old; mean body weight, 517.7 ± 27.54 g) and 6 adult animals (12 weeks old; mean body weight, 266± 19.30 g). The animals were divided into three groups: control, aged tendinopathy, and aged tendinopathy PBMT; the aged groups were subdivided based on time to euthanasia: 7, 14, and 21 days. PBMT involved a gallium-arsenide-aluminum laser (Theralaser, DMC®) with active medium operating at wavelength 830 ± 10 nm, 50 mW power, 0.028 cm2 laser beam, 107 J/cm2 energy density, 1.8 W/cm2 power density, and an energy of 3 J per point. The laser was applied by direct contact with the left Achilles tendon during 60 s per point at a frequency of three times per week, until the euthanasia date (7, 14, and 21 days). VEGF, MMP-3, and MMP-9 were analyzed by immunohistochemistry, and collagen type I and III by Sirius red. PBMT increased the deposition of collagen type I and III in a gradual manner, with significant differences relative to the group aged tendonitis (p < 0.001), and in relation to VEGF (p < 0.001); decreased expression of MMP-3 and 9 were observed in group aged tendinopathy (p < 0.001). PBMT, therefore, increased the production of collagen type I and III, downregulated the expression of MMP-3 and MMP-9, and upregulated that of VEGF, with age and age-induced hormonal deficiency.

Radiotherapy for benign achillodynia. Long-term results of the Erlangen Dose Optimization Trial.

BACKGROUND: The aim of this study was to evaluate the long-term efficacy of two dose-fractionation schedules for radiotherapy of achillodynia. PATIENTS AND METHODS: Between February 2006 and February 2010, 112 evaluable patients were recruited for this prospective trial. All patients received orthovoltage radiotherapy. One course consisted of 6 fractions/3 weeks. In the case of insufficient remission of pain after 6 weeks, a second series was performed. Patients were randomly assigned to receive either single doses of 0.5 or 1.0 Gy. The endpoint was pain reduction. Pain was measured before, right after (early response), 6 weeks after (delayed response), and approximately 2 years after radiotherapy (long-term response) with a questionnaire-based visual analogue scale (VAS) and a comprehensive pain score (CPS). RESULTS: The median follow-up was 24 months (range, 11-56). The overall early, delayed, and long-term response rates for all patients were 84 %, 88 %, and 95 %, respectively. The mean VAS values before treatment for early, delayed, and long-term responses for the 0.5-Gy and 1.0-Gy groups were 55.7 ± 21.0 and 58.2 ± 23.5 (p = 0.53), 38.0 ± 23.2 and 30.4 ± 22.6 (p = 0.08), 35.5 ± 25.9 and 30.9 ± 25.4 (p = 0.52), and 11.2 ± 16.4 and 15.3 ± 18.9 (p = 0.16), respectively. The mean CPS values before treatment for early, delayed, and long-term responses were 8.2 ± 3.0 and 8.9 ± 3.3 (p = 0.24), 5.6 ± 3.1 and 5.4 ± 3.3 (p = 0.76), 4.4 ± 2.6 and 5.3 ± 3.8 (p = 0.58), and 2.2 ± 2.9 and 2.8 ± 3.3 (p = 0.51), respectively. No significant differences in long-term response quality between the two arms was found (p = 0.73). CONCLUSION: Radiotherapy is a very effective treatment for the management of benign achillodynia. For radiation protection, the dose for a radiotherapy series should not exceed 3.0 Gy.

Low-level laser therapy in IL-1ß, COX-2, and PGE2 modulation in partially injured Achilles tendon.

This study evaluated IL-1ß, COX-2, and PGE2 modulation in partially injured Achilles tendons treated with low-level laser therapy (LLLT). Sixty-five male Wistar rats were used. Sixty were submitted to a direct injury on Achilles tendon and then distributed into six groups: LASER 1 (a single LLLT application), LASER 3 (three LLLT applications), and LASER 7 (seven LLLT applications) and Sham 1, 3, and 7 (the same injury but LLLT applications were simulated). The five remaining animals were allocated at control group (no procedure performed). LLLT (780 nm) was applied with 70 mW of mean power and 17.5 J/cm(2) of fluency for 10 s, once a day. The tendons were surgically removed and assessed immunohistochemically for IL-1ß, COX-2, and PGE2. In comparisons with control (IL-1ß: 100.5 ± 92.5 / COX-2: 180.1 ± 97.1 / PGE2: 187.8 ± 128.8) IL-1ß exhibited (mean ± SD) near-normal level (p > 0.05) at LASER 3 (142.0 ± 162.4). COX-2 and PGE2 exhibited near-normal levels (p > 0.05) at LASER 3 (COX-2: 176.9 ± 75.4 / PGE2: 297.2 ± 259.6) and LASER 7 (COX-2: 259.2 ± 190.4 / PGE2: 587.1 ± 409.7). LLLT decreased Achilles tendon's inflammatory process.

The low level laser therapy (LLLT) operating in 660 nm reduce gene expression of inflammatory mediators in the experimental model of collagenase-induced rat tendinitis.

Tendinopathy is a common disease with a variety of treatments and therapies. Laser therapy appears as an alternative treatment. Here, we investigate the effects of laser irradiation in an experimental model of tendinitis induced by collagenase injection on rats' Achilles tendon, verifying its action in important inflammatory markers. Male Wistar rats were used and divided into five groups: control saline (C), non-treated tendinitis (NT) and tendinitis treated with sodium diclofenac (D) or laser (1 J) and (3 J). The tendinitis was induced by collagenase (100 µg/tendon) on the Achilles tendon, which was removed for further analyses. The gene expression for COX-2; TNF-α; IL-6; and IL-10 (RT-PCR) was measured. The laser irradiation (660 nm, 100 mW, 3 J) used in the treatment of the tendinitis induced by collagenase in Achilles tendon in rats was effective in the reduction of important pro-inflammatory markers such as IL-6 and TNF-α, becoming a promising tool for the treatment of tendon diseases.

Re-irradiation for painful heel spur syndrome. Retrospective analysis of 101 heels.

PURPOSE: Painful heel spur syndrome is a common disease with a lifetime prevalence of approximately 10 %. One of the most effective treatment options is radiotherapy. Many authors recommend a second or third series of radiation for recurrent pain and partial or no response to the initial treatment. As the results of re-irradiation have not been systematically analyzed the aim of this study was to document the results of repeated radiation treatment and to identify patients who could benefit from this treatment. MATERIAL AND METHODS: The analysis was performed on patients from 2 German radiotherapy institutions and included 101 re-irradiated heels. Pain was documented with the numeric rating scale (NRS) and carried out before and directly after each radiation therapy as well as for the follow-up period of 24 months. The median age of the patients was 56 years with 30.1 % male and 69.9 % female patients. Pain was caused by plantar fasciitis in 72.3 %, Haglund's exostosis in 15.8 % and Achilles tendinitis in 11.9 %. Repeated radiation was indicated because the initial radiotherapy resulted in no response in 35.6 % of patients, partial response in 39.6 % and recurrent pain in 24.8 %. RESULTS: A significant response to re-irradiation could be found. For the whole sample the median NRS pain score was 6 before re-irradiation, 2 after 6 weeks and 0 after 12 and 24 months. Of the patients 73.6 % were free of pain 24 months after re-irradiation. All subgroups, notably those with no response, partial response and recurrent pain had a significant reduction of pain. CONCLUSION: Re-irradiation of painful heel spur syndrome is an effective and safe treatment. All subgroups showed a good response to re-irradiation for at least 24 months.

Use of X-rays to treat shoulder tendonitis/bursitis: a historical assessment.

This article assesses the therapeutic efficacy of ionizing radiation for the treatment of shoulder tendonitis/bursitis in the USA over the period of its use (human 1936-1961; veterinary 1954-1974). Results from ~3,500 human cases were reported in the clinical case studies over 30 articles, and indicated a high treatment efficacy (>90 %) for patients. Radiotherapy was effective with a single treatment. The duration of treatment effectiveness was prolonged, usually lasting until the duration of the follow-up period (i.e., 1-5 years). Therapeutic effectiveness was reduced for conditions characterized as chronic. Similar findings were reported with race horses in the veterinary literature. These historical findings are consistent with clinical studies over the past several decades in Germany, which have used more rigorous study designs and a broader range of clinical evaluation parameters. Radiotherapy treatment was widely used in the mid twentieth century in the USA, but was abandoned following the discovery of anti-inflammatory drugs and the fear of radiation-induced cancer. That X-ray treatment could be an effective means of treating shoulder tendonitis/bursitis, as a treatment option, and is essentially unknown by the current medical community. This paper is the first comprehensive synthesis of the historical use of X-rays to treat shoulder tendonitis/bursitis and its efficacy in the USA.

Analysis of the effect of phototherapy in model with traumatic Achilles tendon injury in rats.

The aim of this study was to investigate the effect of low-intensity laser (LILT) infrared (830 nm) therapy in tendon inflammation, tendinitis induced by mechanical trauma in rat Achilles tendon. For this, we used 65 young male Wistar rats, weighing ± 300 g divided into different groups: C = control (n = 5) and experimental (n = 10/group), with two different times of sacrifice such as treated with L = laser, D = treated with diclofenac, and T = untreated injured. The tendon inflammation was induced by controlled contusion in the medial region of the Achilles tendon of the animals. The treated groups received some kind of intervention every 24 h, all groups were sacrificed on the 7th or 14th day after the trauma. The tendons were dissected, extracted, and sent for analysis. Histological analysis of the L group showed a decrease in the number of inflammatory cells in relation to other groups in both periods studied. The comparative results between the number of inflammatory cells in the control and treated groups at 7 and 14 days showed statistically significant differences. Qualitative analysis findings obtained by the picrosirius red technique under polarized light showed that in 7 days, the T group presented collagen types I and III in the same proportion; group D presented a predominance of type III fibers, while in group L, type I collagen predominated. The 14-day group D showed collagen types I and III in the same proportion, while in group L, there was a predominance of type I fibers. Biomechanical analysis showed that 7-day groups L and C showed similar stiffness and increased breaking strength. The 14-day groups L and C showed greater rupturing strength as well as increased stiffness angle. Group D showed a decrease of maximum traction strength and degree of rigidity. It was concluded that treatment with LIL in the parameters used and the times studied reduces migration of inflammatory cells and improves the quality of repair while reducing the functional limitations.

Radiotherapy for achillodynia : results of a single-center prospective randomized dose-optimization trial.

BACKGROUND AND PURPOSE: The aim of this study was to compare the efficacy of two different dose-fractionation schedules for radiotherapy of patients with achillodynia. PATIENTS AND METHODS: Between February 2006 and February 2010, 112 consecutive evaluable patients were recruited for this prospective randomized trial. All patients underwent radiotherapy with an orthovoltage technique. One radiotherapy course consisted of 6 single fractions over 3 weeks. In case of insufficient remission of pain after 6 weeks, a second radiation series was performed. Patients were randomly assigned to receive either single doses of 0.5 or 1.0 Gy. The endpoint was pain reduction. Pain was measured before, right after, and 6 weeks after radiotherapy with a visual analogue scale (VAS) and a comprehensive pain score (CPS). RESULTS: The overall response rate for all patients was 84% directly after and 88% 6 weeks after radiotherapy. The mean VAS values before, directly after, and 6 weeks after treatment for the 0.5 and 1.0 Gy groups were 55.7 ± 21.0 and 58.2 ± 23.5 (p = 0.526), 38.0 ± 23.2 and 30.4 ± 22.6 (p = 0.076), and 35.4 ± 25.9 and 30.9 ± 25.4 (p = 0.521), respectively. The mean CPS before, directly after, and 6 weeks after treatment was 8.2 ± 3.0 and 8.9 ± 3.3 (p = 0.239), 5.6 ± 3.1 and 5.4 ± 3.3 (p = 0.756), 4.4 ± 2.6 and 5.3 ± 3.8 (p = 0.577), respectively. No statistically significant differences were found between the two single-dose trial arms for early (p = 0.366) and delayed response (p = 0.287). CONCLUSION: Radiotherapy is an effective treatment option for the management of achillodynia. For radiation protection, the dose of a radiotherapy series is recommended not to exceed 3-6 Gy.

Low-level laser therapy in experimental model of collagenase-induced tendinitis in rats: effects in acute and chronic inflammatory phases.

A variety of treatments for tendinopathies is currently used or has been trialed. However, in fact, there is a remarkably little evidence that any conventional therapies are effective. In the last years, low-level laser therapy (LLLT) has been showing interesting results in inflammatory modulation in different musculoskeletal disorders, but the optimal parameters and mechanisms behind these effects are not fully understood. The aim of this study is to investigate if the LLLT modulates the acute and chronic phase of collagenase-induced tendinitis in rat by interfering in mRNA expression for matrix metalloproteinases (MMP13 and MMP1), vascular endothelial growth factor (VEGF), and anti-inflammatory mediator (interleukin (IL)-10). For such, tendinitis was induced by collagenase injection in male Wistar rats. Animals were treated with LLLT (780 nm, potency of 22 mW, 107 mW/cm(2), energy density of 7.5 J/cm(2), and energy delivered of 1.54 J) with different number of treatments in accordance with the inflammatory phase analyzed. LLLT was able to modulate mRNA gene expression of IL-10, VGEF, MMP1, and MMP13 both in acute than in chronic inflammatory phase (p<0.05). Our results suggest that LLLT with parameters employed in the present study was able to modulate IL-10, VEGF, MMP1, and MMP13 mRNA gene expression both in acute than in chronic tendon inflammation. However, further studies are needed to establish optimal parameters for LLLT.

Clinical effectiveness of low-level laser therapy as an adjunct to eccentric exercise for the treatment of Achilles' tendinopathy: a randomized controlled trial.

OBJECTIVE: To investigate the effectiveness of low-level laser therapy (LLLT) as an adjunct to a program of eccentric exercises for the treatment of Achilles' tendinopathy. DESIGN: Randomized controlled trial with evaluations at baseline and 4, 12, and 52 weeks. SETTING: Primary care clinic. PARTICIPANTS: Participants with midportion Achilles' tendinopathy were randomly assigned to 2 groups (LLLT n=20: mean age ± SD, 45.6±9.1y; placebo n=20: mean age ± SD, 46.5±6.4y). The 12-week evaluation was completed by 36 participants (90%), and 33 participants (82.5%) completed the 52-week evaluation. INTERVENTION: Both groups of participants performed eccentric exercises over a 3-month period. In addition, they received either an active or placebo application of LLLT 3 times per week for the first 4 weeks; the dose was 3J per point. MAIN OUTCOME MEASURES: The primary outcome was the Victorian Institute of Sport Assessment-Achilles' questionnaire (VISA-A) score at 12 weeks; secondary outcome was a visual analog scale for pain. Outcomes were measured at baseline and 4, 12, and 52 weeks. RESULTS: Baseline characteristics exhibited no differences between groups. At the primary outcome point, there was no statistically significant difference in VISA-A scores between groups (P>.05). The difference in VISA-A scores at the 4-week point significantly favored the placebo group (F(1)=6.411, sum of squares 783.839; P=.016); all other outcome scores showed no significant difference between the groups at any time point. Observers were blinded to groupings. CONCLUSIONS: The clinical effectiveness of adding LLLT to eccentric exercises for the treatment of Achilles' tendinopathy has not been demonstrated using the parameters in this study.

Effects of low-level laser therapy in combination with physiotherapy in the management of rotator cuff tendinitis.

Rotator cuff tendinitis is one of the main causes of shoulder pain. The objective of this study was to evaluate the possible additive effects of low-power laser treatment in combination with conventional physiotherapy endeavors in these patients. A total of 50 patients who were referred to the Physical Medicine and Rehabilitation Clinic with shoulder pain and rotator cuff disorders were selected. Pain severity measured with visual analogue scale (VAS), abduction, and external rotation range of motion in shoulder joint was measured by goniometry, and evaluation of daily functional abilities of patients was measured by shoulder disability questionnaire. Twenty-five of the above patients were randomly assigned into the control group and received only routine physiotherapy. The other 25 patients were assigned into the experimental group and received conventional therapy plus low-level laser therapy (4 J/cm(2) at each point over a maximum of ten painful points of shoulder region for total 5 min duration). The above measurements were assessed at the end of the third week of therapy in each group and the results were analyzed statistically. In both groups, statistically significant improvement was detected in all outcome measures compared to baseline (p < 0.05). Comparison between two different groups revealed better results for control of pain (reduction in VAS average) and shoulder disability problems in the experimental group versus the control (3.1 ± 2.2 vs. 5 ± 2.6, p = 0.029 and 4.4 ± 3.1 vs. 8.5 ± 5.1, p = 0.031, respectively ) after intervention. Positive objective signs also had better results in the experimental group, but the mean range of active abduction (144.92 ± 31.6 vs. 132.80 ± 31.3) and external rotation (78.0 ± 19.5 vs. 76.3 ± 19.1) had no significant difference between the two groups (p = 0.20 and 0.77, respectively). As one of physical modalities, gallium-arsenide low-power laser combined with conventional physiotherapy has superiority over routine physiotherapy from the view of decreasing pain and improving the patient's function, but no additional advantages were detected in increasing shoulder joint range of motion in comparison to other physical agents.

Photobiomodulation for Tendinopathy: A Review of Preclinical Studies.

The outcomes of clinical studies utilizing Photobiomodulation on tendon disorders are not homogeneous and since its design depends on preclinical studies utilizing animal models as a prerequisite, this review investigates the literature to help extrapolate preclinical evidence-based outcomes (safety and efficacy) into clinical treatment options. PubMed and Embase databases were searched for tendinopathy, Photobiomodulation and preclinical studies with inclusion criteria were restricted to in vivo animal studies using rat's models subjected to partially injured tendons. Data extracted were methodology quality and design, light parameters, study methods, and outcomes. Twenty two articles were included, half of them were partially transected, while the other half were partially traumatized. The most common wavelengths used were 660, 830, and 904 nm with energy density range between 1 and 17 J/cm2 and applied mostly daily. Fourteen studies (64%) relied merely on a single assessment. Histological measurements were the most common method of evaluation (75%) and 35% of studies used chemical measures. Mechanical outcomes were reported in four, and two studies demonstrate significant effects. Photobiomodulation has the potential to enhance tendon structure and function, however, inevitable embedded heterogeneity related to study design and quality of methods, light parameters delivered, and evaluations methods renders the ability to establish unified treatment parameters difficult. Adjustments for variability within preclinical studies might lead to better designing of clinical studies. It is recommended to embrace a protocol for designing and performing preclinical studies to improve its quality. Moreover, it is recommended to prove efficacy using at least two evaluation methods and apply Photobiomodulation as a combined varying energy/wavelength protocol (several energies with several wavelengths). Clinical relevance: Establishing a proof of concept for Photobiomodulation that may lead to further high-quality clinical studies, in which the applicable parameters can be determined.

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.

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

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