Research - Musculoskeletal Rehab

Diode Laser in Cervical Myofascial Pain: A Double-Blind Study versus Placebo

* F. Ceccherelli, * L. Altafini, * G. Lo Castro, * A. Avila, *F. Ambrosio, and * G. P. Giron

*Institute of Anesthesiology and Intensive Care, University of Padua, and the Associazione Italiana per la Ricerca e, l'Aggiornamento Scientif co, Padua, Italy

Summary: We present a double-blind trial in which a pulsed infrared beam was compared with a placebo in the treatment of myofascial pain in the cervical region. The patients were submitted to 12 sessions on alternate days to a total energy dose of 5 J each. At each session, the four most painful muscular trigger points and five bilateral homometameric acupuncture points were irradiated. Those in the placebo group submitted to the same number of sessions following an identical procedure, the only difference being that the laser apparatus was nonoperational. Pain was monitored using the Italian version of the McGill pain questionnaire and the ScottHuskisson visual analogue scale. The results show a pain attenuation in the treated group and a statistically significant difference between the two groups of patients, both at the end of therapy and at the 3-month follow-up examination.

Key Words: Laser&emdash;Infrared laser beam&emdash;Pain&emdash;Chronic pain&emdash;Placebo&emdash;Double blind study.

Address correspondence and repent requests to Dr. F. Ceccherelli at the Istituto di Anestesiologiae Rianimazione, via C. Battisti 267, 35121 Padova, Italia.

The Clinical journal of Pain 5:301-304 copyright 1989 Raven Press, Ltd., New York

Wave-
length

Power

Energy
Density

Power
Density

Energy
per point

Pulses

904nm

5mW av
(25Wpeak)

(not given)

(not given)

1 J

1KHz
x 200nS

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PAIN SCORES AND SIDE EFFECTS IN RESPONSE TO LOW LEVEL LASER THERAPY (LLLT) FOR MYOFASCIAL TRIGGER POINTS

E Liisa Laakso Carolyn Richardson, and Tess Cramond

1: Physiotherapy Department, Royal Brisbane Hospital, Brisbane; 2: Physiotherapy Department, University of Queensland, Brisbane; and 3: Pain Clinic, Royal Brisbane Hospital, Brisbane, Queensland, Australia.

Clinically, Low Level Laser Therapy - LLLT has been used successfully in the treatment of chronic pain but many have questioned the scientific basis for its use. Many studies have been poorly designed or poorly controlled. A double-blind, placebo-controlled, random allocation study was designed to analyse the effect of second daily infrared (JR) laser (820 nm, 25 mW) and visible red laser (670 nm, 10 mW) at 1 J/cm2 and 5 J/cm2 on chronic pain. Forty-one consenting subjects with chronic pain conditions exhibiting myofascial trigger points in the neck and upper trunk region underwent five treatment sessions over a two week period. To assess progress, pain scores were measured using visual analogue scales before and after each treatment. The incidence of side effects was recorded. All groups demonstrated significant reductions in pain over the duration of the study with those groups which received infrared (820 nm) laser at I J/cm2 and 5 J/cm2. demonstrating the most significant effects (p < 0.001). Only those subjects who had active laser treatment experi enced side effects. Results indicated that responses to LLLT at the parameters used in this study are subject to placebo and may be dependant on power output, dose and/or wavelength.

Key words: chronic pain, Visual Analogue Scal, LLLT, side effects, phototherapy.

Addressee for Correspondence: E Liisa Laakso BPhty PhD, Physiotherapy Department, Royal Brisbane Hospital, Herston, (Queensland, Australia, 4029.

6/97 Rep. US $8-10-12 copyright 1997 by LT Publishers, , U.K.' Ltd. Manuscript received:January, 1997 Accepted for publication: March, 1997

LASER THERAPY. 9: 67-72 67

Two wavelengths studied.

Best results with the higher powered infrared laser compared with the lower powered red laser

Wave-
length
Average
Power

Energy
Density

Power
Density

Energy

Pulses

Time

Beam
Spot size

820

25mW

5 J/Cm2

0.89
W/Cm2

0.14 J

5,000Hz

5.62 secs

0.89Cm2

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LOW LEVEL LASER THERAPY ( LLLT) OF TENDINITIS AND MYOFASCIAL PAINS A RANDOMIZED, DOUBLE-BLIND, CONTROLLED STUDY

Mimmi Logdberg-Anderssont1, Sture Mutzell2, and Ake Hazel3

1: Akersberga Health Care Centre, 2: Danderyd University Hospital, Danderyd, and

3: Vaxholm Health Care Centre, Stockholm, Sweden.

The purpose of this randomised, double-blind study was to examine the effect of GaAs laser therapy for tendinitis and myofascial pain in a sample from the general population of Akersberga in the northern part of Greater Stockholm. 176 patients (of an original group of 200) completed the scheduled course of treatment. The patients were assigned randomly to either a laser group (92 patients, of whom 74 had tendinitis, completed the study) or a placebo group (84 patients, of whom 68 had tendinitis, completed the study). All 176 patients received six treatments during a period of 3-4 weeks. Their pain was estimated objectively using a pain threshold meter, and subjectively with a visual analogue scale before, at the end of, and four weeks after the end of treatment. Laser therapy had a significant, positive effect compared with placebo measured from the first assessment to the third assessment, four weeks after the end of treatment. Laser treatment was most effective on acute tendinitis.

Addressee for Correpondance, Sture Mutzell, Danderyd University Hospital 5-182 87 Danderyd, Sweden.

03/07 Rep US 10-12-14 , 1997 By LT Publishers, U.K., Ltd., LASER THERAPY, 1997:9: 79-86

Wave-
length

Power

Energy
Density

Power
Density

Energy
per point

Pulses

904nm

8mW av
(10Wpeak)

0.5-1.0
J/Cm2

(not given)

1J

4KHz x
180nS

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THE EFFICACY OF LASER THERAPY FOR MUSCULOSKELETAL AND SKIN DISORDERS:

A CRITERIA-BASED META-ANALYSIS OF RANDOMIZED CLINICAL TRIALS

Beckerman H, de Bie RA, Bouter LM, et al.

The efficacy of laser therapy for musculoskeletal and skin disorders has been assessed on the basis of the results of 36 randomized clinical trials (RCTs) involving 1,704 patients. For this purpose, a criteria-based meta-analysis that took into account the methodological quality of the individual trials was used. The studies with a positive outcome were generally of a better quality than the studies with a negative outcome. No clear relationship could be demonstrated between the laser dosage applied and the efficacy of laser therapy, or between the dosage and the methodological score. In general, the methodological quality of these studies appeared to be rather low. Consequently, no definite conclusions can be drawn about the efficacy of laser therapy for skin disorders. The efficacy of laser therapy for musculoskeletal disorders seems, on average, to be larger than the efficacy of a placebo treatment. More specifically, for rheumatoid arthritis, post-traumatic joint disorders, and myofascial pain, laser therapy seems to have a substantial specific therapeutic effect. Further RCTs, avoiding the most prevalent methodological errors, are needed in order to enable the benefits of laser therapy to be more precisely and validly evaluated.

Physical Therapy. 72(7):483-91, 1992 Jul. (60 ref)

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LLLT USING A DIODE LASER IN SUCCESSFUL TREATMENT OF A HERNIATED LUMBAR/SACRAL DISC, WITH MAGNETIC RESONANCE IMAGING (MRI) ASSESSMENT: A CASE REPORT

Tatsuhide Abe

Abe Orthopaedic Clinic Futuoka City Fukuoka Prefecture Japan X12'

A 40-year-old woman presented at the Abe Orthopedic Clinic with a 2-year history of lower hack pain and pain in the left hip and leg diagnosed as a ruptured disc between the 5th lumbar/lst sacral vertebrae. The condition had failed to respond to conventional treatment methods including pelvic traction, nonsteroid anti-inflammatory drugs and aural block anesthetic injections. MRI scans were made of the affected disc, showing it protruding on the left side through the aural membrane. The gallium aluminum arsenide (GaAlAs) diode laser (830 nm, 60 mW) was used in outpatient therapy. and after 7 months, the patient's condition had dramatically improved. demonstrated by motility exercises. This improvement was confirmed by further MRI scans, which showed clearly the normal condition of the previously herniated L5/SI disc.

O898-5901/89/020093-03 $05.00 © 1989 by John Wiley & Sons. Ltd.

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PHYSIOLOGICAL RESPONSES IN CHRONIC PAIN PATIENTS LLLT PROTOCOL

Scott D. Fender and David Diffee

Pain Research Group, Arvada, Colorado, U.S.A.

Use of Low Reactive Level Laser Therapy (LLLT) utilising helium-neon lasers has increased lately especially in pain control. New protocols are being developed aimed at a complex of primary and secondary symptomologies. One of these protocols Stellate Ganglion Stimulation has shown in our research a unique set of developments. Targeting the area of the stellate ganglion is showing great promise in the rehabilitation of patients with a history of chronic musculoskeletal pain syndromes, but several patients with preexisting psychological symptomology have exacerbated during the initial stages of utilization of this protocol. Patients with a history of psychological diagnosis for dysthymia, anxiety, post traumatic stress disorder or minor diffuse brain injury have shown an exacerbation of these symptomologies during the initial phases of stimulation treatment. Overall, response to this form of therapy seems to be positive but some patients require dermatomal and/or site-specific therapy to maximize outcome. With specific psychological treatment combined with a more conservative amount of stimulation initially the increase in these symptoms shows a tendency to remit with the pain response. Our continued research is currently focusing on the mechanisms for this type of response as well as protocol refinement to maximize its effectiveness.

Addressee for correspondence: Scott D. Fender DDS DAPM, 5275 Marshall Street, Suite 203, Arvada, CO 80002, U.S.A.

0898-5901/92/040169-05$07.50 © 1992 by John Wiley & Sons, Ltd.

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CLINICAL APPLICATION OF GaAIAs 830 NM DIODE LASER IN TREATMENT OF RHEUMATOID ARTHRITIS

Kanji Asada, Yasutaka Yutani, Akira Sakawa and Akira Shimazu

Department of Orthopaedic Surgery, Osaka City University Medical School, Japan

The authors have been involved in the treatment of rheumatoid arthritis (RA), in particular chronic poly-arthritis and the associated pain complaints. The biggest problem facing such patients is joint contracture, leading to bony ankylosis. This in turn severely restricts the range of motion (ROM) of the RA-affected joints, thereby seriously restricting the patient's quality of life (QOL). The authors have determined that in these cases, daily rehabilitation practice is necessary to maintain the patient's QOL at a reasonable level. The greatest problem in the rehabilitation practice is the severe pain associated with RA-affected joints, which inhibits restoration of mobility and improved ROM. LLLT or low reactive level laser therapy has been recognized in the literature as having been effective in pain removal and attenuation. The authors accordingly designed a clinical trial to assess the effectiveness of LLLT in RA related pain (subjective self-assessment) and ROM improvement (objective documented data). From July 1988 to June 1990, 170 patients with a total of 411 affected joints were treated using a GaAlAs diode laser system (830 nm, 60 mW C/W). Patients mean age was 61 years, with a ratio of males: females of 1: 5.25 (16%: 84%). Effectiveness was graded under three categories: excellent (remarkable improvement), good (clearly apparent improvement), and unchanged (little or no improvement). For pain attenuation, scores were: excellent&emdash;59.6%; good&emdash;30.4%; unchanged&emdash;10%. For ROM improvement the scores were: excellent&emdash;12.6%; good&emdash;43.7%; unchanged&emdash;43.7%. This gave a total effective rating for pain attenuation of 90%, and for ROM improvement of 56.3%.

0898-5901/91/020077-06$05.00 © 1991 by John Wiley & Sons, Ltd.

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MECHANISMS OF THE ANALGESIC EFFECT OF THERAPEUTIC LASERS IN VIVO

L Navratil1 and I Dylevsky2

1: Outpatient Department of Radiobiology, Institute of Biophysics, First Medical Faculty, and 2: Department of Functional Anatomy, Second Medical Faculty and Faculty of Physical Education Charles University, Prague, Czech Republic

The analgesic effects in the course of application of therapeutic lasers to affected tissue have been described in a number of works in the literature. Although a few scientific-based reports have appeared, those on laser-induced analgesia are mainly clinical works describing the effect of the therapy which, however, do not study the mechanism of the laser action. There are several different possible responses induced by non-invasive low level laser therapy (LLLT). The purpose of the present communication is to review the arrangement and characterisation of these responses. By being aware of these effects, the laser therapist can acquire a physiological and morphological scheme making possible the appropriate choice of the site of application of LLLT, choice of the irradiation technique, and selection of appropriate doses.

Addressee for Correspondence: Leos Navratil MD PhD, Department of Clinical Radiahiology, Institute of Biophysics, First Medical Faculty, Charles University Saln1ovska 3, CZ 120 00, Prague 2, Czech Republic.

03/97 Rep. US 5 10 12 14 © 1997 by LT Publishers U.K, Ltd. LASER THERAPY 1997:9::'): 33-40 Experimental Physiology (1994) 79. 227-234 Printed in Great Britain

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Laser's Effect on Bone and Cartilage Change Induced by Joint Immobilization An Experiment With Animal Model

Masami Akai, MD,1* Mariko Usuba, RPT,1 Toru Maeshima, Yoshio Shirasaki,2 and Shozo Yasuaka, MD3 'Department of Physical Therapy Tsukuba College of Technology, Tsukuba, Ibaraki, Japan Mechanical Engineering Laboratory, Agency of Industrial Science and Technology, TsuPuba, Ibaraki Japan. Yasuoka Orthopaedic Clinic, Mitaka, Tokyo, Japan

Objective: Influence of low-level (810nm, Ga-Al-As semiconductor) laser on bone and cartilage during joint immobilization was examined with rats' knee model.

Materials and Methods: The hind limbs of 42 young Wistar rats were operated on in order to immobilise the knee joint. One week after operation they were assigned to three groups; irradiance 3.9W/cm2, 5.8W/cm2, and sham treatment. After 6 times of treatment for another 2 weeks both hind legs were prepared for 1) indentation of the articular surface of the knee (stiffness and loss tangent), and for 2) dual energy X-ray absorptiometry (bone mineral density) of the focused regions.

Results and Conclusions: The indentation test revealed preservation of articular cartilage stiffness with 3.9 and 5.8W/cm2 therapy. Soft laser treatment has a possibility for prevention of biomechanical changes by immobilisation. Lasers Surg. Med. 21:480-484, 1997. C) 1997 Wiley-Liss, Inc.

Correspondence to: Masami Akai, M.D., Department of Central Rehabilitation Service University Hospital, Faculty of Medicine, University of Tokyo 7-3-1 Hongo, Bunkyo-ku, Tokyo 113, Japan.

Accepted 20 May 1997 Lasers in Surgery and Medicine 21:480-484 (1997) © 1997 Wiley-Liss, Inc.

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Histological and Clinical Responses of Articular Cartilage to Low-level Laser Therapy: Experimental Study

I. RUIZ CALATRAVA, J.M.SANTISTEBAN VALENZUELA, R.J.G0MEZ-VILLAMANDOS J.I.REDONDO, J.C.G0MEZ-VILLAMANDOS, l.AVIGA JURADO

Department of Veterinary Clinical Pathology-Surgery, Faculty of Veterinary Medicine, University of Cordoba, Spain. Correspondence to 1. Ruiz Calatrava, Department of Veterinary Clinical Pathology-Surgery, Faculty of Veterinary Medicine, University of Cordoba, Avda. Medina Azahara, 9, 14005 Cordoba, Spain

Abstract. This study was carried out to evaluate the effects of low-level laser irradiation on experimental lesions of articular cartilage. A standard lesion was practised on the femoral trochlea of both hind limbs of 20 clinically normal Californian rabbits. These animals were divided into two groups of 10 individuals each, depending on the laser equipment used for treatment. One group was treated with HeNe laser (8 J cm - 2, 632.8 nm wavelength) and the other with infra-red (JR) laser (8 J cm - 2, 904 nm wavelength). In both groups, five points of irradiation to the right limb alone were irradiated per session for a total of 13 sessions, applied with an interval of 24 h between sessions. These points were the following: left and right femoral epicondyles, left and right tibial condyles and the centre of articulation. The distance between these points was approximately 1 cm. The untreated left limb was left as a control. During treatment, extension angle and periarticular thickness were considered. At the end of the treatment, samples were collected for histopathological study and stained with: Haematoxylin-Eosin, PAS and Done. The results show a statistically higher anti-inflammatory capacity of the IR laser ( p<0.0001). The functional recovery was statistically similar for both treatments (p<0.176). Histological study showed, at the end of the treatment, hyaline cartilage in the IR group, fibrocartilage in the HeNe group and granulation tissue in the control limbs. Clinical and histological results indicated that this laser treatment had a clear anti-inflammatory effect that provided a fast recuperation and regeneration of the articular cartilage.

Lasers in Medical Science 1997, 12:117-121 0268 - 892 1/97/020117 +05 $1 2.00/0 © 1997 W.B. Saunders Company Ltd

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Successful management of female office workers with "repetitive stress injury" or "carpal tunnel syndrome" by a new treatment modality- application of low level laser

E. Wong G LEE J. Zu CHERMAN and D. P. MASON

Western Heart Institute and St. Mary's Spine Center St. Mary's Medical Center. San Francisco. CA. USA and Head and Neck Pain Center, Honolulu HL. USA

Abstract. Female office workers with desk jobs who are incapacitated by pain and tingling in the hands and fingers are often diagnosed by physicians as "repetitive stress injury'' (RSI) or "carpal tunnel syndrome'' (CTS). These patients usually have poor posture with their head and neck stooped forward and shoulders rounded; upon palpation. they have pain and tenderness at the spinous processes C5 - T1 and the medial angle of the scapula. In 35 such patients we focused the treatment primarily at the posterior neck area and not the wrists and hands. A low level laser ( 100 mW) was used and directed at the tips of the spinous processes C5 - Tl. The laser rapidly alleviated the pain and tingling in the arms, hands and fingers. and diminished tenderness at the involved spinous processes. Thereby, it has become apparent that many patients labeled as having RSI or CTS have predominantly cervical radicular dysfunction resulting in pain to the upper extremities which can be managed by low level laser. Successful long-term management involves treating the soft tissue lesions in the neck combined with correcting the abnormal head, neck and shoulder posture by taping. cervical collars, and clavicle harnesses as well as improved work ergonomics.

  Manuscript received: July, 1997 Accepted for publication: September, 1997 LASER THERAPY, 1997:9: 131- 136 09/97 Rep. US $ 10-12-14 © 1997 by LT Publishers, U.K., Ltd

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MECHANISTIC APPROACH TO GaAIAs DIODE LASER EFFECTS ON PRODUCTION OF REACTIVE OXYGEN SPECIES FROM HUMAN NEUTROPHILS AS A MODEL FOR THERAPEUTIC MODALITY AT CELLULAR LEVEL

Makoto Yamaya*, Chiyuki Shiroto', Hiroki Kobayashi*, Shinji Naganuma*, Jyuichi Sakamoto*, Koh-Jun Suzuki*, Shigeyuki Nakaji*, Kazuo Sugawara* and Takashi Kumae *Department of' Hygiene, Hirosaki University School of Medicine. Hirosaki; .-Shiroto Clinic Coshogawara, Aomori: Department of Industrial Health. The Institute of Public Health, Tokyo. Japan

There have been many reports on the applications of low reactive level laser (LLL) therapy for pain attenuation or pain removal. Our group has reported previously on the effects of in vitro irradiation of LLLT particularly on the phagocytic activity of human Neutrophils. using luminol-dependent chemiluminescence (LmCL) for measurement of reactive oxygen species (ROS) production from human Neutrophils. But the mechanisms of the attenuation of phagocytic activity of NEUTROPHILS by LLL irradiation is not yet full understood,

In this study. we used luminol-dependent and lucigenin-dependent chemiluminescence (LgCL) for detection of affected ROS producing process of human Neutrophils by LLL irradiation. Two soluble action stimuli. N-formyl-Met-Leu-Phc (fMLP) and phorbol myristate acetate (PMA) were used to avoid the possible influence of lag-time from recognition to uptake of particles at the ROS production.

In case of using fMLP as a stimulus, the maximum luminescence intensity of LULL was increased hut LgCL luminescence was decreased by LLL irradiation. When PMA was used as a stimulus, the times to reach the maximum luminescence intensity of LmCL and LgCL were shortened by LLL irradiation but there was no effect on the maximum luminescence intensity of both.

These results suggest that LLL irradiation enhances the ROS production activity of human Neutrophils by the activation of the superoxide converting system, the active clement in which is mainly myeloperoxidase. LLL irradiation enabled a more rapid activation of the superoxide production system, NADPH -oxidase.

0898-5901/93/03011 1-06$08.00 © 1993 by John Wiley & Sons. Ltd.

LASER THERAPY 1993: 5: 111-116

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