Management of chronic tendon injuries.
- Fort Belvoir Community Hospital, Fort Belvoir, VA 22060, USA.
Chronic tendon injuries present unique management challenges. The assumption that these injuries result from ongoing inflammation has caused physicians to rely on treatments demonstrated to be ineffective in the long term. Nonsteroidal anti-inflammatory drugs should be limited in the treatment of these injuries. Corticosteroid injections should be considered for temporizing pain relief only for rotator cuff tendinopathy. For chronic Achilles tendinopathy (symptoms lasting longer than six weeks), an intense eccentric strengthening program of the gastrocnemius/ soleus complex improved pain and function between 60 and 90 percent in randomized trials. Evidence also supports eccentric exercise as a first-line option for chronic patellar tendon injuries. Other modalities such as prolotherapy, topical nitroglycerin, iontophoresis, phonophoresis, therapeutic ultrasound, extracorporeal shock wave therapy, and low-level laser therapy have less evidence of effectiveness but are reasonable second-line alternatives to surgery for patients who have persistent pain despite appropriate rehabilitative exercise.
Effectiveness of low-level laser therapy combined with an exercise program to reduce pain and increase function in adults with shoulder pain: a critically appraised topic.
- Old Dominion University, Norfolk, VA, USA.
Shoulder pain is a common musculoskeletal condition that affects up to 25% of the general population. Shoulder pain can be caused by any number of underlying conditions including Subacromial impingement syndrome, rotator–cuff tendinitis, and biceps tendinitis. Regardless of the specific pathology, pain is generally the number 1 symptom associated with shoulder injuries and can severely affect daily activities and quality of life of patients with these conditions. Two of the primary goals in the treatment of these conditions are reducing pain and increasing shoulder range of motion (ROM). Conservative treatment has traditionally included a therapeutic exercise program targeted at increasing ROM, strengthening the muscles around the joint, proprioceptive training, or some combination of those activities. In addition, these exercise programs have been supplemented with other interventions including nonsteroidal anti-inflammatory drugs, corticosteroid injections, manual therapy, activity modification, and a wide array of therapeutic modalities (eg, cryotherapy, EMS, ultrasound). Recently, low-level laser therapy (LLLT) has been used as an additional modality in the conservative management of patients with shoulder pain. However, the true effectiveness of LLLT in decreasing pain and increasing function in patients with shoulder pain is unclear.
FOCUSED CLINICAL QUESTION:
Is low-level laser therapy combined with an exercise program more effective than an exercise program alone in the treatment of adults with shoulder pain?
Effects of low-level laser therapy in combination with physiotherapy in the management of rotator cuff tendinitis.
Physical Medicine and Rehabilitation Research Center, Imam Reza hospital, Tabriz University of Medical Sciences, Golgasht Ave, Tabriz, Iran, email@example.com.
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.
Clin Rheumatol. 2011 May 4. [Epub ahead of print]
Additive effects of low-level laser therapy with exercise on subacromial syndrome: a randomised, double-blind, controlled trial.
Orthopedics Department, Shahid Sadoughi University of Medical Sciences, Yazd, Iran, firstname.lastname@example.org
The subacromial syndrome is the most common source of shoulder pain. The mainstays of conservative treatment are non-steroidal anti-inflammatory drugs and exercise therapy. Recently, low-level laser therapy (LLLT) has been popularized in the treatment of various musculoskeletal disorders. The aim of this study is to evaluate the additive effects of LLLT with exercise in comparison with exercise therapy alone in treatment of the subacromial syndrome. We conducted a randomised clinical study of 80 patients who presented to clinic with subacromial syndrome (rotator cuff and biceps tendinitis). Patients were randomly allocated into two groups. In group I (n=40), patients were given laser treatment (pulsed infrared laser) and exercise therapy for ten sessions during a period of 2 weeks. In group II (n=40), placebo laser and the same exercise therapy were given for the same period. Patients were evaluated for the pain with visual analogue scale (VAS) and shoulder range of motion (ROM) in an active and passive movement of flexion, abduction and external rotation before and after treatment. In both groups, significant post-treatment improvements were achieved in all parameters (P=0.00). In comparison between the two groups, a significant improvement was noted in all movements in group I (P=0.00). Also, there was a substantial difference between the groups in VAS scores (P=0.00) which showed significant pain reduction in group I. This study indicates that LLLT combined exercise is more effective than exercise therapy alone in relieving pain and in improving the shoulder ROM in patients with subacromial syndrome.
Phys Ther. 2009 Jul;89(7):643-52. Epub 2009 May 29.
Short-term effects of high-intensity laser therapy versus ultrasound therapy in the treatment of people with subacromial impingement syndrome: a randomized clinical trial.
Santamato A<>, Solfrizzi V<>, Panza F<>, Tondi G<>, Frisardi V<>, Leggin BG<>, Ranieri M<>, Fiore P<>.Department of Physical Medicine and Rehabilitation, University of Foggia, Foggia, Italy.
BACKGROUND: Subacromial impingement syndrome (SAIS) is a painful condition resulting from the entrapment of anatomical structures between the anteroinferior corner of the acromion and the greater tuberosity of the humerus.
OBJECTIVE: The aim of this study was to evaluate the short-term effectiveness of high-intensity laser therapy (HILT) versus ultrasound (US) therapy in the treatment of SAIS. DESIGN: The study was designed as a randomized clinical trial.
SETTING: The study was conducted in a university hospital. PATIENTS: Seventy patients with SAIS were randomly assigned to a HILT group or a US therapy group.
INTERVENTION: Study participants received 10 treatment sessions of HILT or US therapy over a period of 2 consecutive weeks. MEASUREMENTS: Outcome measures were the Constant-Murley Scale (CMS), a visual analog scale (VAS), and the Simple Shoulder Test (SST).
RESULTS: For the 70 study participants (42 women and 28 men; mean [SD] age=54.1 years [9.0]; mean [SD] VAS score at baseline=6.4 [1.7]), there were no between-group differences at baseline in VAS, CMS, and SST scores. At the end of the 2-week intervention, participants in the HILT group showed a significantly greater decrease in pain than participants in the US therapy group. Statistically significant differences in change in pain, articular movement, functionality, and muscle strength (force-generating capacity) (VAS, CMS, and SST scores) were observed after 10 treatment sessions from the baseline for participants in the HILT group compared with participants in the US therapy group. In particular, only the difference in change of VAS score between groups (1.65 points) surpassed the accepted minimal clinically important difference for this tool. LIMITATIONS: This study was limited by sample size, lack of a control or placebo group, and follow-up period.
CONCLUSIONS: Participants diagnosed with SAIS showed greater reduction in pain and improvement in articular movement functionality and muscle strength of the affected shoulder after 10 treatment sessions of HILT than did participants receiving US therapy over a period of 2 consecutive weeks.
Photomed Laser Surg. 2005 Oct;23(5):459-64.
Low-power laser treatment for shoulder pain.
Bingöl U<>, Altan L<>, Yurtkuran M<>.
Faculty of Medicine, Atatürk Rehabilitation Center, Rheumatic Disease and Hydrotherapy Section, Uludaà University, Cekirge, Bursa, Turkey. email@example.com
OBJECTIVE: The objective of this study is to investigate the effect of low-power gallium-arsenide laser treatment on the patients with shoulder pain.
BACKGROUND DATA: Low-energy laser therapy has recently been popularized in the treatment of various rheumatologic, neurologic, and musculoskeletal disorders such as osteoarthritis, rheumatoid arthritis, fibromyalgia, carpal tunnel syndrome, rotator cuff tendinitis, and chronic back pain syndromes.
METHODS: A total of 40 patients who applied to our clinic with shoulder pain and complied with the selection criteria were included in the study. The patients were randomly assigned into Group I (n = 20, laser treatment) and Group II (n = 20, control). In Group I, patients were given laser treatment and an exercise protocol for 10 sessions during a period of 2 weeks. Laser was applied over tuberculum majus and minus, bicipital groove, and anterior and posterior faces of the capsule, regardless of the existence of sensitivity, for 1 min at each location at each session with a frequency of 2000 Hz using a GaAs diode laser instrument (Roland Serie Elettronica Pagani, wavelength 904 nm, frequency range of 5-7000 Hz, and maximum peak power of 27 W, 50 W, or 27 x 4 W). In Group II, placebo laser and the same exercise protocol was given for the same period. Patients were evaluated according to the parameters of pain, palpation sensitivity, algometric sensitivity, and shoulder joint range of motion before and after treatment.
RESULTS: Analysis of measurement results within each group showed a significant posttreatment improvement for some active and passive movements in both groups, and also for algometric sensitivity in Group I (p < 0.05-0.01). Posttreatment palpation sensitivity values showed improvement in 17 patients (85%) for Group I and six patients (30%) for Group II. Comparison between two groups showed superior results (p < 0.01 and p < 0.001) in Group I for the parameters of passive extension and palpation sensitivity but no significant difference for other parameters.
CONCLUSIONS: The results of our study have shown better results in palpation sensitivity and passive extension, but no significant improvement in pain, active range, and algometric sensitivity in laser treatment group compared to the control group in the patients with shoulder pain.
THE USE OF LOW LEVEL LASER THERAPY (LLLT) IN THE TREATMENT OF TRIGGER POINTS THAT ARE ASSOCATED WITH ROTATOR CUFF TENDONITIS.
Al-Shenqiti, J Oldham
60 patients were randomly allocated to either sham or laser therapy. The active laser parameters included a wavelength 820 nm, power output 100 mW, frequency 5000 Hz (modulated) and energy density 32 J/cm2. 12 treatments were given over four weeks. The blinded outcome measures were pain, range of motion (ROM), functional activities and pressure pain threshold (PPT). Outcome measures were carried out pre and post treatment, then 3 months later. Considerable improvement in pain (p < 0.001) was seen for the laser compared to sham group post treatment, and at follow-up (6 points on a 10 VAS compared to 2 points respectively). Similarly, significant differences in favour of laser were seen for ROM (p < 0.01), functional activities (p < 0.001) and PPT (p < 0.05).
Br J Rheumatol. 1993 Aug;32(8):740-2.
A double-blind study of the effectiveness of low level laser treatment of rotator cuff tendinitis.
Rheumatology Research Unit, Addenbrooke’s Hospital, Cambridge.
Thirty-five patients with rotator cuff tendinitis were randomly allocated to active (CB Medico Master III 830 nm Ga As AL diode) laser or dummy laser treatment twice weekly for 8 weeks. Movement range, painful arc score, resisted movement score and responses to visual analogue scales for night pain, rest pain, movement pain and functional limitation were measured second weekly. All responses improved from baseline but there was no difference between the two groups. These results fail to demonstrate the effectiveness of laser therapy in rotator cuff tendinitis.