Elbow Pain

Br J Sports Med.  2013 Jan 18. [Epub ahead of print]

Evidence for the effectiveness of electrophysical modalities for treatment of medial and lateral epicondylitis: a systematic review.

Dingemanse R, Randsdorp M, Koes BW, Huisstede BM.

Source

Department of Rehabilitation Medicine and Physical Therapy, Erasmus Medical Center-University Medical Centre Rotterdam, Rotterdam, The Netherlands.

Abstract

BACKGROUND:

Several treatments are available to treat epicondylitis. Among these are instrumental electrophysical modalities, ranging from ultrasound, extracorporeal shock wave therapy (ESWT), transcutaneous electrical nerve stimulation (TENS) to laser therapy, commonly used to treat epicondylitis.

OBJECTIVES:

To present an evidence-based overview of the effectiveness of electrophysical modality treatments for both medial and lateral epicondylitis (LE).

METHODS:

Searches in PubMed, EMBASE, CINAHL and Pedro were performed to identify relevant randomised clinical trials (RCTs) and systematic reviews. Two reviewers independently extracted data and assessed the methodological quality. A best-evidence synthesis was used to summarise the results.

RESULTS:

A total of 2 reviews and 20 RCTs were included, all of which concerned LE. Different electrophysical regimes were evaluated: ultrasound, laser, electrotherapy, ESWT, TENS and pulsed electromagnetic field therapy. Moderate evidence was found for the effectiveness of ultrasound versus placebo on mid-term follow-up. Ultrasound plus friction massage showed moderate evidence of effectiveness versus laser therapy on short-term follow-up. On the contrary, moderate evidence was found in favour of laser therapy over plyometric exercises on short-term follow-up. For all other modalities only limited/conflicting evidence for effectiveness or evidence of no difference in effect was found.

CONCLUSIONS:

Potential effectiveness of ultrasound and laser for the management of LE was found. To draw more definite conclusions high-quality RCTs examining different intensities are needed as well as studies focusing on long-term follow-up results.

Clin Evid (Online).  2011 Jun 27;2011. pii: 1117.

Tennis elbow.

Bisset L, Coombes B, Vicenzino B.

Source

Department of Health and Rehabilitation, University of Queensland, Brisbane, Australia.

Abstract

INTRODUCTION:

Lateral pain in the elbow affects up to 3% of the population, and is considered an overload injury of the extensor tendons of the forearm where they attach at the lateral epicondyle. Although usually self-limiting, symptoms may persist for over 1 year in up to 20% of people.

METHODS AND OUTCOMES: We conducted a systematic review and aimed to answer the following clinical question: What are the effects of treatments for tennis elbow? We searched: Medline, Embase, The Cochrane Library, and other important databases up to November 2009 (Clinical Evidence reviews are updated periodically, please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA).

RESULTS:

We found 80 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions.

CONCLUSIONS:

In this systematic review we present information relating to the effectiveness and safety of the following interventions: acupuncture, autologous whole blood injections, corticosteroid injections, combination physical therapies, exercise, extracorporeal shock wave therapy, iontophoresis, low-level laser therapy, manipulation, non-steroidal anti-inflammatory drugs (oral and topical), orthoses (bracing), platelet-rich plasma injections, pulsed electromagnetic field treatment, surgery, and ultrasound.

Photomed Laser Surg. 2009 Oct 30. [Epub ahead of print]

Therapeutic Effects of Low-Level Laser on Lateral Epicondylitis from Differential Interventions of Chinese-Western Medicine: Systematic Review.

Chang WD, Wu JH, Yang WJ, Jiang JA.

1 Department of Rehabilitation Medicine, Da Chien General Hospital , Miaoli City, Taiwan .

Abstract 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.

Photomed Laser Surg. 2009 Jun;27(3):513-20.

Comparing the effects of exercise program and low-level laser therapy with exercise program and polarized polychromatic non-coherent light (bioptron light) on the treatment of lateral elbow tendinopathy.

Stasinopoulos D, Stasinopoulos I, Pantelis M, Stasinopoulou K.

Rheumatology and Rehabilitation Centre, Athens, Greece. d_stasinopoulos@yahoo.gr

Abstract

BACKGROUND DATA: The use of low-level laser therapy (LLLT) and polarized polychromatic non-coherent light as supplements to an exercise program has been recommended for the management of lateral elbow tendinopathy (LET).

OBJECTIVE: To investigate whether an exercise program supplemented with LLLT is more successful than an exercise program supplemented with polarized polychromatic non-coherent light in treating LET.

MATERIALS AND METHODS: Patients with unilateral LET for at least 4 wk were sequentially allocated to receive either an exercise program with LLLT or an exercise program with polarized polychromatic non-coherent light. The exercise program consisted of eccentric and static stretching exercises of wrist extensors. In the LLLT group a 904-nm Ga-As laser was used in continuous mode, and the power density was 130 mW/cm(2), and the dose was 0.585 J/point. In the group receiving polarized polychromatic non-coherent light the Bioptron 2 was used to administer the dose perpendicularly to the lateral epicondyle at three points at an operating distance of 5-10 cm for 6 min at each position. The outcome measures were pain and function and were evaluated at baseline, at the end of the treatment (week 4), and 3 mo after the end of treatment (week 16).

RESULTS: Fifty patients met the inclusion criteria. At the end of treatment there was a decline in pain and a rise in function in both groups compared with baseline (p < 0.0005 on the paired t-test). There were no significant differences in the reduction of pain and the improvement of function between the groups at the end of treatment and at the 3-mo follow-up (p > 0.0005 on the independent t-test).

CONCLUSIONS: The results suggest that the combination of an exercise program with LLLT or polarized polychromatic non-coherent light is an adequate treatment for patients with LET. Further research to establish the relative and absolute effectiveness of such a treatment approach is needed.

BMC Musculoskeletal Disorders 2008, 9:75doi:10.1186/1471-2474-9-75

A systematic review with procedural assessments and meta-analysis of Low Level Laser Therapy in lateral elbow tendinopathy (tennis elbow)

Jan M Bjordal , Rodrigo AB Lopes-Martins , Jon Joensen , Anne E Ljunggren , Christian Couppe , Apostolos Stergioulas and Mark I Johnson

Published: 29 May 2008

Abstract (provisional)

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 EggerA’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.

Conclusions

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.

J Hand Ther. 2008 Jan-Mar;21(1):63-8.

The Short-term Efficacy of Laser, Brace, and Ultrasound Treatment in Lateral Epicondylitis: A Prospective, Randomized, Controlled Trial.

Oken O, Kahraman Y, Ayhan F, Canpolat S, Yorgancioglu ZR, Oken OF.

Ankara Education and Research Hospital, Department of Physical Medicine and Rehabilitation, Division of Hand Rehabilitation, Ankara, Turkey.

The aims of this study were to evaluate the effects of low-level laser therapy (LLLT) and to compare these with the effects of brace or ultrasound (US) treatment in tennis elbow. The study design used was a prospective and randomized, controlled, single-blind trial. Fifty-eight outpatients with lateral epicondylitis (9 men, 49 women) were included in the trial. The patients were divided into three groups: 1) brace group-brace plus exercise, 2) ultrasound group-US plus exercise, and 3) laser group-LLLT plus exercise. Patients in the brace group used a lateral counterforce brace for three weeks, US plus hot pack in the ultrasound group, and laser plus hot pack in the LLLT group. In addition, all patients were given progressive stretching and strengthening exercise programs. Grip strength and pain severity were evaluated with visual analog scale (VAS) at baseline, at the second week of treatment, and at the sixth week of treatment. VAS improved significantly in all groups after the treatment and in the ultrasound and laser groups at the sixth week (p<0.05). Grip strength of the affected hand increased only in the laser group after treatment, but was not changed at the sixth week. There were no significant differences between the groups on VAS and grip strength at baseline and at follow-up assessments. The results show that, in patients with lateral epicondylitis, a brace has a shorter beneficial effect than US and laser therapy in reducing pain, and that laser therapy is more effective than the brace and US treatment in improving grip strength.

Photomed Laser Surg. 2007 Jun;25(3):205-13.

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

Stergioulas A.

Faculty of Human Movement & Quality of Life, Peloponnese University, Sparta, Greece. asterg@uop.gr

Abstract

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.

Photomed Laser Surg. 2007 Apr;25(2):65-71

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

Lam LK, Cheing GL.

Physiotherapy Department, Queen Elizabeth Hospital, Hong Kong.

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.

Photomed Laser Surg. 2007 Jun;25(3):205-13

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

Stergioulas A.

Faculty of Human Movement & Quality of Life, Peloponnese University, Sparta, Greece.

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.

Clin Rehabil. 2006 Jan;20(1):12-23.

Comparison of effects of Cyriax physiotherapy, a supervised exercise programme and polarized polychromatic non-coherent light (Bioptron light) for the treatment of lateral epicondylitis.

Stasinopoulos D, Stasinopoulos I.

Rheumatology and Rehabilitation Centre, Athens, Greece. d_stasinopoulos@yahoo.gr

Abstract

OBJECTIVE: To compare the effectiveness of Cyriax physiotherapy, a supervised exercise programme, and polarized polychromatic non-coherent light (Bioptron light) in the treatment of lateral epicondylitis.

DESIGN: Controlled clinical trial.

SETTING: Rheumatology and rehabilitation centre.

SUBJECTS: This study was carried out with 75 patients who had lateral epicondylitis. They were allocated to three groups by sequential allocation.

INTERVENTIONS: Group A (n = 25) was treated with Cyriax physiotherapy. A supervised exercise programme was given to group B (n = 25). Group C (n = 25) received polarized polychromatic non-coherent light (Bioptron light). All patients received three treatments per week for four weeks.

OUTCOMES: Pain was evaluated using a visual analogue scale and function using a visual analogue scale and pain-free grip strength at the end of the four-week course of treatment (week 4), one month (week 8), three months (week 16) and six months (week 28) after the end of treatment.

RESULTS: The supervised exercise programme produced the largest effect in the reduction of pain and in the improvement of function at the end of the treatment (P<0.05) and at any of the follow-up time points (P< 0.05).

CONCLUSION: The supervised exercise programme should be the first treatment option for therapists when they manage lateral epicondylitis patients. If this is not possible, Cyriax physiotherapy and polarized polychromatic non-coherent light (Bioptron light) may be suitable.

Photomed Laser Surg. 2005 Feb;23(1):66-9.

The use of polarized polychromatic non-coherent light as therapy for acute tennis elbow/lateral epicondylalgia: a pilot study.

Stasinopoulos D.

Rheumatolory and Rehabilitation Centre, Orfanidou 16, Patissia, Athens 11141, Greece. d_stasinopoulos@yahoo.gr

Abstract

OBJECTIVE: The aim of this study was to assess the efficacy of polarized, polychromatic, non-coherent, low energy light (Bioptron 2, Bioptron AG, Switzerland) in the treatment of acute tennis elbow.

BACKGROUND: Tennis elbow, or lateral epicondylitis, is one of the most common lesions affecting the arm. A plethora of treatment regimes have been described for this condition, but no specific therapy has emerged as a gold standard.

METHODS: A pilot study was carried out with 25 patients who had acute tennis elbow. Bioptron 2 device was applied over lateral epicondyle three times per week for 4 weeks. Pain on VAS, function on VAS, and painfree grip strength were measured at the beginning (week 0) and at the end of the study (week 4).

RESULTS: The pain on VAS was reduced at the end of treatment (t(24) = 3.84, p = 0.001). Function on VAS was increased at the end of treatment (t(24) = 4.23, p < 0.001). Pain-free grip strength was increased at the end of treatment (t(24) = 4.23, p < 0.004).

CONCLUSION: Although the results suggested that the Bioptron 2 could reduce patients’ symptoms with acute tennis elbow, future controlled studies are needed to establish the relative and absolute effectiveness of Bioptron 2.

TREATMENT OF MEDIAL AND LATERAL EPICONDYLITIS- TENNIS AND GOLFER’S ELBOW-WITH LOW LEVEL LASER THERAPY: A MULTICENTER STUDY

Zlatko Simunovic, M.D., F.M.H., 2Tatjana Trobonjaca, M.D. and 3Zlatko Trobonjaca, M.D. 1Pain Clinic-Laser Center, Locarno, Switzerland 2Laser Center, Opatija, Croatia 3Department of Physiology and Immunology, Faculty of Medicine, University of Rijeka, Croatia

Among the other treatment modalities of medial and lateral epicondylitis, Low Level Laser Therapy (LLLT) has been promoted as a highly successful method. The aim of this clinical study was to assess the efficacy of LLLT using trigger points (TPs) and scanning application techniques under placebo controlled conditions The current clinical study was completed at two laser centers (Locarno, Switzerland and Opatija, Croatia) as a double-blind, placebo controlled, crossover clinical study. The patient population (n=324), with either medial epicondylitis (Golfer’s elbow; n=50) or lateral epicondylitis (Tennis elbow; n=274), was recruited. Unilateral cases of either type of epicondylitis (n=283) were randomly allocated to one of three treatment groups according to the LLLT technique applied: (1) TPs; (2) scanning, and (3) Combination treatment (i.e., TPs and scanning technique). Bilateral cases of either type of epicondylitis (n=41) were subject to crossover, placebo controlled conditions. Laser devices used to perform these treatments were infrared (IR) diode laser (GaAlAs) 830nm continuous wave for treatment of TPs and HeNe 632.8nm combined with IR diode laser 904nm pulsed wave for scanning technique. Energy doses were equally controlled and measured in Joules/cm2 either during TPs or scanning technique sessions in all groups of patients. The treatment outcome (pain relief and functional ability) was observed and measured according to the following methods: (1) short form of McGill’s Pain Questionnaire (SF-MPQ); (2) Visual analogue scale (VAS); (3) Verbal Rating Scale (VRS); (4) Patient’s pain diary; and (5) hand dynamometer. Total relief of the pain with consequently improved functional ability was achieved in 82% of acute and 66% of chronic cases, all of which were treated by combination of TPs and scanning technique.
This clinical study has demonstrated that the best results are obtained using combination treatment (i.e., TPs and scanning technique). Good results are obtained from adequate treatment technique correctly applied, individual energy doses, adequate medical education, clinical experience and correct approach of laser therapists. We observed that under-and over-irradiation dosage can result in the absence of positive therapy effects or even opposite, negative (i.e. inhibitory) effects. The current clinical study provides further evidence of the efficacy of LLLT in the management of lateral and medial epicondylitis. ENTER DOUBLE BLIND, PLACEBO CONTROLLED CLINICAL STUDY ON 324 PATIENTS

LLLT is as well documented as NSAIDs and steroid injections for shoulder tendinitis/bursitis and epicondylalgia.

The Norwegian physiotherapist Jan M Bjordal published his thesis “Low level laser therapy in shoulder tendinitis/bursitis, epicondylalgia and ankle sprain” in 1997, at the Division of Physiotherapy Science, University of Bergen. It has also been published in Physical Therapy Reviews. 1998; 3: 121-132.

Here is the Conclusion of the thesis: “A systematic review has been performed on the effect of LLLT for three diagnoses. LLLT was evaluated on similar criteria for methodological assessments of trials as previously established for medical interventions. No evidence was found to indicate that randomized controlled trials on LLLT for tendinitis/bursitis of the shoulder, lateral epicondylalgia and ankle sprains were methodologically inferior to RCTs on medical interventions. The clinical effects of LLLT were found to be supported by scientific evidence regarding short (0-4 weeks) and medium term (<3 months) efficacy for subacute or chronic lateral epicondylitis, and short term efficacy (>3 months) for subacute or chronic lateral epicondylitis, and short term efficacy (> 3 months) for subacute or chronic shoulder tendinitis/bursitis. The evidence of effect from LLLT for acute ankle sprain is inconclusive, although there seems to be a slight tendency in favour of LLLT. Adverse effects of LLLT are rarely seen and only in minor forms (nausea, headache) compared to medication, where more serious gastrointestinal discomfort or ulcers are not uncommon. It has also been shown that trials in favour of active treatment had more treatments per week than the trials showing no difference in effect. In short one could say that LLLT should be used much in the same way as NSAID are used for short periods of time. Most trials showing significant effects used an IR 904 nm laser, but some results in favour of IR lasers with wavelengths of 780, 820 and 830 nm were also observed. Clinical effects of LLLT were best in subacute conditions. In chronic conditions a higher dosage and more treatments seem to be needed. The results of the high quality LLLT trials were all in favour of treatment with confidence intervals not including zero, and the trials came from several different research groups. Evidence was found to be at the highest or the second highest level depending on what level of clinical significance is decided according to the classification of Oxman (1994) and McQuay (1997). The review found little support for the alleged large placebo effects of LLLT. In chronic cases the placebo effect is probably less that 10%, after the natural history of the complaints is taken into account.”

In the “Summary of discussion on clinical effect estimates for LLLT” the author writes:

“The majority of the included LLLT-trials found significant clinical effect from LLLT. Seven of the eleven LLLT-trials with acceptable methods included calculations of 95% confidence limits above zero, and one LLLT-trial on anke sprain included zero (Axelsen & Bjerno 1993). The clincal effect estimates from LLLT-trials for shoulder tendinitis/bursitis are similar or higher than for NSAID or steroid injections. For lateral epicondylalgia estimates for short term clinical effects are similar or lower for LLLT than for steroid injections, but medium clinical effect estimates are similar or higher for LLLT. Recurrence of symptoms in lateral epicondylalgia is less likely after LLLT than after steroid injections. Evidence of clinical effects from ankle sprain is inconclusive. Adverse effects from LLLT are seldom seen and they appear less serious than for patients treated with NSAID and steroid injections.”

 


Treatment of Tennis Elbow

Kazuyoshi Zenba, the president of Isehara Threrapeutic Institute
PHOTO:”Treatment of tennis elbow”


From http://www.greenmed.co.jp/lpl/E/tennisE.htm
Although moderate sports are good for health, too much exercise gives damages
to bones and muscles. If the excessive stress is repeated to a Certain part of
the elbow, bones or muscles, the part becomes inflamed and will be leaded to
the pain. In case of the tennis elbow, the outside part is typically damaged. An
early treatment by the low power laser is very effective to eliminate the
inflammation and the pain of such tennis elbow.
The 10mW laser is recommended to irradiate for 2 minutes at the most painful
point (trigger point) and surrounding points 2 to 3 times a week.
Low Power Laser therapy is said to be one of the most idealistic treatment for
sports injuries, from the viewpoint of efficacy and safety.


Scand J Rehabil Med. 1992;24(1):37-42.

Low level laser versus placebo in the treatment of tennis elbow.

Vasseljen O Jr, Hoeg N, Kjeldstad B, Johnsson A, Larsen S.

Trondheim Fysikalske Institutt, Norway.

The effect of low level laser (GaAs) on lateral epicondylitis was investigated in a double-blind, randomized, controlled study. Thirty patients were assigned equally to a laser (n = 15) or a placebo laser (n = 15) group. All patients received eight treatments and were evaluated subjectively and objectively before, at the end of, and four weeks after treatment. Patients also completed a follow-up questionnaire on an average of five to six months after treatment. A significant improvement in the laser compared to the placebo group was found on visual analog scale (p = 0.02) and grip strength (p = 0.03) tests four weeks after treatment. In this study low level laser therapy was shown to have an effect over placebo; however, as a sole treatment for lateral epicondylitis it is of limited value. Further studies are needed to evaluate the reliability of our findings and to compare laser to other established treatment methods.

J Hand Ther. 2004 Apr-Jun;17(2):243-66.

 

Rehabilitation for patients with lateral epicondylitis: a systematic review.

Trudel D, Duley J, Zastrow I, Kerr EW, Davidson R, MacDermid JC.

Canadian Forces Base Kingston, Ontario, Canada.

The purpose of this systematic review was to determine the effectiveness of conservative treatments for lateral epicondylitis and to provide recommendations based on this evidence. Five reviewers searched computerized bibliographic databases for articles on the conservative treatment of lateral epicondylitis from the years 1983 to 2003. A total of 209 studies were located; however, only 31 of these met the study inclusion criteria. Each of the articles was randomly allocated to reviewers and critically appraised using a structured critical appraisal tool with 23 items. Treatment recommendations were based on this rating and Sackett’s Level of Evidence. This review has determined, with at least level 2b evidence, that a number of treatments, including acupuncture, exercise therapy, manipulations and mobilizations, ultrasound, phonophoresis, Rebox, and ionization with diclofenac all show positive effects in the reduction of pain or improvement in function for patients with lateral epicondylitis. There is also at least level 2b evidence showing laser therapy and pulsed electromagnetic field therapy to be ineffective in the management of this condition. Practitioners should use the treatment techniques that have strongest evidence and ensure that studies findings are generalized to patients who are similar to those reported in primary research studies in terms of patient demographics and injury presentation

Photomed Laser Surg. 2005 Aug;23(4):425-30.

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

Stasinopoulos DI, Johnson MI.

School of Health and Human Sciences, Leeds Metropolitan University, Leeds, UK. d_stasinopoulos@yahoo.gr

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.

 

J Clinical Laser Med & Surg. 1998; 16 (3): 145-151.

 

Laser is effective for medial and lateral epicondylitis

Simunovic Z, Trobonjaca T et al.

Treatment of medial and lateral epicondylitis – tennis and golfer¹s elbow – with low level laser therapy: a multicenter double blind, placebo controlled clinical study of 324 patients.

In a two center study 324 patients with unilateral medial or lateral epicondylitis were treated with LLLT. Trigger points were treated with 830 nm.  633 and 904 nm in combination was used in the scanning mode. Total pain relief was obtained in 82% of the acute cases and 66% in the chronic cases. A combination of trigger points (TP) and scanning was more effective than TP alone and TP alone were more effective than scanning alone. One of the centers had slightly less powerful lasers and the outcome was a bit lower, although the dosage was the same in both centers.

Australas Chiropr Osteopathy. 1998 Jul;7(2):53-67.

A critical review of the current conservative therapies for tennis elbow (lateral epidcondylitis).

Viola L.

The pathogenesis, pathology, natural course, and in particular the treatment of lateral epicondylitis (tennis elbow) remains controversial. An extensive review of the scientific literature with respect to the conservative treatment of tennis elbow, revealed that acceptable epidemiological techniques of the prospective randomised control trials or case controlled studies are scarce. While administration of steroid compounds has traditionally been the mainstay of conservative treatment of tennis elbow, the high recurrence rate of side effects and structural tissue changes associated with steroid therapy, leaves this modality as the most controversial approach in the treatment of tennis elbow. In contrast, in some studies evidence in favour of a role for classical acupuncture, ultrasound and low level laser as effective therapeutic means in the treatment of tennis elbow has been provided. As these modalities have not been associated with any side effects, in view of the ease of application, low cost and good curative effects, their increased application has been suggested by some authors. This proposition, however, remains rather conjectural until it could be convincingly substantiated by future studies with appropriate epidemiological design.

TREATMENT OF MEDIAL AND LATERAL EPICONDYLITIS – TENNIS AND GOLFER’S ELBOW – WITH LOW LEVEL LASER THERAPY: A MULTICENTER STUDY

Zlatko Simunovic, M.D., F.M.H., 2Tatjana Trobonjaca, M.D. and 3Zlatko Trobonjaca, M.D. 1Pain Clinic-Laser Center, Locarno, Switzerland 2Laser Center, Opatija, Croatia 3Department of Physiology and Immunology, Faculty of Medicine, University of Rijeka, Croatia

Among the other treatment modalities of medial and lateral epicondylitis, Low Level Laser Therapy (LLLT) has been promoted as a highly successful method. The aim of this clinical study was to assess the efficacy of LLLT using trigger points (TPs) and scanning application techniques under placebo controlled conditions The current clinical study was completed at two laser centers (Locarno, Switzerland and Opatija, Croatia) as a double-blind, placebo controlled, crossover clinical study. The patient population (n=324), with either medial epicondylitis (Golfer’s elbow; n=50) or lateral epicondylitis (Tennis elbow; n=274), was recruited. Unilateral cases of either type of epicondylitis (n=283) were randomly allocated to one of three treatment groups according to the LLLT technique applied: (1) TPs; (2) scanning, and (3) Combination treatment (i.e., TPs and scanning technique). Bilateral cases of either type of epicondylitis (n=41) were subject to crossover, placebo controlled conditions. Laser devices used to perform these treatments were infrared (IR) diode laser (GaAlAs) 830nm continuous wave for treatment of TPs and HeNe 632.8nm combined with IR diode laser 904nm pulsed wave for scanning technique. Energy doses were equally controlled and measured in Joules/cm2 either during TPs or scanning technique sessions in all groups of patients. The treatment outcome (pain relief and functional ability) was observed and measured according to the following methods: (1) short form of McGill’s Pain Questionnaire (SF-MPQ); (2) Visual analogue scale (VAS); (3) Verbal Rating Scale (VRS); (4) Patient’s pain diary; and (5) hand dynamometer. Total relief of the pain with consequently improved functional ability was achieved in 82% of acute and 66% of chronic cases, all of which were treated by combination of TPs and scanning technique.
This clinical study has demonstrated that the best results are obtained using combination treatment (i.e., TPs and scanning technique). Good results are obtained from adequate treatment technique correctly applied, individual energy doses, adequate medical education, clinical experience and correct approach of laser therapists. We observed that under-and over-irradiation dosage can result in the absence of positive therapy effects or even opposite, negative (i.e. inhibitory) effects. The current clinical study provides further evidence of the efficacy of LLLT in the management of lateral and medial epicondylitis. ENTER DOUBLE BLIND, PLACEBO CONTROLLED CLINICAL STUDY ON 324 PATIENTS

LLLT is as well documented as NSAIDs and steroid injections for shoulder tendinitis/bursitis and epicondylalgia.

The Norwegian physiotherapist Jan M Bjordal published his thesis “Low level laser therapy in shoulder tendinitis/bursitis, epicondylalgia and ankle sprain” in 1997, at the Division of Physiotherapy Science, University of Bergen. It has also been published in Physical Therapy Reviews. 1998; 3: 121-132.

Here is the Conclusion of the thesis: “A systematic review has been performed on the effect of LLLT for three diagnoses. LLLT was evaluated on similar criteria for methodological assessments of trials as previously established for medical interventions. No evidence was found to indicate that randomized controlled trials on LLLT for tendinitis/bursitis of the shoulder, lateral epicondylalgia and ankle sprains were methodologically inferior to RCTs on medical interventions. The clinical effects of LLLT were found to be supported by scientific evidence regarding short (0-4 weeks) and medium term (<3 months) efficacy for subacute or chronic lateral epicondylitis, and short term efficacy (>3 months) for subacute or chronic lateral epicondylitis, and short term efficacy (> 3 months) for subacute or chronic shoulder tendinitis/bursitis. The evidence of effect from LLLT for acute ankle sprain is inconclusive, although there seems to be a slight tendency in favour of LLLT. Adverse effects of LLLT are rarely seen and only in minor forms (nausea, headache) compared to medication, where more serious gastrointestinal discomfort or ulcers are not uncommon. It has also been shown that trials in favour of active treatment had more treatments per week than the trials showing no difference in effect. In short one could say that LLLT should be used much in the same way as NSAID are used for short periods of time. Most trials showing significant effects used an IR 904 nm laser, but some results in favour of IR lasers with wavelengths of 780, 820 and 830 nm were also observed. Clinical effects of LLLT were best in subacute conditions. In chronic conditions a higher dosage and more treatments seem to be needed. The results of the high quality LLLT trials were all in favour of treatment with confidence intervals not including zero, and the trials came from several different research groups. Evidence was found to be at the highest or the second highest level depending on what level of clinical significance is decided according to the classification of Oxman (1994) and McQuay (1997). The review found little support for the alleged large placebo effects of LLLT. In chronic cases the placebo effect is probably less that 10%, after the natural history of the complaints is taken into account.”

In the “Summary of discussion on clinical effect estimates for LLLT” the author writes:

“The majority of the included LLLT-trials found significant clinical effect from LLLT. Seven of the eleven LLLT-trials with acceptable methods included calculations of 95% confidence limits above zero, and one LLLT-trial on anke sprain included zero (Axelsen & Bjerno 1993). The clincal effect estimates from LLLT-trials for shoulder tendinitis/bursitis are similar or higher than for NSAID or steroid injections. For lateral epicondylalgia estimates for short term clinical effects are similar or lower for LLLT than for steroid injections, but medium clinical effect estimates are similar or higher for LLLT. Recurrence of symptoms in lateral epicondylalgia is less likely after LLLT than after steroid injections. Evidence of clinical effects from ankle sprain is inconclusive. Adverse effects from LLLT are seldom seen and they appear less serious than for patients treated with NSAID and steroid injections.”

 Low level laser versus placebo in the treatment of tennis elbow.

Vasseljen O Jr, Hoeg N, Kjeldstad B, Johnsson A, Larsen S.

Trondheim Fysikalske Institutt, Norway.

The effect of low level laser (GaAs) on lateral epicondylitis was investigated in a double-blind, randomized, controlled study. Thirty patients were assigned equally to a laser (n = 15) or a placebo laser (n = 15) group. All patients received eight treatments and were evaluated subjectively and objectively before, at the end of, and four weeks after treatment. Patients also completed a follow-up questionnaire on an average of five to six months after treatment. A significant improvement in the laser compared to the placebo group was found on visual analog scale (p = 0.02) and grip strength (p = 0.03) tests four weeks after treatment. In this study low level laser therapy was shown to have an effect over placebo; however, as a sole treatment for lateral epicondylitis it is of limited value. Further studies are needed to evaluate the reliability of our findings and to compare laser to other established treatment methods.

J Hand Ther. 2004 Apr-Jun;17(2):243-66.

Rehabilitation for patients with lateral epicondylitis: a systematic review.

Trudel D, Duley J, Zastrow I, Kerr EW, Davidson R, MacDermid JC.

Canadian Forces Base Kingston, Ontario, Canada.

The purpose of this systematic review was to determine the effectiveness of conservative treatments for lateral epicondylitis and to provide recommendations based on this evidence. Five reviewers searched computerized bibliographic databases for articles on the conservative treatment of lateral epicondylitis from the years 1983 to 2003. A total of 209 studies were located; however, only 31 of these met the study inclusion criteria. Each of the articles was randomly allocated to reviewers and critically appraised using a structured critical appraisal tool with 23 items. Treatment recommendations were based on this rating and Sackett’s Level of Evidence. This review has determined, with at least level 2b evidence, that a number of treatments, including acupuncture, exercise therapy, manipulations and mobilizations, ultrasound, phonophoresis, Rebox, and ionization with diclofenac all show positive effects in the reduction of pain or improvement in function for patients with lateral epicondylitis. There is also at least level 2b evidence showing laser therapy and pulsed electromagnetic field therapy to be ineffective in the management of this condition. Practitioners should use the treatment techniques that have strongest evidence and ensure that studies findings are generalized to patients who are similar to those reported in primary research studies in terms of patient demographics and injury presentation

Scand J Rehabil Med. 1992;24(1):37-42.

Low level laser versus placebo in the treatment of tennis elbow.

Vasseljen O Jr, Høeg N, Kjeldstad B, Johnsson A, Larsen S.

Trondheim Fysikalske Institutt, Norway.

The effect of low level laser (GaAs) on lateral epicondylitis was investigated in a double-blind, randomized, controlled study. Thirty patients were assigned equally to a laser (n = 15) or a placebo laser (n = 15) group. All patients received eight treatments and were evaluated subjectively and objectively before, at the end of, and four weeks after treatment. Patients also completed a follow-up questionnaire on an average of five to six months after treatment. A significant improvement in the laser compared to the placebo group was found on visual analog scale (p = 0.02) and grip strength (p = 0.03) tests four weeks after treatment. In this study low level laser therapy was shown to have an effect over placebo; however, as a sole treatment for lateral epicondylitis it is of limited value. Further studies are needed to evaluate the reliability of our findings and to compare laser to other established treatment methods.