Low power laser therapy of shoulder tendonitis.

England S; Farrell AJ; Coppock JS; Struthers G; Bacon PA

Scandinavian journal of rheumatology; VOL: 18 (6); p. 427-31 /1989/

Department of Rheumatology, Coventry & Warwickshire Hospital, UK.

30 patients with supraspinatus or bicipital tendonitis were randomly allocated to active infrared laser therapy at 904 nm three times weekly for 2 weeks, dummy laser or drug treatment for 2 weeks. O

bjectively maximum active extension, flexion and abduction of the shoulder, and subjectively pain stiffness movement and function were measured at 0 and 2 weeks.

Significant improvement of active over dummy laser was noted for all seven assessments. Active laser therapy produced significant improvement over drug therapy for all three objective measures and pain. Naproxen sodium significantly improved only movement and function compared to dummy laser.

Laser Treatment for Tendinitis

Jan M. Bjordal, PT-MSc, Faculty of Medicine, University of Bergen, Norway Christian Couppe, PT, Copenhagen, Denmark

Tendinitis is a common disorder of the musculoskeletal system. Cardinal symptoms from the tendon are pain from increased tension like muscle contraction or stretching and pain on pressure. In an acute stage inflammation is the most common pathophysiological manifestation, while degeneration of the collagen structure is observed in subacute and chronic cases. However, the episodic nature of chronic tendinitis with increased pain after strenous use of the affected tendon, may indicate that inflammation also play a part at this stage. A succesful strategy of treatment should include reduction of inflammation and regeneration of collagen. In the laboratory several experiments have shown that laser treatment may have the potential to achieve both these goals. The findings of the laboratory also shows that these effects are highly dependent on dose.

A synthesis of dose from 4 laboratory trials on inflamed collagen producing cell cultures gives the following dose for optimal reduction of tendon tissue inflammation:
Dose : 3 - 8 J/cm2
Intensity : 5 - 21 mW/cm2

A synthesis from 10 laboratory trials investigating collagen proliferation gives the following optimal dose for stimulation of tendon regeneration :
Dose : 0.2 - 4 J/cm2
Intensity : 2 - 10 mW/ cm2 

For the treatment of tendinitis an optimal suggested dosage at target location will be :
Dose : 0.2 - 4 J/cm2
Intensity : 2 - 10 mW/ cm2

Treatment should be applied daily for at least five days to reduce inflammation, and for at least 10 days to increase collagen production.

Determination of clinical dose
The clinical dose depends on several factors such as laser type, depth to target from skin surface, the type of tissue between skinsurface and target location and the volume of injured tissue.

Characteristics for common tendon disorders
The various tendon locations have different characteristics that affects determination of dose.

Tendon Depth to target tendon (mm)
Tendon thickness (mm)
Typical area of tendon defect (cm2)

Values for different conditions are as follows:

Plantar fasciitis
10.0 - 12.0
3.0 - 4.0
0.1 - 0.8
Achilles
1.5 - 3.0
4.5 - 6.0
0.5 - 2.0
Patellar
2.5 - 4.0
5.5 - 8.0
1.0 - 4.0
Epicondylitis
1.5 - 2.5
2.0 - 4.0
0.09 - 0.3
Rotatorcuff
5.0 - 10.0
5.5 - 8.0
0.5 - 1.5

Recommendations for optimal laser therapy for common tendon disorders:
Infrared lasers (GaAlAs 820/830 nm) are recommended when :
* Power density on skin does not exceed 30 mW/cm2, when treating superficial disorders
* Spot size should not be smaller than 0.5 cm2

Dose on skin: Number of points:Lateral epicondylitis :2 J/cm21 - 2 Rotatorcuff : 2.5 J/cm22 - 4 Patellar :8 J/cm2 :3 - 5Achilles :6 J/cm22 - 3
It must be added that there are only two clinical trials showing effect on tendinitis (rotatorcuff) with these lasers and that the dose recommendations for other locations are extrapolations and have not yet been tested clinically.

Infrared pulse lasers (GaAs 904 nm) are recommended when :
* Power density on skin does not exceed 20 mW/cm2, when treating superficial disorders
* Spot size should not be smaller than 0.5 cm2
 

Dose on skin: Number of points:Lateral epicondylitis :0.5 - 2 J/cm2 1 - 2 Rotatorcuff : 0.8 - 6 J/cm2 2 - 4 Patellar :0.8 - 6 J/cm2 :3 - 5Achilles :0.5 - 4 J/cm2 2 - 3

Clinical results from seven trials suggests that pulse lasers overcome the skin barrier with less need for variation of dose for the different tendon locations.

Red HeNe lasers (632 nm) are only recommended for superficially situated tendon disorders like epicondyitis and paratendonitis of the achilles or patellar tendon. Use of HeNe laser on rotatorcuff, deeply situated patellar tendinitis (jumpers' knee), plantar fascitis or carpal tunnel is not recommended, due to the poor penetration of visible red light.

Editors note: The master thesis in Physiotherapy Science of Jan Bjordal is called "Low Level Laser therapy in shoulder tendinitis/bursitis, epicondylalgia and ankle sprain. A critical review on clinical effects". Division of Physiotherapy Science, University of Bergen. 1997.

Part of this thesis can be found in Physical Therapy Reviews. 1998; 3: 121-132. "What may alter the conclusions of reviews?".

LOW LEVEL LASER THERAPY CAN BE EFFECTIVE FOR TENDINITIS: A META-ANALYSIS

J.M. Bjordal, C. Couppe University of Bergen, Dept. Physiotherapy Science, Bergen, Norway

Purpose: To investigate if low level laser therapy (LLLT) with previously defined optimal treatment parametres can be effective for tendinitis. Material : Randomized controlled trials with LLLT for tendinitis. Method : Literature search for trials published after 1980 using LLLT on Medline, Embase, Cochrane Library and handsearch of physiotherapy journals in English and Scandinavian languages. Only trials that compared laser exposure of the skin directly over the injured tendon with optimal treatment parametres with identical placebo treatment were included.
Results: The literature search identified 77 randomized controlled trials with LLLT, of which 18 included tendinitis. Three trials were excluded for lack of placebo control, of which one trial was comparative, another lacked patients with tendinitis in the treatment group, while the last unwittingly gave the placebo group active treatment. Four trials used too high power density or dose, and three trials did not expose the skin directly overlying the injured tendon. The remaining eight trials were included in a statistical pooling, where the mean effect of LLLT over placebo in tendinitis was calculated to 32% [25.0-39.0, 95% CI].

Conclusion: Low level laser therapy with optimal treatment procedure/parametres can be effective in the treatment of tendinitis.

Low level laser therapy for tendinopathy. Evidence of a dose-response pattern.

Physical Therapy Reviews. 2001; 6: 91-99.
Bjordal J M, Couppé C, Ljunggren E.

To investigate whether low-level laser therapy can reduce pain from tendinopathy, the authors performed a review of randomised placebo-controlled trials with laser therapy for tendinopathy. Validity assessment of each trial was done acc. to predefined criteria for location-specific dosage and irradiation of the skin directly overlying the affected tendon.

The literature search identified 78 randomised control trials of which 20 included tendinopathy. Seven trails were excluded for not meeting the validity criteria on treatment procedure and trial design. 12 of the remaining 13 trials investigated the effect of laser therapy for patients with subacute and chronic tendinopathy and provided a pooled mean effect of 21%.

If results from only the nine trials adhering to assumed optimal treatment parameters were included, the mean effect over placebo increased to 32%.

Laser therapy can reduce pain in subacute and chronic tendinopathy if a valid treatment procedure and location-specific dose is used.