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.

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 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.

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.

Effect of low intensity photobiomodulation associated with norbixin-based poly (hydroxybutyrate) membrane on post-tenotomy tendon repair. In vivo study.

PURPOSE: To evaluate the in vivo response of photobiomodulation therapy associated with norbixin-based poly(hydroxybutyrate) membrane (PHB) in tenotomized calcaneal tendon. METHODS: Thirty rats were randomly allocated to six groups (n=5 each): LED groups (L1, L2 and L3) and membrane + LED groups (ML1, ML2 and ML3). The right calcaneal tendons of all animals were sectioned transversely and were irradiated with LED daily, one hour after surgery every 24 hours, until the day of euthanasia. At the end of the experiments the tendons were removed for histological analysis. RESULTS: The histological analysis showed a significant reduction in inflammatory cells in the ML1, ML2 and ML3 groups (p=0.0056, p=0.0018 and p<0.0001, respectively) compared to those in the LED group. There was greater proliferation of fibroblasts in the ML1 (p<0.0001) and L3 (p<0.0001) groups. A higher concentration of type I collagen was also observed in the ML1 group (p=0.0043) replacing type III collagen. CONCLUSION: Photobiomodulation in association with norbixin-based PHB membrane led to control of the inflammatory process. However, it did not favor fibroblast proliferation and did not optimize type I collagen formation in the expected stage of the repair process.

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 low intensity photobiomodulation associated with norbixin-based poly (hydroxybutyrate) membrane on post-tenotomy tendon repair. In vivo study

Abstract Purpose: To evaluate the in vivo response of photobiomodulation therapy associated with norbixin-based poly(hydroxybutyrate) membrane (PHB) in tenotomized calcaneal tendon. Methods: Thirty rats were randomly allocated to six groups (n=5 each): LED groups (L1, L2 and L3) and membrane + LED groups (ML1, ML2 and ML3). The right calcaneal tendons of all animals were sectioned transversely and were irradiated with LED daily, one hour after surgery every 24 hours, until the day of euthanasia. At the end of the experiments the tendons were removed for histological analysis. Results: The histological analysis showed a significant reduction in inflammatory cells in the ML1, ML2 and ML3 groups (p=0.0056, p=0.0018 and p<0.0001, respectively) compared to those in the LED group. There was greater proliferation of fibroblasts in the ML1 (p<0.0001) and L3 (p<0.0001) groups. A higher concentration of type I collagen was also observed in the ML1 group (p=0.0043) replacing type III collagen. Conclusion: Photobiomodulation in association with norbixin-based PHB membrane led to control of the inflammatory process. However, it did not favor fibroblast proliferation and did not optimize type I collagen formation in the expected stage of the repair process.

Photobiomodulation of Matrix Metalloproteinases in Rat Calcaneal Tendons.

Objective: The main objective was to verify the modulatory effects of MMP-1, MMP-3, and MMP-13 levels on the partially injured calcaneal tendons of rat exposure to photobiomodulation. Background: Photobiomodulation has been shown to have anti-inflammatory and regenerative effects on tendon injuries. However, there is still uncertainty regarding the beneficial effects in matrix metalloproteinase (MMP) levels, especially MMP-1, -3, and -13. Materials and methods: Sixty-five male Wistar rats were used. Sixty were submitted to a direct trauma on the calcaneal tendons and were randomly distributed into the following six groups: LASER 1, 3, and 7 (10 partially injured calcaneal tendons in each group treated with photobiomodulation for 1, 3, and 7 days, respectively) and Sham 1, 3, and 7 (same injury, with simulated photobiomodulation). The remaining five animals were allocated to the normal group (no injury or treatment procedure). The 780 nm low-level laser was applied with 70 mW of mean power and 17.5 J/cm2 of fluency for 10 sec, once a day. The tendons were surgically removed and analyzed for MMP-1, MMP-3, and MMP-13 through immunohistochemistry. Results: MMP-3 levels remained close to normal in all experimental groups (p > 0.05); however, reductions (p < 0.05) in MMP-1 and MMP-13 levels were detected in the groups submitted to one, three, and seven low level laser therapy applications. Conclusions: The photobiomodulation protocol was able to reduce MMP-1 and MMP-13 levels in injured calcaneal tendons.

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.

Long-Term Effect of Pulsed Nd:YAG Laser in the Treatment of Patients with Rotator Cuff Tendinopathy: A Randomized Controlled Trial.

OBJECTIVE: The purpose of the present study was to investigate the long-term effect of pulsed Nd:YAG laser on the treatment of rotator cuff tendinopathy. METHODS: Sixty patients with rotator cuff tendinopathy participated and completed the study. The mean age was 50.2 ± 3.6 years. Participants were randomly assigned to one of two groups: the control group and the treatment group. Both groups were treated with an exercise program, in addition to the pulsed Nd:YAG laser received by the treatment group and the "sham" laser received by the control group, both for three sessions per week for 4 weeks. Outcome measures included pain, assessed by the visual analog scale, and range of motion (ROM), assessed using a traditional goniometer, while the shoulder pain and disability index were used to evaluate the functional recovery of the shoulder joint. Evaluation was carried out before treatment, immediately after treatment, 3 months posttreatment, and 6 months posttreatment. Statistical analyses were used to investigate the effect of interventions and to compare the study groups' pretreatment, posttreatment, and at follow-up points. The significance level was set to p < 0.05. RESULTS: Pain was significantly decreased after treatment and at follow-up points, while ROM and shoulder functions were significantly improved after treatment and at follow-up intervals in both groups. The improvement was more significant in the treatment group than in the control group posttreatment and at follow-up intervals. CONCLUSIONS: Pulsed Nd:YAG laser combined with an exercise program seems to be more effective in the treatment of patients with rotator cuff tendinopathy than a sham laser with exercises.

Radiotherapy for calcaneodynia, achillodynia, painful gonarthrosis, bursitis trochanterica, and painful shoulder syndrome - Early and late results of a prospective clinical quality assessment.

BACKGROUND: The aim of this prospective clinical quality assessment was to evaluate the short-term and long-term efficacy of low dose radiotherapy (RT) for calcaneodynia, achillodynia, painful gonarthrosis, painful bursitis trochanterica, and painful shoulder syndrome. METHODS: Between October 2011 and October 2013, patients with calcaneodynia, achillodynia, painful gonarthrosis, painful bursitis trochanterica, and painful shoulder syndrome were recruited for this prospective clinical quality assessment. Single doses of 0.5-1.0 Gy and a total dose of 6.0 Gy per series were used. Pain was measured before and directly after RT (early response) with a visual analogue scale (VAS). Additionally, pain relief was measured with the four-scale pain score according to "von Pannewitz" (VPS) immediately at the end of RT and during follow-up. Within this context we defined a good response as complete pain relief and markedly improved. The assessment of the long-term efficacy was carried out by a telephone survey. RESULTS: 703 evaluable patients (461 female, 242 male) with a mean age of 63.2 years (28-96) were recruited for this prospective clinical quality assessment. In 254 patients RT was performed with the linear accelerator, 449 patients received orthovoltage radiotherapy. After a median follow-up of 33 months (3-60) 437 patients could be reached for evaluation of follow up results. The mean VAS value before treatment was 6.63 (1.9-10) and immediately on completion of RT 4.51 (0-10) (p < 0,001). Concerning the VPS immediately on completion of RT, a good response could be achieved in 264/703 patients (37.6%), and with the follow up in 255/437 patients (58.4%) (p < 0.001). Only in patients with gonarthrosis we could not observe a significantly improved long-term success in comparison to the results immediately after RT (30.2% versus 29.9%). CONCLUSION: Low dose RT is a very effective treatment for the management of calcaneodynia, achillodynia, painful gonarthrosis, painful bursitis trochanterica, and painful shoulder syndrome. Due to the delayed onset of analgesic effects low dose RT results in a significantly improved long-term efficacy in comparison to the results immediately after RT particularly in patients with calcaneodynia, achillodynia, bursitis trochanterica, and shoulder syndrome.

Low level laser therapy accelerates the extracellular matrix reorganization of inflamed tendon.

In tendon lesions, inflammation indicates the beginning of tissue repair and influences cell proliferation and the remodeling of the extracellular matrix (ECM). Low level laser (LLL) therapy has been an important method to induce tissue repair, and several studies have sought to better understand the therapeutic possibilities of this modality. This study analyzed the effect of LLL on the ECM of rat tendons during the early phase of the inflammatory process. Wistar rats received an intratendinous application of carrageenan adjacent to the osteotendinous region in the right paw. The animals were divided into the following groups: G1-intact, G2-animals with no treatment after the inflammation induction, G3-animals treated with LLL 1 and 3h after induction of inflammation (4J/cm2 continuous). After 4h of application, the animals of the two groups were euthanized with isoflurane overdose. Our results demonstrate that LLL therapy can promote decrease in non-collagenous protein and glycosaminoglycans content, as well as an increase in metalloproteinases -9, which proved, for the first time, that LLL therapy promotes alterations in the inflamed tendons even when analyzed only four hours after this process occur and could be a useful tool to improve the balance in inflamed tissues.

[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.

Low-Dose Radiation Therapy for Benign Painful Skeletal Disorders: The Typical Treatment for the Elderly Patient?

PURPOSE: To prospectively evaluate the short-term and long-term efficacy of low-dose radiation therapy (RT) for calcaneodynia, achillodynia, painful gonarthrosis, and painful bursitis trochanterica in elderly patients aged ≥70 years. METHODS AND MATERIALS: Between October 2011 and October 2013, patients aged ≥70 years with painful degenerative disorders of joints were recruited for a prospective trial. Single doses of 0.5 to 1.0 Gy and a total dose of 6.0 Gy per series were used. Pain was measured before and right after RT (early response) with a 10-point visual analogue scale. Additionally, pain relief was measured with the 4-point pain scale according to "von Pannewitz" immediately on completion of RT and during follow-up. We defined a good response as complete pain relief and markedly improved. RESULTS: A total of 166 evaluable patients with a mean age of 76.6 years (range, 70-90 years) with calcaneodynia (n=51), achillodynia (n=8), painful gonarthrosis (n=80), and painful bursitis trochanterica (n=27) were recruited. The mean visual analogue scale value before treatment was 6.38 and immediately upon completion of RT was 4.49 (P<.001). Concerning the von Pannewitz status immediately on completion of RT, 6 patients were free of pain, 56 were much improved, 47 reported slight improvement, and 57 experienced no change. After a median follow-up of 29 months, 109 patients could be reached for evaluation of follow-up results. Thirty-three patients were free of pain, 21 had marked improvement, 18 had some improvement, and 37 experienced no change. Therefore, a good response immediately on completion of RT could be achieved in 62 of 166 patients, and with the follow-up in 54 of 109 patients (P=.001). CONCLUSIONS: Low-dose RT is a very effective treatment for the management of painful degenerative disorders of joints in the elderly. Low-dose RT offers a low-risk, genuinely conservative, noninvasive therapeutic alternative for elderly patients.

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.

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.

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.

Effect of MLS(®) laser therapy with different dose regimes for the treatment of experimentally induced tendinopathy in sheep: pilot study.

OBJECTIVE: The aim of this preliminary study was to investigate the effect of Multiwave Locked System (MLS(®)), a particular model of low-level laser, in the acute phase of collagenase-induced tendon lesions in six adult sheep randomly assigned to two groups. BACKGROUND DATA: Tendon injuries are common among human athletes and in sport horses, require a long recovery time, and have a high risk of relapse. Many traditional treatments are not able to repair the injured tendon tissue correctly. In recent years, the use of low-level laser therapy (LLLT) produced interesting results in inflammatory modulation in different musculoskeletal disorders. METHODS: Group 1 received 10 treatments of MLS laser therapy at a fluence of 5 J/cm(2) on the left hindlimb. Group 2 received 10 treatments of MLS laser therapy at a fluence of 2.5 J/cm(2) on the left hindlimb. In every subject in both groups, the right hindlimb was considered as the control leg. RESULTS: Clinical follow-up and ultrasonography examinations were performed during the postoperative period, and histological examinations were performed at day 30 after the first application of laser therapy. In particular, results from histological examinations indicate that both treatments induced a statistically significant cell number decrease, although only in the second group did the values return to normal. Moreover, the MLS laser therapy dose of 2.5 J/cm(2) (group 2) caused a significant decrease of vessel area. CONCLUSIONS: In this study, clinical and histological evaluation demonstrated that a therapeutic dose <5 J/cm(2) furnished an anti-inflammatory effect, and induced a decrease of fibroblasts and vessel area. Overall, our results suggest that MLS laser therapy was effective in improving collagen fiber organization in the deep digital flexor tendon.

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.