Key words: low level laser therapy, MLS therapy, abarticular rheumatism, shoulder periarthritis, tendinitis, epicondylitis, bursitis. Energy for Health [08]

movement (abduction is the most painful movement), limitation of movements, Efficiency of MLS muscular contraction, which may generate the blockage of the shoulder. therapy in abarticular Burses are located among tendons, muscles, ligaments and bones, in the areas where tendons and muscles pass by rheumatism several bone eminences. Their role is to reduce friction between these anatomic structures in movement, smoothing the revealed by digital slide and facilitating the moves. There are 80 burses on each side of the human body. The burse inflammation causes thermography and bursitis. There are multiple causes that may lead to their occurrence: overstraining (exercising excessive friction forces), vicious positions (“cleaning woman’s visual analog scale. knee”, “policeman’s heel”), direct traumatisms; some bursites may represent A. Momanu, A. Csapo the manifestation of a systemic disease, Physiotherapy and Rehabilitation Centre “FIZIOMEDICA” Iasi, Romania such as rheumatoid polyarthritis or gout (in gout, the olecranian and prepatelar burses are the most frequently affected Abstract Introduction ones). The clinical symptomatology of A lot of 22 patients with acute pathology Abarticular rheumatism represents the bursitis is dominated by pain, which soft-tissue injuries (shoulder periarthritis, inflammatory suffering of periarticular has the following characteristics: it is tendinitis, epicondylitis, bursitis), which soft tissues (muscles, tendons, ligaments, spontaneous or caused by pain or by was divided into two groups. The first burses). The clinical expression is the the pressure upon the bursa, it is more group (G1) received treatment with stiffness and pain of the affected areas. intense at night, and it may irradiate to conventional electrotherapy (interferential The causes include physical overstraining, the related limb; in the case of superficial or diadynamics current, ultrasound) wear, tissular degeneration. The clinical bursites (olecranian bursa, prepatelar and 100 mW laser. The second group forms are: periarthritis, bursitis, tendinitis, bursa), the inflammation generates their myositis, and epicondylitis. tumefaction; the inflammation of the (G2), received conventional therapy burses located nearby joints generated electrotherapy and MLS therapy. The aim The most frequent form of periarthritis is a certain degree of joint stiffness. The of this study was to compare the anthalgic the scapula-humeral periarthritis due to topographic perspective reveals numerous and anti-inflammatory effect of the MLS the anatomic characteristics of this joint, forms of bursitis. The most frequent and laser therapy and the mono-channel laser which provides great mobility. The most most important locations are at limbs treatment in abarticular rheumatism, by frequent causes are the degenerative (“goosefoot” bursitis, trochanteric bursitis, digital thermography (outlining the local lesions of tendons (especially those of prepatellar bursitis – “cleaning woman’s anti-inflammatory effect by the decrease supraspinatus and biceps), characterized bursitis”, achilian bursitis, calcaneal in the cutaneous temperature), soft tissue by necrosis, which lead to partial fractures bursitis, hallux bursitis, subdeltoid bursitis, echography (visualization of tissular and calcifications. The wearing processes olecranian bursitis). modifications) and by clinical methods are frequent in people more than 40 years (the visual analogue pain scale). The of age, but they are generally clinically Tendinitis and tenosynovitis represent decrease of VAS values to 5 or 10 days masked; in the presence of certain factors an inflammation of tendons, of synovial of treatment is more important for MLS (traumatisms, exposures to cold and wet theca, respectively, covering the muscle therapy. It is also apparent decrease in conditions), an inflammatory process tendons. De Quervain tenosynovitis and the temperature difference between the also occurs, followed by fibrosis. Clinical epicondylitis are the most frequent ones. affected and the healthy area. signs: localized or diffuse pain, suddenly Tenosynovitis of the short extensor and or insidiously installed, emphasized in long abductor muscles of the thumb

12 Efficiency of MLS therapy in abarticular rheumatism revealed by digital thermography and visual analog scale Energy for Health [08]

is also named De Quervain disease. The anti-inflammatory and anti- for instance), facilitating the repairing Patients find it difficult to hold objects in edematous effect. Lasers may influence processes. [13] their hand, and they cannot lift weights. the inflammation mechanisms at different In comparison to the classical laser Lateral epicondylitis frequently occurs at levels. First of all, an active hyperemia is therapy, the MLS therapy has several tennis players, due to the degenerative produced by the increased diameter and special characteristics: it combines laser modifications of the tendon from the the decreased permeability of lymphatic emissions with two wavelengths (808 and common extensor of the fingers and of vessels and capillaries, which generates 905 nm), one in the continuous system the short radial extensor muscle of the a washing effect on the inflammatory (808 nm, with a maximum power of 1W), carpus. Medial epicondylitis occurs in substances (histamine, bradykinin, and the other one in a pulsed system golf players and it affects the radial flexor cytokine and lymphokine). Vasodilation (905 nm, with a maximum power of 25 muscle of the carpus, which makes the increases the intake of oxygen and nutritive W). The advantage of this combination hand flexion against some resistance substances, an essential process in the consists in better penetrability and in become painful. repairing of the injured tissues. The laser the possibility of increasing the emitted stabilizes the membrane of the mastocytes energy. Therefore, the pulsing system As all these affections of the periarticular (histamine producers) and stimulates combines the stimulating effect on soft tissues are associated to pain and, phagocytes, which will eventually remove microcirculation with the advantage of sometimes, to the limitation of the joint the harmful substances. an increased top power, but they have a mobility, they may lead to an incapacity low average energy, and the combination for work; moreover, as there are numerous The analgesic effect. This effect is to a continuous laser wave secures cases which are caused by professional generated by several mechanisms. First of an appropriate energetic intake. The overstraining, their treatment must be all, the laser induces the blockage of the synchronizing of the two wavelengths may prompt and intense. The therapeutic action potential at the nociceptor level by transfer the energy towards the cellular behaviour includes the administration of the modification of the axonal membrane sublayer in a more efficient manner than NSAD, general and local corticotherapy permeability. Then, the active hyperemia the emission of a single component. Thus, or physiotherapy in many forms caused by heat and by the photochemical the MLS impulse has bigger antiphlogistic, bio-stimulating and analgesic effects than (electrotherapy, ultrasounds, short waves, reactions encourages the drainage of the algogenic substances, eliminating the cause a continuous emission or a pulsed one, laser therapy), but the symptomatology of the pain sensation. Pulsed emission used separately or in combination, but is often protracted and rebellious to lasers, especially the low-frequency unsynchronized. Enjoying the advantage treatment. ones, act on pain modulation by means of a bigger divergence of the diodes of the big, myelinized fibers, according irradiation cones, the multidiode laser Ever since it was discovered, the LASER has to the “gate” theory. [13] The laser may have a spot of big dimensions – 50 permanently extended its application field. eventually generates the production of mm. its wavelength and the energetic Since 1970, laser has been successfully morphinomimetic substances (endorphins transfer method in relation to time. used, first of all in surgery, and then in and enkephalins), which have an analgesic medical specializations as well. action (a mechanism that is also proven MLS therapy creates the conditions for Controlled clinical studies of LLLT by the emphasized increase in the urinary the achievement of numerous therapeutic effectiveness in abarticular rheumatism excretion of a serotonin degradation effects, as it has an anti-inflammatory, anti- (especially in shoulder periarthritis) product - 5-Hydroxyindoleacetic acid, edematous, and analgetic action, which showed different and sometime which precedes the amelioration of pain eventually leads to rapid ameliorations. contradictory results. Some studies have by several days). [14] demonstrated that low-level laser therapy Starting from these theoretical premises, is either totally ineffective in treating The biostimulation effect of Laser we have monitored the evolution under a the scapular-humeral periarthritis [1-5] increases the ATP production, a complex physiotherapy treatment of a lot and the epicondylitis [4,6-7], but other phenomenon that encourages the cellular of patients with abarticular rheumatism, studies proved higher efficiency compared energetic processes. Mitochondria are the in order to compare the analgetic and with other therapeutic means when cellular organelle where these processes anti-inflammatory effects of MLS laser recommended dosages are used.[8-12] are developed, but the mediator between therapy with traditional laser therapy. In The lasers used in physiotherapy have photons and the activation of biological order to monitor the analgetic effects, several common biological effects, but processes has not been identified yet. Laser we have used the visual analogue also particular effects, depending on the light may encourage cellular replication scale of pain (VAS). As laser therapy power and the type of the source. and RNA and proteins synthesis (collagen, generates an analgetic effect both by

13 Efficiency of MLS therapy in abarticular rheumatism revealed by digital thermography and visual analog scale Energy for Health [08]

direct action at the nociceptor level, and Material and methods by the production of morphinomimetic We have studied a lot of 22 patients presenting an acute abarticular pathology substances, not merely as a consequence (scapulohumeral peri-arthritis, tendinitis, epicondylitis, and bursitis) (table I) which was of the local anti-inflammatory effect, VAS divided in two parts. The first group (G1) made of 12 patients (8 women, 4 men) is not appropriate to monitor the anti- with an average age of 50,7 years received a conventional electrotherapy treatment inflammatory effects, and have therefore (interferential and diadynamic currents, ultrasound) and 100 mW LASER. The second used a parameter which directly reflects group (G2) made of 10 patients (6 women, 4 men) with an average age of 45,8 benefited local inflammation, that is the cutaneous from conventional electrotherapy and MLS therapy (table II). temperature measured by digital thermography. Table I. Distribution types of the diseases studied within both groups. G1 G2 Digital thermography is a non-invasive physiological test. It is a valuable Shoulder periarthritis 6 6 investigation that may provide medical Epicondylitis 3 2 alerts in relation to the modifications Quervaine’s tenosynovitis 1 1 indicating a precocious stage of breast cancer, or it may be used in the exploration Prepatellar bursitis/housemaid’s knee 2 1 of unknown origin pain. It is also useful in the monitoring of treatment evolution for numerous diseases. Table II. Demographical data G1 G2 In 1965, Gershon-Cohen, a radiologist and researcher from Albert Einstein Mean age 50,7 45,8 Medical Center, introduced thermography Sex (F/M) 8/4 6/4 in USA. Ever since the last period of the 70s, numerous medical centres Both groups included all types of studied pathology, with a balanced distribution and independent clinics have used this (fig 1. and fig. 2). exploration method on thousands of patients. In 1982, FDA (Food and Drugs

Administration) approved thermography as a screening method for breast PREPATELLAR BURSITIS cancer, and, since 1990, it has been SHOULDER PERIARTRITIS acknowledged as a diagnostic instrument EPICONDYLITIS by the American Academy of Physical QUERVAINE'S TENOSYNOVITIS Medicine and Rehabilitation. [15]

In the case of periarticular soft tissues affections, thermography may reveal the local vasomotor and inflammatory Fig. 1. Distribution types of the diseases studied within the group treated with the classic laser therapy reaction by increased local temperatures and/or by the modification of the cutaneous heat map, as it is well-known that the heat symmetry principle is normally observed. [16] PREPATELLAR BURSITIS SHOULDER PERIARTRITIS Since it is a non-invasive method, the EPICONDYLITIS investigation may be repeated at any QUERVAINE'S TENOSYNOVITIS time throughout the treatment in order to monitor local modifications of temperature, which follow the evolution of the local inflammatory process. Fig. 2. Distribution types of the diseases studied within the group treated with the MLS laser therapy

14 Efficiency of MLS therapy in abarticular rheumatism revealed by digital thermography and visual analog scale Energy for Health [08]

Methodology therapy, the differences between the two Also within both groups, the difference The patients received a physiotherapy groups being statistically significant in all between the local temperature of the session per day for 10 days. The first moments (p<0.005). affected area and the contra lateral group was applied a laser therapy (830 stimulated area has dropped, the nm wavelength) by non-contact technique reduction being more important in the with a 100 mW probe, in dosages of 6 group treated with the MLS laser therapy J/cm2, by punctiform irradiation in 6-10 (p=0,034). points. In order to treat the second group, 10 we have used all the preset programs of the 8

MLS M6 device, by scanning the affected 6 0,7 area (with the 3300 mW probe) and after 4 0,6 2 that the irradiation of the painful points 0,5

(with the 1500 mW probe). The evolution 0,4 of pain through the visual analogue scale 0,3 INITIAL 0,2 (VAS) was monitored in both groups; the 5 DAYS instant pain, the pain upon palpation G1 10 DAYS 0,1 30 DAYS and the pain upon mobilization initially, G2 after 5, 10 days of treatment and 30 days after the termination of treatment was Fig. 3. Evolution of spontaneous pain – VAS score G1 assessed; digital thermography and soft G2 parts ultrasound were performed before INITIAL starting the treatment and after the 10 10 DAYS session cure. The thermo graphical determinations Fig. 6. Evolution of skin temperature difference (p=0.034) 10 have been performed with a Flir 8

B60 termocamera under controlled 6 Discussions measurement conditions (22- 23 C room 4 The results from our study may support the temperature, the patient needs 15 minutes 2 importance of MLS therapy for analgesic for room temperature accommodation) and anti-inflammatory effects in patients and aimed to determine the modification with abarticular rheumatism over classical of the temperature difference between INITIAL 5 DAYS laser therapy. In this kind of pathology, the treated area and the contra lateral 10 DAYS G1 unaffected area. 30 DAYS pain control represents one of the principal G2 tasks in order to get over acute phases. In Inclusion criteria: suggestive symtomatology this study, patients enrolled in the MLS for abarticular rheumatism with less Fig. 4. Evolution of pain at palpation – VAS score therapy group reported very early (in than 3 weeks debut and the existence of some cases even after 2-3 treatments) a ultrasound modifications. significant pain reduction and increased Exclusion criteria: AINS previous or mobility of affected joints. concomitant treatment, local/general The results of this study also demonstrate corticosteroid therapy or the presence of 10 some lesions in which the laser therapy 8 anti-inflammatory effect of MLS therapy is contraindicated: neoplasia, infectious 6 by lowering the local temperature cutaneous lesions, bleeding tendency 4 measured by digital thermography. body surfaces. 2 Of the studied cases, an impressive evolution of the issued pursued, both pain Results INITIAL and local inflammation shown through In both groups studied, was observed 5 DAYS 10 DAYS determining temperature by digital infrared reduction of spontaneous pain (fig. 3), G1 30 DAYS thermography, was found in a prepatellar of pain on palpation (fig. 4) and of pain G2 during mobilization (fig. 5), lower VAS bursitis in which clinical symptoms values being more important in the MLS Fig. 5. Evolution of Pain during mobilization – VAS score improved after the first treatment session

15 Efficiency of MLS therapy in abarticular rheumatism revealed by digital thermography and visual analog scale Energy for Health [08]

and the temperature difference between Conclusions On Lateral Epicondylitis From Differential the affected knee and the healthy one • MLS therapy leads to a faster Interventions Of Chinese-Western reduced from 3.8 °C to 0.3°C at the end reduction of pain symptoms. Medicine: Systematic Review. Photomed Laser Surg. 2010 Jun;28(3):327-36. of 10 treatment sessions (fig. 7). Could • In case of periarticular soft tissue 9. emanet SK, Altan LI, Yurtkuran M. also be ascertained by ultrasonography of diseases, the anti-inflammatory effect Investigation Of The Effect Of Gaas of MLS laser therapy may be soft tissue the reduction of the amount of Laser Therapy On Lateral Epicondylitis. confirmed through the reduction fluid from the bursa prepatellar. Photomed Laser Surg. 2010 Jun;28(3):397- of temperature differences compared 403. with the healthy contra lateral area. 10. Tumilty S, Munn J, Abbott JH, Mcdonough • The analgetic effect obtained with S, Hurley DA, Baxter GD. Laser Therapy In MLS therapy is long lasting. The Treatment Of Achilles Tendinopathy: A Pilot Study. Photomed Laser Surg. 2008

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