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Objectives To investigate the effect of prolonged low-level laser therapy application combined with exercise on pain and disability in patients with osteoarthritis of the knee. Design A randomized controlled trial. Setting Special rehabilitation services. Subjects Forty-three participants with knee osteoarthritis. Intervention Following initial assessment, participants were randomly allocated to the Laser group (n = 22, 44 knees) and received low-level laser therapy while the Placebo group (n = 21, 42 knees) received placebo therapy three times a week for 3 weeks. Both groups then received low-level laser therapy combined with exercise three times a week for the following 8 weeks. Main outcome measures The primary outcome was change in knee pain and disability (Lequesne). Secondary outcomes included change in mobility (Timed Up and Go test), range of motion (goniometer), muscular strength (dynamometer), activity (Western Ontario and McMaster Universities Osteoarthritis questionnaire), and medication intake and relief. Results Mean (SD) age of participants was 63.02 (9.9) years. Pain scores at baseline, 3 weeks, 11 weeks, and 6 months follow-up were 9.1 (1.3), 2.6 (2.3), 0.2 (0.9), and 0.2 (0.8) for the Laser group and 9.5 (8.0), 7.7 (5.3), 5.6 (2.4), and 7.4 (5.0) for the Placebo group, respectively. Disability scores at baseline, 3 weeks, 11 weeks, and 6 months follow-up were 14.9 (4.7), 7.6 (4.8), 3.9 (4.2), and 3.5 (4.1) for the Laser group and 17.8 (14.7), 15.2 (11.5), 11.6 (6.4), and 15.8 (11.9) for the Placebo Group, respectively. Conclusion In participants with osteoarthritis of the knee, the isolated application of low-level laser therapy in the initial 3 weeks and combined with exercises in the final 8 weeks reduced pain, disability, and intake of medication over a 6-month period.

Objective: To investigate the effect of low-level laser therapy (LLLT) combined with exercise on shoulder pain and disability in patients with subacromial impingement syndrome (SIS). Design: Randomised controlled trial. Setting: Pontifical Catholic University. Subjects: We enrolled 120 subacromial impingement syndrome patients Intervention: Groups I ( n = 42), II ( n = 42) and III ( n = 36) were treated with Low-level laser therapy and exercise, exercise only and Low-level laser therapy only, respectively. Interventions were conducted three times a week for 8 weeks. Main outcome measures: The primary outcome was the change in shoulder pain and disability index (SPADI). Secondary outcomes included changes in the numeric pain rating scale and medication intake. Results: Average ages of patients in groups I, II and III were 51.9 ± 8.7 years, 56.0 ± 10.4 years and 54.2 ± 7.1 years, respectively. Pain scores at baseline ( P = 0.829), 2 months ( P = 0.057) and 3 months follow-ups ( p = 0.004) were 6.8 (4.7–7.7), 0.2 (0.0–0.5) and 0.3 (0.0–1.0) for group I; 6.6 (5.7–8.0), 0.5 (0.2–2.0) and 0.2 (0.0–3.3) for group II; and 6.5 (5.1–7.4), 2.4 (0.1–6.7) and 4.0 (2.0–5.0) for group III, respectively. SPADI scores at baseline ( P = 0.029), 2 months ( P Conclusion: Low-level laser therapy combined with exercises reduce pain intensity, improve shoulder function and reduces pain intensity and medication intake over 3 months. Clinical Trial Registration number: NCT 02725749

Made available in DSpace on 2020-12-10T20:04:15Z (GMT). No. of bitstreams: 0 Previous issue date: 2020-06-26 Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP) Background:Photobiomodulation therapy (PBMT) and creatine (Cr) intake have been used in conjunction with heavy training, but little is known about their possible effects during a long-term training program. Objective:We assessed long-term use of PBMT and Cr in an exercise training program. Methods:Twenty-five male Wistar rats weighing similar to 300 g were randomly allocated to one of five groups: a nontraining control group, a training group, a training group receiving Cr, a training group receiving PBMT, and a training group receiving both PBMT and Cr. The training program consisted of 12 weeks of daily swimming training. PBMT was delivered in six points with a laser device (808 nm, 100 mW, 30 s per point of irradiation, 3 J, 75 J/cm(2)). Results:All training groups showed significantly higher peak force and longer time to 50% decay of force, and lower creatine kinase (CK) levels than the nontraining control group, thus confirming the benefit of the training program. In all outcomes related to muscle performance, the groups receiving PBMT with or without Cr supplement performed significantly better (p < 0.05) peak force and time of force decay during an electrical stimulation protocol than all the other groups. In addition, CK levels were also significantly lower for the PBMT groups than for the other groups. Conclusions:We conclude that PBMT alone or in conjunction with Cr supplement during a 12-week training program resulted in significantly better muscle performance and lower levels of CK, a biochemical marker of muscle damage. Sao Paulo State Univ UNESP, Postgrad Program Movement Sci, Lab Physiol & Sport Performance LAFIDE, Dept Phys Educ, Ave Eng Luiz Edmundo Carrijo Coube, BR-17033360 Bauru, SP, Brazil Univ Brasil, Postgrad Program Biomed Engn, Sao Paulo, SP, Brazil UNESP, Med Sch, Postgrad Program Pathophysiol, Med Clin, Botucatu, SP, Brazil Univ Bergen, Dept Global Publ Hlth & Primary Care, Physiotherapy Res Grp, Bergen, Norway Univ Vale Paraiba UNIVAP, Lab Biophoton & Expt Therapeut, Inst Res & Dev, Sao Jose Dos Campos, SP, Brazil UNINOVE Appl Biophoton Hlth Sci, Sao Paulo, SP, Brazil Sao Paulo State Univ UNESP, Postgrad Program Movement Sci, Lab Physiol & Sport Performance LAFIDE, Dept Phys Educ, Ave Eng Luiz Edmundo Carrijo Coube, BR-17033360 Bauru, SP, Brazil UNESP, Med Sch, Postgrad Program Pathophysiol, Med Clin, Botucatu, SP, Brazil FAPESP: 2017/21724-8 FAPESP: 2019/17445-1

ObjectivesWe investigated the effectiveness of low-level laser therapy (LLLT) in lower extremity tendinopathy and plantar fasciitis on patient-reported pain and disability.DesignSystematic review and meta-analysis.Data sourcesEligible articles in any language were identified through PubMed, Embase and Physiotherapy Evidence Database (PEDro) on the 20 August 2020, references, citations and experts.Eligibility criteria for selection of studiesOnly randomised controlled trials involving participants with lower extremity tendinopathy or plantar fasciitis treated with LLLT were included.Data extraction and synthesisRandom effects meta-analyses with dose subgroups based on the World Association for Laser Therapy treatment recommendations were conducted. Risk of bias was assessed with the PEDro scale.ResultsLLLT was compared with placebo (10 trials), other interventions (5 trials) and as an add-on intervention (3 trials). The study quality was moderate to high.Overall, pain was significantly reduced by LLLT at completed therapy (13.15 mm Visual Analogue Scale (VAS; 95% CI 7.82 to 18.48)) and 4–12 weeks later (12.56 mm VAS (95% CI 5.69 to 19.42)). Overall, disability was significantly reduced by LLLT at completed therapy (Standardised Mean Difference (SMD)=0.39 (95% CI 0.09 to 0.7) and 4–9 weeks later (SMD=0.32 (95% CI 0.05 to 0.59)). Compared with placebo control, the recommended doses significantly reduced pain at completed therapy (14.98 mm VAS (95% CI 3.74 to 26.22)) and 4–8 weeks later (14.00 mm VAS (95% CI 2.81 to 25.19)). The recommended doses significantly reduced pain as an add-on to exercise therapy versus exercise therapy alone at completed therapy (18.15 mm VAS (95% CI 10.55 to 25.76)) and 4–9 weeks later (15.90 mm VAS (95% CI 2.3 to 29.51)). No adverse events were reported.ConclusionLLLT significantly reduces pain and disability in lower extremity tendinopathy and plantar fasciitis in the short and medium term. Long-term data were not available. Some uncertainty about the effect size remains due to wide CIs and lack of large trials.PROSPERO registration numberCRD42017077511.

IntroductionShoulder pain affects approximately one in four adults and is thus one of the most common musculoskeletal problems. Only 50% of patients who begin treatment for shoulder pain are cured within 6 months. There is a need for systematic reviews to estimate the effectiveness of shoulder treatments. We decided to evaluate the effect of mobilisation with movement (MWM) on chronic shoulder pain in a systematic review.Methods and analysisThe review will include controlled trial articles identified via five electronic databases (PubMed, Embase, Cumulative Index to Nursing and Allied Health Literature, Physiotherapy Evidence Database and Cochrane Central Register of Controlled Trials), reference lists, citations searches and experts in the field. Only controlled trials involving participants with a mean duration of pain of ≥3 months, in which the effectiveness of MWM has been compared with non-invasive treatments, sham mobilisation or wait-and-see will be included. The included trials will be synthesised with random effects meta-analyses. Risk-of-bias will be assessed with the Physiotherapy Evidence Database 0–10 point scale.Ethics and disseminationThe review does not require ethics approval as it is based on anonymised data from trial reports. The results of the review will be disseminated through a peer-reviewed publication.PROSPERO registration numberCRD42018109380.

Objective: With distal radius fracture (DRF) many patients experience stiffness and pain after removal of the cast. The aim of this study was to investigate possible effects of photobiomodulation t...

We read with interest the article by Gomes et al. entitled: “Exercise program combined with electrophysical modalities in subjects with knee osteoarthritis: A randomised, placebo-controlled clinical trial”. Gomes et al. concluded that the low-level laser therapy (LLLT) did not reduce knee osteoarthritis pain when applied as an adjunct to exercise therapy. We argue that Gomes et al. neglected relevant laser treatment recommendations in the conduct and reporting of the trial.Gomes et al. did not state the Joules per treatment spot applied. We calculated the Joules applied from other laser information in the report and found that it is too low of a dose according to the World Association for Laser Therapy (WALT) guidelines. Furthermore, we have published a meta-analysis of 22 placebo-controlled trials demonstrating a significant difference in pain-relieving effect between doses in adherence and non-adherence to the WALT guidelines. However, neither the WALT guidelines, nor our meta-analysis was mentioned by Gomes et al.Moreover, Gomes et al. did not state whether the output power of the laser device was measured, and this is concerning because in the city of São Paulo, where the trial was conducted, most laser devices have been found to deliver less of a dose than specified by the manufacturers.In summary, we found that the best available evidence regarding effective and ineffective LLLT dosing from systematic reviews was neglected in the conduct and reporting of the trial, and that the laser device may not have been calibrated.

Objective: In professional sports activities, the search for increased performance is constant. Electrophysical agents, including photobiomodulation (PBM), have been used in the sports context to a...

Background There is about ten years since the first randomized controlled trial looking for the effects of photobiomodulation therapy using low-level laser therapy and/or light emitting diodes therapy in athletic performance enhancement was published. Since then, the knowledge in this field has increasing exponentially. Objective Given the fast advance in clinical interest, research and development in the use of photobiomodulation therapy for athletic performance enhancement and also to accelerate post-exercise recovery, as pioneers in this research field we felt the need to establish recommendations to ensure the correct use of the therapy, and also to guide the further studies in this area looking for the achievement of highest scientific evidence. It is important to highlight that the establishment of both clinical and scientific recommendations in this masterclass article were based on the most recent systematic reviews with meta-analysis and randomized controlled trials published in this field. It is important to stress that the recommendations of this masterclass article are based on most recent systematic reviews with meta-analysis and RCTs published in this research field. Future guidelines must follow the same direction and must be based only at the highest scientific evidence, avoiding overstatements and extrapolations based on animal experiments and case-studies.

Objectives: To assess the long-term effects of low-level laser therapy (LLLT), in combination with strengthening exercises in patients with osteoarthritis of the knee. Design: Follow-up results at three and six months in a previously published randomized, double-blind, placebo-controlled trial. Setting: Specialist Rehabilitation Services. Subjects: Forty participants of both genders, aged 50–75 years with knee osteoarthritis grade 2–4 on Kellgren–Lawrence scale. Intervention: The LLLT group received 10 LLLT treatments with invisible infrared laser (904 nm, 3 Joules/point) over three weeks followed by an eight-week supervised strengthening exercise program. The placebo LLLT group received identical treatment, but the infrared laser output was disabled. Main measures: Pain on a visual analogue scale, paracetamol consumption, and osteoarthritis severity measured by the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and Lequesne Index. Results: The new data obtained during the follow-up period showed that all outcomes remained stable and there were no significant differences between the groups at three and six months. However, daily consumption of rescue analgesics (paracetamol) was significantly lower in the LLLT group throughout the follow-up period, ending at a group difference of 0.45 vs. 3.40 units ( P Conclusion: We find that the immediate post-intervention improvements from LLLT plus strengthening exercises were maintained for six months.

Question In people with non-specific low back pain (LBP), what are the effects of photobiomodulation therapy (PBMT) on pain, disability and other outcomes when compared with no intervention, sham PBMT and other treatments, and when used as an adjunct to other treatments? Design Systematic review of randomised trials with meta-analysis. Participants People with acute/subacute or chronic non-specific LBP. Interventions Any type of PBMT (laser class I, II and III and light-emitting diodes) compared with no treatment, sham PBMT and other types of treatment, or used as an adjunct to another treatment. Outcome measures Pain intensity, disability, overall improvement, quality of life, work absence and adverse effects. Results Twelve randomised controlled trials were included (pooled n = 1,046). Most trials had low risk of bias. Compared with sham PBMT, the effect of PBMT on pain and disability was clinically unimportant in people with acute/subacute or chronic LBP. In people with chronic LBP, there was no clinically important difference between the effect of PBMT and the effect of exercise on pain or disability. Although benefits were observed on some other outcomes, these estimates were imprecise and/or based on low-quality evidence. PBMT was estimated to reduce pain (MD −11.20, 95% CI −20.92 to −1.48) and disability (MD −11.90, 95% CI −17.37 to −6.43) more than ultrasound, but these confidence intervals showed important uncertainty about whether the differences in effect were worthwhile or trivial. Conversely, PBMT was estimated to reduce pain (MD 19.00, 95% CI 9.49 to 28.51) and disability (MD 17.40, 95% CI 8.60 to 26.20) less than Tecar (Energy Transfer Capacitive and Resistive) therapy, with marginal uncertainty that these differences in effect were worthwhile. Conclusion Current evidence does not support the use of PBMT to decrease pain and disability in people with non-specific LBP. Registration CRD42018088242.

ObjectivesLow-level laser therapy (LLLT) is not recommended in major knee osteoarthritis (KOA) treatment guidelines. We investigated whether a LLLT dose–response relationship exists in KOA.DesignSystematic review and meta-analysis.Data sourcesEligible articles were identified through PubMed, Embase, Cumulative Index to Nursing and Allied Health Literature, Physiotherapy Evidence Database and Cochrane Central Register of Controlled Trials on 18 February 2019, reference lists, a book, citations and experts in the field.Eligibility criteria for selecting studiesWe solely included randomised placebo-controlled trials involving participants with KOA according to the American College of Rheumatology and/or Kellgren/Lawrence criteria, in which LLLT was applied to participants’ knee(s). There were no language restrictions.Data extraction and synthesisThe included trials were synthesised with random effects meta-analyses and subgrouped by dose using the World Association for Laser Therapy treatment recommendations. Cochrane’s risk-of-bias tool was used.Results22 trials (n=1063) were meta-analysed. Risk of bias was insignificant. Overall, pain was significantly reduced by LLLT compared with placebo at the end of therapy (14.23 mm Visual Analogue Scale (VAS; 95% CI 7.31 to 21.14)) and during follow-ups 1–12 weeks later (15.92 mm VAS (95% CI 6.47 to 25.37)). The subgroup analysis revealed that pain was significantly reduced by the recommended LLLT doses compared with placebo at the end of therapy (18.71 mm (95% CI 9.42 to 27.99)) and during follow-ups 2–12 weeks after the end of therapy (23.23 mm VAS (95% CI 10.60 to 35.86)). The pain reduction from the recommended LLLT doses peaked during follow-ups 2–4 weeks after the end of therapy (31.87 mm VAS significantly beyond placebo (95% CI 18.18 to 45.56)). Disability was also statistically significantly reduced by LLLT. No adverse events were reported.ConclusionLLLT reduces pain and disability in KOA at 4–8 J with 785–860 nm wavelength and at 1–3 J with 904 nm wavelength per treatment spot.PROSPERO registration numberCRD42016035587.

OBJECTIVE Wrist fracture is a common injury in Norway. Pressure algometry is widely used to quantify patients' pain threshold in various anatomical locations. The aim of this study was to explore the reliability of pain pressure threshold (PPT) algometry in persons with conservatively managed distal radius fractures. METHODS In this cross-sectional study, three raters (A, B, and C) tested the PPT of participants (18-97 years of age) with a unilateral distal radius fracture after removal of the cast. The raters conducted two measurements of both wrists. Intrarater reliability was examined in 75, 50, and 25 participants by Raters A, B, and C, respectively. Interrater reliability was tested in 50 and 25 participants by Rater Pairs A-B and A-C, respectively. Relative reliability was calculated with intraclass correlation coefficient (ICC1.1 ) and absolute reliability using within-subject standard deviation (Sw ). RESULTS There was a significant difference in the PPT between the participants' injured and noninjured wrists (p

The effects of preexercise photobiomodulation therapy (PBMT) to enhance performance, accelerate recovery, and attenuate exercise-induced oxidative stress were still not fully investigated, especially in high-level athletes. The aim of this study was to evaluate the effects of PBMT (using infrared low-level laser therapy) applied before a progressive running test on functional aspects, muscle damage, and inflammatory and oxidative stress markers in high-level soccer players. A randomized, triple-blind, placebo-controlled crossover trial was performed. Twenty-two high-level male soccer players from the same team were recruited and treated with active PBMT and placebo. The order of interventions was randomized. Immediately after the application of active PBMT or placebo, the volunteers performed a standardized high-intensity progressive running test (ergospirometry test) until exhaustion. We analyzed rates of oxygen uptake (VO2 max), time until exhaustion, and aerobic and anaerobic threshold during the intense progressive running test. Creatine kinase (CK) and lactate dehydrogenase (LDH) activities, levels of interleukin-1β (IL-1-β), interleukin-6 (IL-6), and tumor necrosis factor alpha (TNF-α), levels of thiobarbituric acid (TBARS) and carbonylated proteins, and catalase (CAT) and superoxide dismutase (SOD) activities were measured before and five minutes after the end of the test. PBMT increased the VO2 max (both relative and absolute values—p<0.0467 and p<0.0013, respectively), time until exhaustion (p<0.0043), time (p<0.0007) and volume (p<0.0355) in which anaerobic threshold happened, and volume in which aerobic threshold happened (p<0.0068). Moreover, PBMT decreased CK (p<0.0001) and LDH (p<0.0001) activities. Regarding the cytokines, PBMT decreased only IL-6 (p<0.0001). Finally, PBMT decreased TBARS (p<0.0001) and carbonylated protein levels (p<0.01) and increased SOD (p<0.0001)and CAT (p<0.0001) activities. The findings of this study demonstrate that preexercise PBMT acts on different functional aspects and biochemical markers. Moreover, preexercise PBMT seems to play an important antioxidant effect, decreasing exercise-induced oxidative stress and consequently enhancing athletic performance and improving postexercise recovery. This trial is registered with Clinicaltrials.gov NCT03803956.

Photobiomodulation therapy (PBMT) has recently been used to alleviate postexercise muscle fatigue and enhance recovery, demonstrating positive results. A previous study by our research group demonstrated the optimal dose for an infrared wavelength (810 nm), but the outcomes could be optimized further with the determination of the optimal output power.The aim of the present study was to evaluate the effects of PBMT (through low-level laser therapy) on postexercise skeletal muscle recovery and identify the best output power.A randomized, placebo-controlled double-blind clinical trial was conducted with the participation of 28 high-level soccer players. PBMT was applied before the eccentric contraction protocol with a cluster with five diodes, 810 nm, dose of 10 J, and output power of 100, 200, 400 mW per diode or placebo at six sites of knee extensors. Maximum isometric voluntary contraction (MIVC), delayed onset muscle soreness (DOMS) and biochemical markers related to muscle damage (creatine kinase and lactate dehydrogenase), inflammation (IL-1β, IL-6, and TNF-α), and oxidative stress (catalase, superoxide dismutase, carbonylated proteins, and thiobarbituric acid) were evaluated before isokinetic exercise, as well as at 1 min and at 1, 24, 48, 72, and 96 h, after the eccentric contraction protocol.PBMT increased MIVC and decreased DOMS and levels of biochemical markers (p 0.05) with the power output of 100 and 200 mW, with better results for the power output of 100 mW.PBMT with 100 mW power output per diode (500 mW total) before exercise achieves best outcomes in enhancing muscular performance and postexercise recovery. Another time it has been demonstrated that more power output is not necessarily better.

This study aimed to evaluate the medium-term effects of low-level laser therapy (LLLT or photobiomodulation) in postexercise skeletal muscle recovery and performance enhancement and to identify the optimal dose of 810 nm LLLT.A randomized, double-blind, placebo-controlled trial was performed, with voluntary participation of 28 high-level soccer athletes. We analyzed maximum voluntary contraction (MVC), delayed onset muscle soreness (DOMS), creatine kinase (CK) activity, and interleukin-6 (IL-6) expression. The assessments were performed before exercise protocols, after 1 min, and 1, 24, 48, 72, and 96 h after the end of eccentric exercise protocol used to induce fatigue. LLLT was applied before eccentric exercise protocol with a cluster with five diodes, and dose of 10, 30, or 50 J (200 mW and 810 nm) in six sites of quadriceps.LLLT increased (p 0.05) MVC from immediately after exercise to 24 h with 50 J dose, and from 24 to 96 h with 10 J dose. Both 10 J then 50 J dose decreased (p 0.05) CK and IL-6 with better results in favor of 50 J dose. However, LLLT had no effect in decreasing DOMS. No differences (p 0.05) were found for 30 J dose in any of the outcomes measured.Pre-exercise LLLT, mainly with 50 J dose, significantly increases performance and improves biochemical markers related to skeletal muscle damage and inflammation.

Chronic obstructive pulmonary disease (COPD) can lead to severe disability as the disease advances. The 6-minute walk test (6MWT) is commonly used to measure functional capacity in COPD patients and has three potential outcomes; walking distance, oxygen desaturation, and self-perceived dyspnea assessed by the Borg scale, all reflecting different aspects of COPD. The aim of this study was to identify predictors of all 3 outcomes of 6MWT in patients with COPD.370 COPD patients, aged 40-75 yrs, were included from the first phase of the Bergen COPD cohort study. They were examined with spirometry, bioelectrical impedance measurements, 6MWT, Center for Epidemiologic Studies of Depression (CES-D) Scale, Medical Research Council (MRC) dyspnea scale, Charlson index for co-morbidities, self-reported physical activity questionnaire, plasma levels of C-reactive protein (CRP) and arterial blood gases.Significant predictors in the multivariate analyses were sex, age, FEV(1) in % predicted, symptoms of dyspnea (MRC), co-morbidities (Charlson Index) and self-reported physical activity for walking distance, FEV(1) in % predicted and PaO(2) for oxygen desaturation, and body composition, smoking and co-morbidities for self-perceived dyspnea assessed by the Borg scale.Several COPD characteristics have predictive value for the 6MWT, and some COPD characteristics are more strongly related to specific 6MWT outcomes than others.

In animal and clinical trials low-level laser therapy (LLLT) using red, infrared and mixed wavelengths has been shown to delay the development of skeletal muscle fatigue. However, the parameters employed in these studies do not allow a conclusion as to which wavelength range is better in delaying the development of skeletal muscle fatigue.With this perspective in mind, we compared the effects of red and infrared LLLT on skeletal muscle fatigue. A randomized double-blind placebo-controlled crossover trial was performed in ten healthy male volunteers. They were treated with active red LLLT, active infrared LLLT (660 or 830 nm, 50 mW, 17.85 W/cm2, 100 s irradiation per point, 5 J, 1,785 J/cm2 at each point irradiated, total 20 J irradiated per muscle) or an identical placebo LLLT at four points of the biceps brachii muscle for 3 min before exercise (voluntary isometric elbow flexion for 60 s). The mean peak force was significantly greater (p

The objective of this review was to systematically identify experimental studies of non-ablative laser irradiation (LI) on peripheral nerve morphology, physiology, and function. The findings were then evaluated with special reference to the neurophysiology of pain and implications for the analgesic effects of low-level laser therapy (LLLT).LLLT is used in the treatment of pain, and laser-induced neural inhibition has been proposed as a mechanism. To date, no study has systematically evaluated the effects of LI on peripheral nerve, other than those related to nerve repair, despite the fact that experimental studies of LI on nerves have been conducted over the past 25 years.We searched computerized databases and reference lists for studies of LI effects on animal and human nerves using a priori inclusion and exclusion criteria.We identified 44 studies suitable for inclusion. In 13 of 18 human studies, pulsed or continuous wave visible and continuous wave infrared (IR) LI slowed conduction velocity (CV) and/or reduced the amplitude of compound action potentials (CAPs). In 26 animal experiments, IR LI suppressed electrically and noxiously evoked action potentials including pro-inflammatory mediators. Disruption of microtubule arrays and fast axonal flow may underpin neural inhibition.This review has identified a range of laser-induced inhibitory effects in diverse peripheral nerve models, which may reduce acute pain by direct inhibition of peripheral nociceptors. In chronic pain, spinal cord changes induced by LI may result in long-term depression of pain. Incomplete reporting of parameters limited aggregation of data.

Background There is lack of evidence for specific treatment interventions for patients with non-specific chronic low back pain (NSCLBP) despite the substantial amount of randomised controlled clinical trials evaluating treatment outcome for this disorder. Hypothesis It has been hypothesised that this vacuum of evidence is caused by the lack of subclassification of the heterogeneous population of patients with chronic low back pain for outcome research. Study design A systematic review. Methods A systematic review with a meta-analysis was undertaken to determine the integration of subclassification strategies with matched interventions in randomised controlled clinical trials evaluating manual therapy treatment and exercise therapy for NSCLBP. A structured search for relevant studies in Embase, Cinahl, Medline, PEDro and the Cochrane Trials Register database, followed by hand searching all relevant studies in English up to December 2008. Results Only 5 of 68 studies (7.4%) subclassified patients beyond applying general inclusion and exclusion criteria. In the few studies where classification and matched interventions have been used, our meta-analysis showed a statistical difference in favour of the classification-based intervention for reductions in pain (p=0.004) and disability (p=0.0005), both for short-term and long-term reduction in pain (p=0.001). Effect sizes ranged from moderate (0.43) for short term to minimal (0.14) for long term. Conclusion A better integration of subclassification strategies in NSCLBP outcome research is needed. We propose the development of explicit recommendations for the use of subclassification strategies and evaluation of targeted interventions in future research evaluating NSCLBP.

Our aim was to investigate the immediate effects of bilateral, 830 nm, low-level laser therapy (LLLT) on high-intensity exercise and biochemical markers of skeletal muscle recovery, in a randomised, double-blind, placebo-controlled, crossover trial set in a sports physiotherapy clinic. Twenty male athletes (nine professional volleyball players and eleven adolescent soccer players) participated. Active LLLT (830 nm wavelength, 100 mW, spot size 0.0028 cm(2), 3-4 J per point) or an identical placebo LLLT was delivered to five points in the rectus femoris muscle (bilaterally). The main outcome measures were the work performed in the Wingate test: 30 s of maximum cycling with a load of 7.5% of body weight, and the measurement of blood lactate (BL) and creatine kinase (CK) levels before and after exercise. There was no significant difference in the work performed during the Wingate test (P0.05) between subjects given active LLLT and those given placebo LLLT. For volleyball athletes, the change in CK levels from before to after the exercise test was significantly lower (P = 0.0133) for those given active LLLT (2.52 U l(-1) +/- 7.04 U l(-1)) than for those given placebo LLLT (28.49 U l(-1) +/- 22.62 U l(-1)). For the soccer athletes, the change in blood lactate levels from before exercise to 15 min after exercise was significantly lower (P0.01) in the group subjected to active LLLT (8.55 mmol l(-1) +/- 2.14 mmol l(-1)) than in the group subjected to placebo LLLT (10.52 mmol l(-1) +/- 1.82 mmol l(-1)). LLLT irradiation before the Wingate test seemed to inhibit an expected post-exercise increase in CK level and to accelerate post-exercise lactate removal without affecting test performance. These findings suggest that LLLT may be of benefit in accelerating post-exercise recovery.

Background Eccentric exercises (EEs) are recommended for the treatment of Achilles tendinopathy, but the clinical effect from EE has a slow onset. Hypothesis The addition of low-level laser therapy (LLLT) to EE may cause more rapid clinical improvement. Study Design Randomized controlled trial; Level of evidence, 1. Methods A total of 52 recreational athletes with chronic Achilles tendinopathy symptoms were randomized to groups receiving either EE + LLLT or EE + placebo LLLT over 8 weeks in a blinded manner. Low-level laser therapy (Λ = 820 nm) was administered in 12 sessions by irradiating 6 points along the Achilles tendon with a power density of 60 mW/cm2 and a total dose of 5.4 J per session. Results The results of the intention-to-treat analysis for the primary outcome, pain intensity during physical activity on the 100-mm visual analog scale, were significantly lower in the LLLT group than in the placebo LLLT group, with 53.6 mm versus 71.5 mm ( P = .0003) at 4 weeks, 37.3 mm versus 62.8 mm ( P = .0002) at 8 weeks, and 33.0 mm versus 53.0 mm ( P = .007) at 12 weeks after randomization. Secondary outcomes of morning stiffness, active dorsiflexion, palpation tenderness, and crepitation showed the same pattern in favor of the LLLT group. Conclusion Low-level laser therapy, with the parameters used in this study, accelerates clinical recovery from chronic Achilles tendinopathy when added to an EE regimen. For the LLLT group, the results at 4 weeks were similar to the placebo LLLT group results after 12 weeks.

Background Pain is the most debilitating symptom in osteoarthritis of the knee (OAK). Aim and methods To determine the short-term pain-relieving effects of seven commonly used pharmacological agents for OAK pain by performing a systematic review of randomised placebo-controlled trials. Results In total, 14,060 patients in 63 trials were evaluated. Opioids and oral NSAIDs therapy in patients with moderate to severe pain (mean baseline 64.3 and 72.8 mm on VAS respectively) had maximum efficacies compared to placebo at 2–4 weeks of 10.5 mm [95% CI: 7.4–13.7] and 10.2 mm [95% CI: 8.8–11.2] respectively. The efficacy of opioids may be inflated by high withdrawal rates (24–50%) and “best-case” scenarios reported in intention-to-treat analyses. In patients with moderate pain scores on VAS (mean range from 51 to 57 mm), intra-articular steroid injections and topical NSAIDs had maximum efficacies at 1–3 weeks of 14.5 mm [95% CI: 9.7–19.2] and 11.6 mm [95% CI: 7.4–15.7], respectively. Paracetamol, glucosamin sulphate and chondroitin sulphate had maximum mean efficacies at 1–4 weeks of only 4.7 mm or lower. Heterogeneity tests revealed that best efficacy values of topical NSAIDs may be slightly deflated, while data for oral NSAIDs may be slightly inflated due to probable patient selection bias. Conclusion Clinical effects from pharmacological interventions in OAK are small and limited to the first 2–3 weeks after start of treatment. The pain-relieving effects over placebo in OAK are smaller than the patient-reported thresholds for relevant improvement.

Background and Purpose. It is not fully understood how transcutaneous electrical nerve stimulation (TENS) intensity affects mechanical pain threshold. Method. Sixty-six healthy volunteers (13 male, 53 female; 132 hands) without prior experience of TENS participated in the study, which comprised a randomized single-blind controlled trial. TENS was administered for 20 minutes through electrodes (25 × 25 mm) placed on the hands and forearms with a fixed frequency of 100 Hz and pulse duration of 150 µs. TENS intensity was randomized and allocated in a concealed manner so that one arm received TENS with stimulation intensity set at participants' subjective sensory threshold and the other received TENS with stimulation intensity continuously adjusted by physiotherapists to a strong but comfortable non-painful stimulation. Observers were blinded to stimulation intensity levels. Results. Mechanical pain threshold increased significantly, by a mean total of 0.79 kg/cm2 (95% confidence interval [95% CI]: 0.54–1.04) (p < 0.001) on the strong but comfortable non-painful stimulation side. The mean change in mechanical pain threshold on the sensory threshold side was 0.19 kg/cm2 and did not reach statistical significance (95% CI–0.15 to 0.51). The mean stimulation intensity level for sensory threshold was 6.7 mA (95% CI: 5.65 to 7.83) which was significantly lower (p < 0.001) than the mean stimulation intensity for the strong stimulation, which was 20.5 mA (95% CI 16.6 to 24.4), respectively. The strong stimulation levels were, on average, 3.05 times higher than sensory threshold, but individual variations were large (range 1.2–6.1). Conclusions. TENS administered at a strong but comfortable non-painful stimulation intensity increases mechanical pain threshold ipsi-laterally in healthy subjects, whereas TENS administered at sensory threshold intensity does not. TENS may be ineffective if electrodes are placed contralaterally or distant to the pain site and if stimulation intensity levels are not titrated to subjective strong levels. Further clinical trials are needed to clarify if these findings may also be generalized to populations of chronic pain sufferers. Copyright © 2007 John Wiley & Sons, Ltd.

International audience; Objective: The objective of this study was to evaluate the effect of laser irradiation on dog bone marrow stem cells. Background data: Low doses of low-level red laser positively affect the viability of mesenchymal stem cells, and also increase proliferation. Methods: Low-level laser (wavelength, 660nm; power output, 50mW), was applied to dog bone marrow stem cell cultures (DBMSC). The energy densities delivered varied from 1 to 12J/cm(2). The effect of the laser irradiation was evaluated on cell proliferation measured with the MTT colorimetric test, cell cycle phase, and on lipidic peroxidation (free radical production). Results: The results indicate that laser irradiation to DBMSC did not change the morphology of the cells, but significantly increased their viability and the number of cells at the G2/M phase with 6, 10, and 12J/cm(2). On the other hand, malonaldehyde production was significantly enhanced with 8J/cm(2). Conclusions: The parameters used to irradiate DBMSC increased significantly proliferation without producing high levels of reactive oxygen species (ROS).

[ Editor's note: Both the letter to the editor by Bjordal and colleagues and the response by White and colleagues are commenting on the author manuscript version of the article that was published ahead of print September 15, 2014. ] We have read “The American Physical Therapy Association's Top Five Choosing Wisely Recommendations”1 (CWR) with interest. The article will probably have great impact as an official white paper originating from APTA, and it joins a national initiative aimed at reducing health care costs across professions. This is an important and timely initiative, and it is welcomed. The first of the 5 specific recommendations is to limit the use of “passive” physical agents (PAs) because: “A carefully designed active treatment plan has a greater impact on pain, mobility, function, and quality of life.” Within our profession, other interventions such as massage, manipulation, and mobilization also are “passive” modalities (cf, exercise), but they are very seldom labeled as such. Similarly, analgesic medications, injections, and surgery also are “passive” treatments. All of these non–physical therapy-related interventions come with higher risk than physical agents or even manual therapies. Physical agents can provide safe, low-cost management as an alternative to analgesic medications or more invasive procedures, such as injections or surgery. Some physical agents also can be provided to the patient for home use as part of a self-management plan. Additionally, this recommendation is not based on the best available evidence. It is important to remember that the framework for CWR demands identification of certain tests or treatments commonly used “in the absence of evidence demonstrating benefit.” The ABIM Foundation even strengthens the evidence criterion to say that: “there is strong evidence that demonstrates that the service offers no benefit to most patients.”1 The first CWR states, “Don't use passive physical agents except …

The aim of this study was to review the biological and clinical short-term effects of photoradiation in acute pain from soft-tissue injury.It is unclear if and how photoradiation can reduce acute pain.Literature search of (i) controlled laboratory trials investigating potential biological mechanisms for pain relief and (ii) randomized placebo-controlled clinical trials which measure outcomes within the first 7 days after acute soft-tissue injury.There is strong evidence from 19 out of 22 controlled laboratory studies that photoradiation can modulate inflammatory pain by reducing levels of biochemical markers (PGE(2), mRNA Cox 2, IL-1beta, TNFalpha), neutrophil cell influx, oxidative stress, and formation of edema and hemorrhage in a dose-dependent manner (median dose 7.5 J/cm(2), range 0.3-19 J/cm(2)). Four comparisons with non-steroidal anti-inflammatory drugs (NSAIDs) in animal studies found optimal doses of photoradiation and NSAIDs to be equally effective. Seven randomized placebo-controlled trials found no significant results after irradiating only a single point on the skin overlying the site of injury, or after using a total energy dose below 5 Joules. Nine randomized placebo-controlled trials (n = 609) were of acceptable methodological quality, and irradiated three or more points and/or more than 2.5 cm(2) at site of injury or surgical incision, with a total energy of 5.0-19.5 Joules. Results in these nine trials were significantly in favor of photoradiation groups over placebo groups in 15 out of 18 outcome comparisons. Poor and heterogeneous data presentation hampered statistical pooling of continuous data. Categorical data of subjective improvement were homogeneous (Q-value = 7.1) and could be calculated from four trials (n = 379) giving a significant relative risk for improvement of 2.7 (95% confidence interval [CI], 1.8-3.9) in a fixed effects model.photoradiation can modulate inflammatory processes in a dose-dependent manner and can be titrated to significantly reduce acute inflammatory pain in clinical settings. Further clinical trials with adequate photoradiation doses are needed to precisely estimate the effect size for photoradiation in acute pain.

Background: Low level laser therapy (LLLT) has gained increasing popularity in the management of tendinopathy and arthritis. Results from in vitro and in vivo studies have suggested that inflammatory modulation is one of several possible biological mechanisms of LLLT action. Objective: To investigate in situ if LLLT has an anti-inflammatory effect on activated tendinitis of the human Achilles tendon. Subjects: Seven patients with bilateral Achilles tendinitis (14 tendons) who had aggravated symptoms produced by pain inducing activity immediately before the study. Method: Infrared (904 nm wavelength) LLLT (5.4 J per point, power density 20 mW/cm 2 ) and placebo LLLT (0 J) were administered to both Achilles tendons in random blinded order. Results: Ultrasonography Doppler measurements at baseline showed minor inflammation through increased intratendinous blood flow in all 14 tendons and measurable resistive index in eight tendons of 0.91 (95% confidence interval 0.87 to 0.95). Prostaglandin E 2 concentrations were significantly reduced 75, 90, and 105 minutes after active LLLT compared with concentrations before treatment (p = 0.026) and after placebo LLLT (p = 0.009). Pressure pain threshold had increased significantly (p = 0.012) after active LLLT compared with placebo LLLT: the mean difference in the change between the groups was 0.40 kg/cm 2 (95% confidence interval 0.10 to 0.70). Conclusion: LLLT at a dose of 5.4 J per point can reduce inflammation and pain in activated Achilles tendinitis. LLLT may therefore have potential in the management of diseases with an inflammatory component.

The aim of this study was to test if a conclusion in a systematic review of low-level laser therapy (LLLT) for osteoarthritis from the Cochrane Library was valid and robust.Health policy decisions often rely on conclusions from the Cochrane Database of Systematic Reviews for approval of new therapies, although their validity for controversial non-pharmacological treatment has been questioned.Validity was tested against a nine-item checklist for systematic reviews. Review selections were analyzed for possible discrepancies between trial and review reports, and omissions of relevant trials and data. Alternative data from discrepancies and omissions were then imputed in a sensitivity analysis, to test if review conclusions were robust.Only clinicians who had performed LLLT trials with negative results were invited into the review group. Review quality was sound in areas of literature search and methodological assessments, and some of the limitations were mentioned. The statistical analysis held 18 questionable selections such as omissions of trials, data, and subgroup analyses. These selections systematically favored the negative review conclusion. Without altering the review protocol, the sensitivity analysis of combined results changed to significantly positive for continuous and categorical data when data from all included trials were combined. Further sensitivity analyses with inclusion of valid non-included trials, performance of missing follow-up, and subgroup analyses revealed consistent and highly significant results in favor of active LLLT.In this example, the Cochrane review conclusion was neither robust nor valid. Representation of experts and different views on efficacy in the review group and extensive use of sensitivity analyses could probably improve quality control of reviews in areas of controversy.

Aim. We investigated the literature of randomised placebo-controlled trials to find out if transcutaneous electrical nerve stimulation (TENS) or acupuncture-like transcutaneous electrical nerve stimulation (ALTENS) can reduce analgesic consumption after surgery. Results. Subgroup analysis for adequate treatment (pulse frequency: 1–8 Hz [ALTENS] or 25–150 Hz [TENS], current intensity: ‘‘strong, definite, subnoxious, maximal tolerable’’ or above 15 mA, and electrode placement in the incision area) were performed. Twenty-one randomised, placebo-controlled trials with a total of 1350 patients were identified. For all trials, the mean reduction in analgesic consumption after TENS/ALTENS was 26.5% (range )6 to +51%) better than placebo. Eleven of the trials compromising 964 patients, had reports which stated that a strong, subnoxious electrical stimulation with adequate frequency was administered. They reported a mean weighted reduction in analgesic consumption of 35.5% (range 14–51%) better than placebo. In nine trials without explicit confirmation of sufficient current intensity and adequate frequency, the mean weighted analgesic consumption was 4.1% (range )10 to +29%) in favour of active treatment. The difference in analgesic consumption was significantly ðp ¼ 0:0002Þ in favour of adequate stimulation. The median frequencies used in trials with optimal treatment was 85 Hz for TENS and 2 Hz in the only trial that investigated ALTENS. Conclusion. TENS, administered with a strong, subnoxious intensity at an adequate frequency in the wound area, can significantly reduce analgesic consumption for postoperative pain. 2002 European Federation of Chapters of the International Association for the Study of Pain. Published by Elsevier Science Ltd. All rights reserved.

Background Recent studies involving phototherapy applied prior to exercise have demonstrated positive results regarding the attenuation of muscle fatigue and the expression of biochemical markers associated with recovery. However, a number of factors remain unknown, such as the ideal dose and application parameters, mechanisms of action and long-term effects on muscle recovery. The aims of the proposed project are to evaluate the long-term effects of low-level laser therapy on post-exercise musculoskeletal recovery and identify the best dose andapplication power/irradiation time. Design and methods A double-blind, randomized, placebo-controlled clinical trial with be conducted. After fulfilling the eligibility criteria, 28 high-performance athletes will be allocated to four groups of seven volunteers each. In phase 1, the laser power will be 200 mW and different doses will be tested: Group A (2 J), Group B (6 J), Group C (10 J) and Group D (0 J). In phase 2, the best dose obtained in phase 1 will be used with the same distribution of the volunteers, but with different powers: Group A (100 mW), Group B (200 mW), Group C (400 mW) and Group D (0 mW). The isokinetic test will be performed based on maximum voluntary contraction prior to the application of the laser and after the eccentric contraction protocol, which will also be performed using the isokinetic dynamometer. The following variables related to physical performance will be analyzed: peak torque/maximum voluntary contraction, delayed onset muscle soreness (algometer), biochemical markers of muscle damage, inflammation and oxidative stress. Discussion Our intention, is to determine optimal laser therapy application parameters capable of slowing down the physiological muscle fatigue process, reducing injuries or micro-injuries in skeletal muscle stemming from physical exertion and accelerating post-exercise muscle recovery. We believe that, unlike drug therapy, LLLT has a biphasic dose–response pattern. Trial registration The protocol for this study is registered with the Protocol Registry System, ClinicalTrials.gov identifier NCT01844271.

Some conclusions from the Cochrane Database of Systematic Reviews (CDSR) seem volatile in areas of controversy and have recently changed conclusions. With this perspective in mind we decided to test the validity and sensitivity of negative conclusions in a systematic review of low-level laser therapy (LLLT) for osteoarthritis (OA) from the Cochrane Library was valid and robust.None as this was a systematic review of literature.Validity was tested against a 9-item checklist for systematic reviews. Review selections were analyzed for possible discrepancies between trial and review reports and omissions of relevant trials and data. Data from discrepancies and omissions were then entered into sensitivity and subgroup analyses.Continuous and dichotomous data for painPatients with osteoarthritis.LLLT.Only clinicians who had performed LLLT trials, and had negative results were invited into the review group. The review was oblivious to findings published after 1993 about physiologic mechanisms and dose response patterns for LLLT. We found 18 questionable selections that favored a negative review conclusion in 17 of 18 cases. These were largely omissions of relevant positive data and selective inclusion of negative data from trials with small, ineffective doses. When existing and omitted data from relevant trials were combined, results changed from negative to significantly positive for continuous and categorical data. Subgrouping trials by location and recommended doses taken from current guidelines, revealed a highly significant effect of LLLT for treating knee OA.The results of this CDSR was not robust and seems to be colored by questionable selections or omissions. For alternative pain therapies, it should be considered if lack of expertise on therapy mechanisms, or conflicts of interests with competing pain drug manufacturers, may bias conclusions. Review groups should recruit a balanced mix of current views and expertise and expand the use of sensitivity analyses to improve quality of CDSRs in areas of controversy.

Background and Purpose Low-level laser therapy (LLLT) is proposed as a treatment for tendinopathies. This is the first systematic review focusing solely on LLLT treatment effects in shoulder tendinopathy. Methods A systematic review with meta-analysis and primary outcome measures pain relief on 100-mm visual analogue scale (VAS) and relative risk for global improvement. Two independent assessors rated the included studies according to the PEDro scale. Intervention quality assessments were performed of LLLT dosage and treatment procedures according to World Association for Laser Therapy guidelines. The included trials were sub-grouped by intervention quality and use of other physiotherapy interventions. Results Seventeen randomized controlled trials (RCTs) met the inclusion criteria, and 13 RCTs were of high and 4 RCTs of moderate methodological quality. Significant and clinically important pain relief was found with weighted mean differences (WMD) over placebo, for LLLT as monotherapy at 20.41 mm (95% CI: 12.38 to 28.44) and as adjunct to exercise therapy at 16.00 mm (95% CI: 11.88 to 20.12). The WMD when LLLT was used in a multimodal physiotherapy treatment regime reached statistical significance over placebo at 12.80 (95% CI: 1.67–23.94) mm pain reduction on VAS. Relative risks for global improvement were statistically significant at 1.96 (95% CI: 1.25–3.08) and 1.51 (95% CI: 1.12–2.03), for laser as monotherapy or adjunctive in a physiotherapy regime, respectively. Secondary outcome measures of shoulder function were only significantly in favour of LLLT when used as monotherapy. Trials performed with inadequate laser doses were ineffective across all outcome measures. Conclusion This review shows that optimal LLLT can offer clinically relevant pain relief and initiate a more rapid course of improvement, both alone and in combination with physiotherapy interventions. Our findings challenge the conclusions in previous multimodal shoulder reviews of physiotherapy and their lack of intervention quality assessments. Copyright © 2014 John Wiley & Sons, Ltd.

We will deal with the most serious issue first. KadhimSaleh et al. excluded a study from one of our investigating team stating that “We further excluded Chow et al. [3] because it most likely included the same cohort as Chow et al. [4]”. this serious error would not have occurred if the reviewers were diligent in their processes. the published trial reports clearly stated that one cohort was recruited in 1998 and 1999, and the other cohort recruited in 2002–2003. Rather than contacting the trial authors to resolve uncertainty about the cohorts, which is normal practice for systematic reviewers Kadhim-Saleh et al. decided to base their decision on guess work, clearly not stringent reviewing practice. the hopefully unintentional insinuation that Chow and colleagues duplicated a cohort and included these duplicates as if they were separate cohorts in a subsequent meta-analysis published in the Lancet should be retracted. Kadhim-Saleh et al. criticize our previous meta-analysis because “... investigators included trials that used different and more subjective tools for assessing the primary pain outcome measure. p2494”. In fact we included studies that used several well-recognized and validated scales for pain assessment. this included calculating weighted mean difference for continuous data from visual analogues scale (VAS) scores for pain intensity, relative risk for dichotomized data for global improvement, and standardized mean difference to combine different validated scales of disability including the Neck Disability Index, Neck Disability Scale and the Northwick Park Questionnaire. this enabled us to conduct a comprehensive analysis of the available evidence and we believe that our finding that the results were consistent across the different measurement tools strengthened the robustness of our conclusion. Kadhim-Saleh et al. used a single outcome measure at a single time-point as their only outcome measure of success. We are concerned Dear editor

We did a retrospective study of all anterior cruciate ligament injuries (972) verified by arthroscopic evalu ation at hospitals in the Hordaland region of Norway from 1982 to 1991. Our final study group comprised 176 patients who had participated in organized soccer and answered a questionnaire. The overall incidence rate was 0.063 injuries per 1000 game hours. Men incurred 75.6% (133) of the injuries. Women had an incidence rate of 0.10 injuries per 1000 game hours, significantly higher than that for men (0.057). The inci dence rate was higher (0.41) for men in the top three divisions. Most of the injuries (124) occurred during games. Contact injuries from tackling was the injury mechanism in 46.0% of the cases. Players on the offensive team incurred 122 (69.3%) of the injuries. Reconstructive surgery was performed on 131 (74.4%) of the injured players and was found necessary for return to a high level of play. Half of the players (87) returned to soccer; men at high levels of play had the highest return rate (88.9%), and men over age 34 had the poorest return rate (22.9%). Nearly one-third of the injured athletes gave up soccer because of poor knee function or fear of new injury.

Recent studies have explored if phototherapy with low-level laser therapy (LLLT) or narrow-band light-emitting diode therapy (LEDT) can modulate activity-induced skeletal muscle fatigue or subsequently protect against muscle injury. We performed a systematic review with meta-analysis to investigate the effects of phototherapy applied before, during and after exercises. A literature search was performed in Pubmed/Medline database for randomized controlled trials (RCTs) published from 2000 through 2012. Trial quality was assessed with the ten-item PEDro scale. Main outcome measures were selected as: number of repetitions and time until exhaustion for muscle performance, and creatine kinase (CK) activity to evaluate risk for exercise-induced muscle damage. The literature search resulted in 16 RCTs, and three articles were excluded due to poor quality assessment scores. From 13 RCTs with acceptable methodological quality (≥6 of 10 items), 12 RCTs irradiated phototherapy before exercise, and 10 RCTs reported significant improvement for the main outcome measures related to performance. The time until exhaustion increased significantly compared to placebo by 4.12 s (95% CI 1.21-7.02, p 0.005) and the number of repetitions increased by 5.47 (95% CI 2.35-8.59, p 0.0006) after phototherapy. Heterogeneity in trial design and results precluded meta-analyses for biochemical markers, but a quantitative analysis showed positive results in 13 out of 16 comparisons. The most significant and consistent results were found with red or infrared wavelengths and phototherapy application before exercises, power outputs between 50 and 200 mW and doses of 5 and 6 J per point (spot). We conclude that phototherapy (with lasers and LEDs) improves muscular performance and accelerate recovery mainly when applied before exercise.

Physiotherapists are expected to practice in an evidence-based way. Evidence-based practice (EBP) should be an integral part of the curriculum to ensure use of the five EBP steps: asking clinical questions, searching for and appraising research evidence, integrating the evidence into clinical practice and evaluating this process. The aim of this study was to compare self-reported EBP behaviour, abilities and barriers during clinical placements reported by five cohorts of final year physiotherapy students' with different EBP exposure across the 3-year bachelor programme.A cross-sectional study was conducted among five cohorts (2006-2010) with third year physiotherapy students at a University College in Norway. In total, 246 students were eligible for this study. To collect data, we used a questionnaire with 42 items related to EBP behaviour, ability and barriers. Associations were investigated using the Spearman's rho (r).In total, 180 out of 246 third year physiotherapy students, who had recently completed a clinical placement, filled out the questionnaire (73 %). The association between the level of EBP exposure and students' self-reported EBP behaviour, abilities and barriers was low for most items in the questionnaire. Statistically significant correlations were found for eight items, related to information need, question formulation, use of checklists, searching and perceived ability to search for and critically appraise research evidence. The strongest correlation was found between the level of EBP exposure and ability to critically appraise research evidence (r = 0.41, p 0.001).An association between the level of EBP exposure and physiotherapy students' EBP behaviour was found for elements such as asking and searching, ability to search for and critically appraise research evidence, and experience of critical appraisal as a barrier. Further research need to explore strategies for EBP exposure throughout the curriculum, regarding content, timing, amount and type of training.

It is very encouraging that the annual scientific output now is exceeding 400 publications about laser phototherapy. This is a 20-fold increase from publication rates for low-level laser therapy (LLLT) a decade ago. Six years ago, another editorial in the journal announced that ‘‘low-level laser therapy’’ is not low, and a debate to change this MeSH term was initiated. At the time, we were worried that ’’low level’’ would be associated with inferior scientific quality.. With the progress that has been made in terms of scientific output, and LLLT publications in high-ranked medical journals, this fear has somewhat ceased. Some guidelines and reputed treatment advisory boards (American Physical Therapy Association, National Cancer Institute, Clinical Evidence at BMJ) now recommend varying strengths of LLLT use for conditions such as Achilles tendinopathy, cancer-therapyinduced oral mucositis, and tennis elbow. Still, the most crucial factors for treatment effects are optimal dosing and hitting a sufficient part of the target pathology. In the Cochrane Database of Systematic Reviews, two of three LLLT reviews fail to address the issue of dosing. It is, however, encouraging that one systematic review cites the guidelines of World Association for Laser Therapy (WALT) and addresses dosage by subgrouping trials by doses that are optimal and ones that are not. The review’s overall conclusion is inconclusive and contains only the usual phrase, stating that more studies are needed. However, the ‘‘implications for practice’’ are more descriptive to read. The authors find that although LLLT may be beneficial for pain relief and disability, they also insist that LLLT should not substituted for other beneficial interventions in low back pain. In the jungle of potentially harmful low back pain interventions, I wonder why it is so important to discourage clinical use of LLLT, which the review otherwise finds both harmless and modestly effective. The evidence-based WALT guidelines for LLLT dosage in musculoskeletal disorders were published for the first time in August 2005. What makes the WALT guidelines stronger than guidelines for other empirically based modalities such as acupuncture, is that sound and credible biological mechanisms can explain LLLT actions. The therapeutic windows were first identified by careful investigation of dose– response patterns in pre-clinical studies. For soft tissue inflammation and soft tissue repair, we found consistent evidence of effects from several independent research groups. These pre-clinical findings, combined with the results from clinical LLLT studies, form the rationale for WALT dosage recommendations. The idea with the first generation of WALT guidelines was that they would serve two purposes. On the one hand they could serve as a treatment guide to clinicians, and on the other hand, they could make it possible to identify trials with obviously ineffective doses. The latter was needed because there are a great number of published trials with low fidelity caused by errors in dosing and treatment procedures. These low-fidelity LLLT trials would invariably be included in systematic reviews and meta-analyses such as the Cochrane reviews, which ended up with largely negative conclusions. Before 2005, LLLT devices were largely operating with mean outputs in the lower part of the Class 3 B range and we did not know if there were upper limits for effective doses. To serve both these purposes, we decided to design the first WALT guidelines with minimum dose thresholds for effectiveness. Since 2005, a new generation of more powerful LLLT devices has entered the market. Several dose-finding laboratory studies have recently shown us that more is not necessarily better, and that the positive effects may in fact be lost in overdosing LLLT. This development has prompted us to take the WALT guidelines one step further. I think that the first-generation guidelines served well, and they were also validated by a review finding that 91% of tendinopathy trials with WALT-recommended doses reported positive effects. The value of WALT dosage recommendations to predict clinical effectiveness also led to the discovery of a massive attempt at fraudulent publication. I received two manuscripts for review from different journals, and both reported significant results in spite of LLLT doses well below the threshold normally needed for effectiveness. My skepticism led to a closer scrutiny of the results, and they proved to report exactly the same mean and variance results in both manuscripts. This is a statistical coincidence that is almost impossible in real life. Further explorations revealed that several manuscripts from the same source, with forged results and plagiarized text, were in editorial circulation. With the joint efforts of editors they were stopped and the superiors of the source were informed for further judgment. There are now at least 125 randomized controlled trials investigating the pain-relieving effects of LLLT. Where possible, we have calculated the doses in most of these trials and

Objectives: To estimate the effects of low level laser therapy in combination with a programme of exercises on pain, functionality, range of motion, muscular strength and quality of life in patients with osteoarthritis of the knee. Design: A randomized double-blind placebo-controlled trial with sequential allocation of patients to different treatment groups. Setting: Special Rehabilitation Services. Subjects: Forty participants with knee osteoarthritis, 2–4 osteoarthritis degree, aged between 50 and 75 years and both genders. Intervention: Participants were randomized into one of two groups: the laser group (low level laser therapy dose of 3 J and exercises) or placebo group (placebo laser and exercises). Main measures: Pain was assessed using a visual analogue scale (VAS), functionality using the Lequesne questionnaire, range of motion with a universal goniometer, muscular strength using a dynamometer, and activity using the Western Ontario and McMaster Universities Osteoarthritis (WOMAC) questionnaire at three time points: (T1) baseline, (T2) after the end of laser therapy (three weeks) and (T3) the end of the exercises (11 weeks). Results: When comparing groups, significant differences in the activity were also found ( P = 0.03). No other significant differences ( P > 0.05) were observed in other variables. In intragroup analysis, participants in the laser group had significant improvement, relative to baseline, on pain ( P = 0.001), range of motion ( P = 0.01), functionality ( P = 0.001) and activity ( P Conclusion: Our findings suggest that low level laser therapy when associated with exercises is effective in yielding pain relief, function and activity on patients with osteoarthritis of the knees.

The management of neuropathic pain is challenging, with medication being the first-line treatment. Transcutaneous electrical nerve stimulation (TENS) is an inexpensive, noninvasive, self-administered technique that is used as an adjunct to medication. Clinical experience suggests that TENS is beneficial providing it is administered at a sufficiently strong intensity, close to the site of pain. At present, there are too few randomized controlled trials on TENS for neuropathic pain to judge effectiveness. The findings of systematic reviews of TENS for other pain syndromes are inconclusive because trials have a low fidelity associated with inadequate TENS technique and infrequent treatments of insufficient duration. The use of electrode arrays to spatially target stimulation more precisely may improve the efficacy of TENS in the future.

The purpose of the study is to compare the effect in healthy young adults of two resistance training protocols, six-repetition maximum (RM) versus 12RM on maximum strength (1RM).A single-blind, randomized controlled trial was used in the study. Sixty-two healthy physical therapy students, with age (mean [+standard deviation]) 23 (+2.6) years, weight 67.4 (+11.7) kg and height 171.7 (+8.4) cm, of both genders who were recreationally active, but not training systematically, volunteered to participate in the study. They were randomized into two groups (group 1: 24 women and 8 men; group 2: 23 women and 7 men) by a block randomization procedure that ensured equal gender distribution. Sealed envelopes were used to conceal allocation to groups.Group 1 did three sets of 6RM of each exercise, and group 2 did three sets of 12RM. Both groups performed the exercises twice per week for 8 weeks with 3 minutes rest between sets and exercises. Primary outcomes were maximum strength defined as one-repetition maximum squat (1RMSq) for lower-body strength and bench press (1RMBp) for upper-body strength. Secondary outcomes were body weight and Uro Kaleva Kekkonen (UKK) Fitness Index.Both groups increased strength significantly (p 0.001) in 1RMSq (6RM 13.6%, 12RM 13.5%) and 1RMBp (6RM 9.2%, 12RM 8.4%). There was no significant difference in the change between the two groups, no change in body weight and only a small increase in UKK Fitness Index.Both 6RM and 12RM training protocols improve maximum strength in recreationally active healthy young adults, with no significant difference between the protocols.

This is a copy of an article published in the Photomedicine and Laser Surgery © 2011 copyright Mary Ann Liebert, Inc.; Photomedicine and Laser Surgery is available online at: http://online.liebertpub.com Objective: To investigate the effect of therapeutic infrared class 3B laser irradiation on skin temperature in healthy participants of differing skin color, age, and gender. Background: Little is known about the potential thermal effects of Low Level Laser Therapy (LLLT) irradiation on human skin. Methods: Skin temperature was measured in 40 healthy volunteers with a thermographic camera at laser irradiated and control (non-irradiated) areas on the skin. Six irradiation doses (2–12 J) were delivered from a 200mW, 810nm laser and a 60mW, 904nm laser, respectively. Results: Thermal effects of therapeutic LLLT using doses recommended in the World Association for Laser Therapy (WALT) guidelines were insignificant; below 1.58C in light, medium, and dark skin. When higher irradiation doses were used, the 60mW, 904 nm laser produced significantly (p

There are 13 authors. Only a few of them have been given author entries in addition to the Collaboration. In the last years, phototherapy has becoming a promising tool to improve skeletal muscle recovery after exercise, however, it was not compared with other modalities commonly used with this aim. In the present study we compared the short-term effects of cold water immersion therapy (CWIT) and light emitting diode therapy (LEDT) with placebo LEDT on biochemical markers related to skeletal muscle recovery after high-intensity exercise. A randomized double-blind placebo-controlled crossover trial was performed with six male young futsal athletes. They were treated with CWIT (5°C of temperature [SD ±1°]), active LEDT (69 LEDs with wavelengths 660/ 850 nm, 10/30 mWof output power, 30 s of irradiation time per point, and 41.7 J of total energy irradiated per point, total of ten points irradiated) or an identical placebo LEDT 5 min after each of three Wingate cycle tests. Pre-exercise, post-exercise, and post-treatment measurements were taken of blood lactate levels, creatine kinase (CK) activity, and Creactive protein (CRP) levels. There were no significant differences in the work performed during the three Wingate tests (p>0.05). All biochemical parameters increased from baseline values (p

Randomized crossover double-blinded placebo-controlled trial.To investigate if low-level laser therapy (LLLT) can affect biceps muscle performance, fatigue development, and biochemical markers of postexercise recovery.Cell and animal studies have suggested that LLLT can reduce oxidative stress and inflammatory responses in muscle tissue. But it remains uncertain whether these findings can translate into humans in sport and exercise situations.Nine healthy male volleyball players participated in the study. They received either active LLLT (cluster probe with 5 laser diodes; lambda = 810 nm; 200 mW power output; 30 seconds of irradiation, applied in 2 locations over the biceps of the nondominant arm; 60 J of total energy) or placebo LLLT using an identical cluster probe. The intervention or placebo were applied 3 minutes before the performance of exercise. All subjects performed voluntary elbow flexion repetitions with a workload of 75% of their maximal voluntary contraction force until exhaustion.Active LLLT increased the number of repetitions by 14.5% (mean +/- SD, 39.6 +/- 4.3 versus 34.6 +/- 5.6; P = .037) and the elapsed time before exhaustion by 8.0% (P = .034), when compared to the placebo treatment. The biochemical markers also indicated that recovery may be positively affected by LLLT, as indicated by postexercise blood lactate levels (P.01), creatine kinase activity (P = .017), and C-reactive protein levels (P = .047), showing a faster recovery with LLLT application prior to the exercise.We conclude that pre-exercise irradiation of the biceps with an LLLT dose of 6 J per application location, applied in 2 locations, increased endurance for repeated elbow flexion against resistance and decreased postexercise levels of blood lactate, creatine kinase, and C-reactiveprotein.Performance enhancement, level 1b.