Clinical Efficacy of High-Intensity Laser Therapy on Lateral Epicondylitis Patients: A Systematic Review and Meta-analysis.

OBJECTIVES: Recently, high-intensity laser therapy has been used in the therapeutic protocols for pain management. We aimed to evaluate the clinical efficacy of high-intensity laser therapy versus other different modalities for improving lateral epicondylitis symptoms. METHODOLOGY: We conducted a systematic review and meta-analysis on prospective randomized controlled trials from PubMed, Embase, Scopus, Web of Science, and Science Direct until June 2021 using relevant key words. We analyzed the data using Review Manager software (RevMan 5.4). RESULTS: Six randomized controlled trials with 344 patients were included. There is low-quality evidence that high-intensity laser therapy generates a small reduction on pain intensity compared with a control group either during activity (mean difference = -0.98, 95% confidence interval = -1.6 to -0.35, P = 0.002) or during rest (mean difference = -0.98, 95% confidence interval = -1.68 to -0.09, P = 0.03). In addition, there is low-quality evidence that high-intensity laser therapy provides small improvements in quality of life (physical component) compared with control (mean difference = 9.76, 95% confidence interval = 2.69 to 16.83, P < 0.0001). CONCLUSIONS: High-intensity laser therapy is an effective therapeutic modality to reduce pain and improve quality of life (36-item short form health survey physical component) in patients experiencing persistent symptoms of lateral epicondylitis. However, grip strength, hand function, and quality of life (36-item short form health survey) did not show significant differences between high-intensity laser therapy and other therapies.

Efficacy of Extracorporeal Shock Wave Therapy for Lateral Epicondylitis: A Systematic Review and Meta-Analysis.

BACKGROUND: Lateral epicondylitis (LE) is a common elbow problem. Extracorporeal shock wave therapy (ESWT) was widely used in the treatment of LE and has been shown to relieve the pain and functional impairment (loss of grip strength) caused by tennis elbow. However, the evidence with regard to whether ESWT has better clinical efficacy over other method is not clear. The aim of the study was to compare the effectiveness of ESWT with other techniques in the treatment of LE. METHODS: Literature searches of PubMed, OVID, Embase, Cochrane Library, and Web of Science were searched up to 30th June, 2019. Only RCTs comparing ESWT with other methods for LE were included. Data collection and extraction, quality assessment, and data analyses were performed according to the Cochrane standards. RESULTS: A total of 13 articles with 1035 patients were included. Of which, 501 underwent ESWT and 534 underwent other methods. The result of meta-analysis showed that pooled VAS (P = 0.0004) and grip strength (P < 0.00001) were better in the ESWT group. CONCLUSION: Based on the existing clinical evidence, extracorporeal shock wave therapy can effectively relieve the pain and functional impairment (loss of grip strength) caused by tennis elbow, with better overall safety than several other methods. However, owing to the limited quality and quantity of the included studies, more high-quality RCTs are needed to support the trend towards better functional outcomes with ESWT.

Re-irradiation for humeral epicondylitis : Retrospective analysis of 99 elbows.

BACKGROUND: Humeral epicondylitis is a common elbow disease. The prevalence is about 1.7%. One of the most effective treatment options is radiotherapy. Some authors mention that they apply a second or third course of radiation for recurrent pain or partial or no response to the initial course. As the results of a re-irradiation have not been systematically analyzed, the aim of this study was to document the results of repeated radiation treatment and to identify those patients who will benefit. MATERIAL AND METHODS: The analysis was performed on patients from three German radiotherapy institutions and included 99 re-irradiated elbows. Pain was documented with the numeric rating scale (NRS). Evaluation of the NRS was done before and directly after each radiation therapy as well as for the follow-up of 24 months. The median age of the patients was 51 years with 48.8% male and 51.2% female patients. Repeated radiation was indicated because the initial radiotherapy resulted in 39.7% of no response, in 41.0% of partial response and in 19.3% of recurrent pain. RESULTS: A significant response to re-irradiation was found. For the whole sample the median pain score was 6 before re-irradiation, 3 after 6 weeks, 2 after 12 months and 1 after 24 months. The percentage of patients being free of pain or with very little pain was 50.9% 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 humeral epicondylitis is an effective and safe treatment. All subgroups showed a good response to re-irradiation for at least 24 months.

Radiotherapy of epicondylitis humeri : Analysis of 138 elbows treated with a linear accelerator.

BACKGROUND: Epicondylitis humeri is a common disease with a prevalence of 1.7%. One of the treatment options is radiotherapy. Most published cases were treated with the orthovoltage technique or with a telecobalt device. Many radiotherapy institutions are nowadays using linear accelerators for treatment of epicondylitis humeri. There is a discussion whether the treatment results with linear accelerators are comparable to the orthovoltage technique. The aim of this study was to analyze the results of radiotherapy with a linear accelerator for epicondylitis humeri. MATERIAL AND METHODS: The analysis was performed on patients of 2 German radiotherapy institutions and included 138 irradiated elbows. Pain was documented with the numeric rating scale (NRS). Evaluation of the NRS was done before and directly after each radiation therapy course as well as for the follow-up of 24 months. The median age of the patients was 49 years with 48.4% male and 51.6% female. In all, 81.0% were suffering from from epicondylitis humeri radialis while 16.7% were treated because of epicondylitis humeri ulnaris. In 65.4% the dominant arm was treated. RESULTS: A significant response to radiotherapy could be found. For the whole sample the median pain was 7 on the NRS before radiotherapy, 4 after 6 weeks and 0 after 12 and 24 months. The percentage of patients with 0 or 1 on the NRS was 64.6% 12 months after radiotherapy. All subgroups, notably those with epicondylitis humeri radialis and epicondylitis humeri ulnaris had a significant reduction of pain. CONCLUSION: Radiotherapy of epicondylitis humeri with a linear accelerator is an effective treatment without showing side effects. All analyzed subgroups showed a good response to radiotherapy for at least 24 months.

Long term effects of high intensity laser therapy in lateral epicondylitis patients.

The objective of this study is to investigate short- and long-term effects of high-intensity laser therapy (HILT) in lateral epicondylitis (LE) patients. Thirty patients with LE diagnosis (23 unilateral and 7 bilateral in total 37 elbows) were treated using HILT. LE patients were evaluated before, right after, and 6 months following HILT intervention post-treatment using visual analogue scale for pain (VAS) during activity and resting. Disabilities of the Arm, Shoulder, and Hand (DASH) Score and hand grip strength test (HGST) were used. The participants of the present study were also evaluated using Short-Form 36 (SF-36) before and 6 months after the treatment. Out of the 30 patients, 8 were male and 22 female with a mean age of 47.2 ± 9.7. The activity and resting VAS, DASH, and HGST scores revealed statistically significant improvement (p = 0.001) following treatment. Whereas VAS activity, DASH, and HGST scores increased after treatment until post-treatment 6 months significantly (p = 0.001), VAS resting scores remained stable (p = 0.476). A statistically significant improvement was also evident in the physical and mental components of SF-36 scores following treatment until post-treatment 6 months compared to pre-treatment scores (p = 0.001). In conclusion, the results of the present study suggest that HILT is a reliable, safe, and effective treatment option in LE patients in the short and long term considering pain, functional status, and quality of life.

Autologous proliferative therapies in recalcitrant lateral epicondylitis.

OBJECTIVE: This study investigates the clinical effects of autologous conditioned plasma (ACP) injections and low-level laser application as therapy options for chronic lateral epicondylitis. DESIGN: A total of 52 patients with chronic lateral epicondylitis were evaluated in this study; 26 of these patients received three ACP injections and the control group, with 26 patients, received 12 laser applications, with standardized physical therapy for all patients afterward. Control examinations took place before treatment, after 2 and 6 mos, and in the 1 yr final follow-up. The control examination included the visual analog scale for pain and Disabilities of the Arm, Shoulder and Hand outcome measure scores. RESULTS: The analysis at final follow-up after 1 yr showed that both treatment options resulted in successful therapy outcome for the patients. In total, 63.5 % were successfully treated. Successful treatment was defined as more than 30% improvement in the visual analog score and more than 10.2 points in the Disabilities of the Arm, Shoulder and Hand score. Both groups showed a significant improvement in time response. CONCLUSIONS: This study demonstrates the beneficial effects of autologous proliferative therapies in the treatment of lateral epicondylitis. The data show that laser application and ACP therapy lead to a clinical improvement in epicondylopathia. Especially the new treatment with ACP can be highlighted as an alternative and as an easy-to-apply therapy option for clinical practice.

An Evaluation of Radiotherapy Effectiveness for Epicondylitis Humeri (EPH).

BACKGROUND: Humeral epicondylitis, a relatively common disease, is classified among inflammatory conditions of soft tissues and is frequently associated with elbow pain. The aim of the study was to assess the effectiveness of radiotherapy in patients with epicondylitis humeri. MATERIAL AND METHODS: The study was based on the observation of 50 cases. All patients were irradiated with 6-MV photons delivered in 1 Gy fraction doses, up to a total of 6 Gy, using two opposite coaxial fields. Follow-up examinations took place immediately after the treatment and at 1, 2-3, 4-6, 8-12, 19-24 and 26-30 months post-treatment. Pain relief, joint mobility, regional edema, joint temperature and the percentage of patients using analgesics were assessed. RESULTS: No adverse events were observed. The mean percentage of patients with pain relief was 22.8% directly after, compared to 70.2% at 8-12 months and 57.5% at 26-30 months post-treatment. A decrease in joint mobility was by 16% of the patients at one year after treatment and in 25% of the patients at 26-30 months after treatment. The percentages of patients with increased elbow temperature, elbow edema and analgesics uptake at the respective time points were 6% and 0%, 36% and 0%, and 0% and 37%. The percentage of patients reporting partial and complete pain relief was 41.7% and 45.8%, and 30% and 40%, respectively. CONCLUSION: Anti-inflammatory radiotherapy of patients with humeral epicondylitis is a safe and effective method of treatment.

Benign painful elbow syndrome. First results of a single center prospective randomized radiotherapy dose optimization trial.

BACKGROUND AND PURPOSE: The goal of the present study was to evaluate the efficacy of two different dose-fractionation schedules for radiotherapy (RT) of patients with painful elbow syndrome. PATIENTS AND METHODS: Between February 2006 and February 2010, 199 consecutive evaluable patients were recruited for this prospective randomized trial. All patients received RT in orthovoltage technique. One RT course consisted of 6 single fractions/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. Endpoint was pain reduction. Pain was measured before, right after, and 6 weeks after RT by a visual analogue scale (VAS) and a comprehensive pain score (CPS). RESULTS: The overall response rate for all patients was 80% direct after and 91% 6 weeks after RT. The mean VAS values before, after and 6 weeks after treatment for the 0.5 and 1.0 Gy groups were 59.6 ± 20.2 and 55.7 ± 18.0 (p = 0.463), 32.1 ± 24.5 and 34.4 ± 22.5 (p = 0.256), and 27.0 ± 27.7 and 23.5 ± 21.6 (p = 0.818). The mean CPS before, after, and 6 weeks after treatment was 8.7 ± 2.9 and 8.1 ± 3.1 (p = 0.207), 4.5 ± 3.2 and 5.0 ± 3.4 (p = 0.507), 3.9 ± 3.6 and 2.8 ± 2.8 (p = 0.186), respectively. No statistically significant differences between the two single dose trial arms for early (p = 0.103) and delayed response (p = 0.246) were found. CONCLUSION: RT is an effective treatment option for the management of benign painful elbow syndrome. For radiation protection reasons the dose for a RT series is recommended not to exceed 3.0 Gy.

Therapeutic effects of low-level laser on lateral epicondylitis from differential interventions of Chinese-Western medicine: systematic review.

BACKGROUND: Low-level laser therapy (LLLT) is a conservative treatment for lateral epicondylitis (LE), but it is also an alternative intervention between the very different approaches of Chinese and Western medicine. OBJECTIVE: The purpose of this study was to systematically review and meta-analyze the therapeutic effects of LLLT on LE. METHODS: We searched several electronic databases, including Medline, PubMed, and CINAHL, and explored studies that were randomized controlled trials on the therapeutic effects of LLLT on LE from 1990 to February 2009. These studies were systematically reviewed for the difference in therapeutic effects among various LLLTs on acupuncture points and on tender and myofascial trigger points (MTrPs). The reviewed therapeutic effects included pain, grip strength, range of motion (ROM), and weight tests, and were compared by meta-analysis. RESULTS: We selected ten articles, and in seven of them the irradiation was conducted on tender points or MTrPs in the experimental groups. In two other articles, the irradiation was conducted on acupuncture points, and the last one was conducted on both kinds of points. Only three articles provided sufficient data for meta-analysis. The results revealed that applying LLLT on tender points or MTrPs is an effective means to improve the effect size (ES) of pain release after treatment (pooled ES: 0.71, 95% CI: 0.82- approximately 0.60) and follow-up (pooled ES: 1.05, 95% CI: 1.16- approximately 0.94). LLLT application was also able to increase the grip force, ROM, and weight test (p < 0.05). CONCLUSIONS: We suggest that using LLLT on tender points or MTrPs of LE could effectively improve therapeutic effects.

Investigation of the effect of GaAs laser therapy on lateral epicondylitis.

BACKGROUND AND OBJECTIVE: There are conflicting reports regarding the efficacy of low energy laser therapy in treatment of lateral epicondylitis (LE). Contradictory results are considered to be due to different joint treatment protocols regarding variables such as dose, duration, and frequency. The aim of this study was to investigate the efficacy of gallium-arsenide (GaAs) laser therapy, which was performed with the dose regimen recommended by the World Association for Laser Therapy, in relieving pain and improving functional activities in patients with LE. PATIENTS AND METHODS: Forty-nine patients (50 elbows) evaluated in our outpatient clinic were included in the study. Elbows were randomized into two groups: laser (n = 25) and placebo laser (n = 25). Either laser or placebo laser therapy was applied to patients for 15 sessions (5 d per week for 3 weeks). Main outcome measures were visual analog scale, tenderness, Disability of the Arm Shoulder and Hand (DASH) questionnaire, the Patient-Related Lateral Epicondylitis Evaluation (PRTEE) test, pain-free grip strength, and the Nottingham Health Profile (NHP) questionnaire. Evaluations were performed before treatment, at the end of 3 weeks of treatment, and after the 12th week of treatment ended. RESULTS: Upon post-treatment evaluation, a significant improvement in all parameters was observed for both groups (p < 0.05). No significant difference was found when the laser and placebo groups were compared. At the 12 week evaluation, a significant sustained improvement in all parameters was observed. On intergroup evaluation, a significant improvement was observed in favor of the active treatment group regarding pain with resisted extension of the wrist, tenderness with pressure, and for both the total and subgroup scores of the DASH questionnaire and PRTEE test, as well as for the pain subgroup of the NHP questionnaire (p < 0.05). CONCLUSION: Although low energy laser therapy had no advantage compared to placebo in patients with LE for the short term, a significant improvement, particularly in functional parameters, was achieved in the long term. Laser, which has relatively no side effects, might be included among long-term treatment options for LE.

Radiofrequency microtenotomy: a promising method for treatment of recalcitrant lateral epicondylitis.

BACKGROUND: Recalcitrant lateral epicondylitis (elbow tendinosis) is a common cause of elbow pain. There are many forms of treatment, none being superior. HYPOTHESIS: The main hypothesis tested in this study is that radiofrequency microtenotomy offers better results than the extensor tendon release and repair operation for elbow tendinosis, especially earlier recovery. STUDY DESIGN: Randomized controlled trial; Level of evidence, 1. METHODS: Twenty-four patients were randomized into 2 treatment groups, extensor tendon release and repair, and microtenotomy. Dynamic infrared thermography (DIRT) was employed as an objective method to verify the diagnosis as well as to document the outcome 3 months after the surgical procedure. RESULTS: Visual analog scale pain scores in the microtenotomy but not in the release group decreased significantly after 3 weeks. There was no statistically significant difference in pain scores between the 2 groups at 3, 6, and 12 weeks, and at 10 to 18 months. At 12 weeks, grip strength had improved significantly in the microtenotomy but not in the release group. The functional score was significantly increased in both groups. The DIRT group showed significant differences in epicondyle skin temperature between diseased and normal elbows both pre- and postoperatively. Abnormal DIRT images correlated well with elevated pain scores. CONCLUSIONS: Radiofrequency microtenotomy provides a promising alternative to the release operation for elbow tendinosis. Dynamic infrared thermography provides a reliable, noninvasive, objective method for the diagnosis of elbow tendinosis, as well as for evaluation of the outcome following treatment.

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

BACKGROUND: Recent reviews have indicated that low level level laser therapy (LLLT) is ineffective in lateral elbow tendinopathy (LET) without assessing validity of treatment procedures and doses or the influence of prior steroid injections. METHODS: Systematic review with meta-analysis, with primary outcome measures of pain relief and/or global improvement and subgroup analyses of methodological quality, wavelengths and treatment procedures. RESULTS: 18 randomised placebo-controlled trials (RCTs) were identified with 13 RCTs (730 patients) meeting the criteria for meta-analysis. 12 RCTs satisfied half or more of the methodological criteria. Publication bias was detected by Egger's graphical test, which showed a negative direction of bias. Ten of the trials included patients with poor prognosis caused by failed steroid injections or other treatment failures, or long symptom duration or severe baseline pain. The weighted mean difference (WMD) for pain relief was 10.2 mm [95% CI: 3.0 to 17.5] and the RR for global improvement was 1.36 [1.16 to 1.60]. Trials which targeted acupuncture points reported negative results, as did trials with wavelengths 820, 830 and 1064 nm. In a subgroup of five trials with 904 nm lasers and one trial with 632 nm wavelength where the lateral elbow tendon insertions were directly irradiated, WMD for pain relief was 17.2 mm [95% CI: 8.5 to 25.9] and 14.0 mm [95% CI: 7.4 to 20.6] respectively, while RR for global pain improvement was only reported for 904 nm at 1.53 [95% CI: 1.28 to 1.83]. LLLT doses in this subgroup ranged between 0.5 and 7.2 Joules. Secondary outcome measures of painfree grip strength, pain pressure threshold, sick leave and follow-up data from 3 to 8 weeks after the end of treatment, showed consistently significant results in favour of the same LLLT subgroup (p < 0.02). No serious side-effects were reported. CONCLUSION: LLLT administered with optimal doses of 904 nm and possibly 632 nm wavelengths directly to the lateral elbow tendon insertions, seem to offer short-term pain relief and less disability in LET, both alone and in conjunction with an exercise regimen. This finding contradicts the conclusions of previous reviews which failed to assess treatment procedures, wavelengths and optimal doses.

Effects of low-level laser and plyometric exercises in the treatment of lateral epicondylitis.

OBJECTIVE: This study was undertaken to compare the effectiveness of a protocol of combination of laser with plyometric exercises and a protocol of placebo laser with the same program, in the treatment of tennis elbow. BACKGROUND DATA: The use of low-level laser has been recommended for the management of tennis elbow with contradictory results. Also, plyometric exercises was recommended for the treatment of the tendinopathy. METHODS: Fifty patients who had tennis elbow participated in the study and were randomised into two groups. Group A (n = 25) was treated with a 904 Ga-As laser CW, frequency 50 Hz, intensity 40 mW and energy density 2.4 J/cm(2), plus plyometric exercises and group B (n = 25) that received placebo laser plus the same plyometric exercises. During eight weeks of treatment, the patients of the two groups received 12 sessions of laser or placebo, two sessions per week (weeks 1-4) and one session per week (weeks 5-8). Pain at rest, at palpation on the lateral epicondyle, during resisted wrist extension, middle finger test, and strength testing was evaluated using Visual Analogue Scales. Also it was evaluated the grip strength, the range of motion and weight test. Parameters were determined before the treatment, at the end of the eighth week course of treatment (week 8), and eighth (week 8) after the end of treatment. RESULTS: Relative to the group B, the group A had (1) a significant decrease of pain at rest at the end of 8 weeks of the treatment (p < 0.005) and at the end of following up period (p < 0.05), (2) a significant decrease in pain at palpation and pain on isometric testing at 8 weeks of treatment (p < 0.05), and at 8 weeks follow-up (p < 0.001), (3) a significant decrease in pain during middle finger test at the end of 8 weeks of treatment (p < 0.01), and at the end of the follow-up period (p < 0.05), (4) a significant decrease of pain during grip strength testing at 8 weeks of treatment (p < 0.05), and at 8 weeks follow-up (p < 0.001), (5) a significant increase in the wrist range of motion at 8 weeks follow-up (p < 0.01), (6) an increase in grip strength at 8 weeks of treatment (p < 0.05) and at 8 weeks follow-up (p < 0.01), and (7) a significant increase in weight-test at 8 weeks of treatment (p < 0.05) and at 8 weeks follow-up (p < 0.005). CONCLUSION: The results suggested that the combination of laser with plyometric exercises was more effective treatment than placebo laser with the same plyometric exercises at the end of the treatment as well as at the follow-up. Future studies are needed to establish the relative and absolute effectiveness of the above protocol.

Effects of 904-nm low-level laser therapy in the management of lateral epicondylitis: a randomized controlled trial.

OBJECTIVE: The aim of this study was to evaluate the effectiveness of 904-nm low-level laser therapy (LLLT) in the management of lateral epicondylitis. BACKGROUND DATA: Lateral epicondylitis is characterized by pain and tenderness over the lateral elbow, which may also result in reduction in grip strength and impairment in physical function. LLLT has been shown effective in its therapeutic effects in tissue healing and pain control. METHODS: Thirty-nine patients with lateral epicondylitis were randomly assigned to receive either active laser with an energy dose of 0.275 J per tender point (laser group) or sham irradiation (placebo group) for a total of nine sessions. The outcome measures were mechanical pain threshold, maximum grip strength, level of pain at maximum grip strength as measured by the Visual Analogue Scale (VAS) and the subjective rating of physical function with Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire. RESULTS: Significantly greater improvements were shown in all outcome measures with the laser group than with the placebo group (p < 0.0125), except in the two subsections of DASH. CONCLUSION: This study revealed that LLLT in addition to exercise is effective in relieving pain, and in improving the grip strength and subjective rating of physical function of patients with lateral epicondylitis.

Effectiveness of low-level laser therapy for lateral elbow tendinopathy.

OBJECTIVE: Our aim was to determine the effectiveness of low-lever laser therapy (LLLT) in the management of lateral elbow tendinopathy (LET) and to provide recommendations based on this evidence. BACKGROUND DATA: LET is a common clinical condition, and a wide array of physiotherapy treatments is used for treating LET. METHODS: Randomized controlled trials (RCTs) identified by a search strategy in six databases were used in combination with reference checking. RCTs that included LLLT, patients with LET, and at least one of the clinically relevant outcome measure were selected. Aqualitative analysis of the selected studies was conducted using the Chalmers' technique. RESULTS: Nine RCTs fulfilled the criteria and were included in the review. Although these studies had satisfactory methodology, shortcomings were not absent; poor results were revealed as to the effectiveness of LLLT for LET management. CONCLUSIONS: LLLT need not be ruled out for LET as it is a dose-response modality, and the optimal treatment dose has obviously not yet have been discovered. Further research with well-designed RCTs is needed to establish the absolute and relative effectiveness of this intervention for LET.