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Efficacy of low level laser therapy associated with exercises in knee osteoarthritis: A randomized double-blind study

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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. A randomized double-blind placebo-controlled trial with sequential allocation of patients to different treatment groups. Special Rehabilitation Services. Forty participants with knee osteoarthritis, 2-4 osteoarthritis degree, aged between 50 and 75 years and both genders. 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). 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). 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 < 0.001). No significant improvement was seen in the placebo group. 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.
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Article
Efficacy of low level laser therapy
associated with exercises in knee
osteoarthritis: a randomized
double-blind study
Patrı
´cia Pereira Alfredo
1
, Jan Magnus Bjordal
2
,
´lvia Helena Dreyer
1
, Sarah Ru
´bia
Ferreira Meneses
1
, Giovana Zaguetti
1
,
Vanessa Ovanessian
3
, Thiago Yukio Fukuda
3
,
Washington Steagall Junior
4
, Rodrigo A
´lvaro
Branda
˜o Lopes Martins
5
,
Raquel Aparecida Casarotto
1
and
Ame
´lia Pasqual Marques
1
Abstract
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
1
Department of Speech Therapy, Physical Therapy and
Occupational Therapy, School of Medicine, Sa
˜o Paulo
University, Sa
˜o Paulo, Brazil
2
School of Health and Social Science, Institute of Physical
Therapy, Bergen University College, Bergen, Norway
3
School of Medical Science, Santa Casa de Miserico
´rdia, Sa
˜o
Paulo, Brazil
4
Department of Dentistic, School of Odontology, Sa
˜o Paulo
University, Sa
˜o Paulo, Brazil
5
Department of Pharmacology, Institute of Biomedical Sciences,
University of Sa
˜o Paulo, Sa
˜o Paulo, Brazil
Corresponding author:
Patrı
´cia Pereira Alfredo, Departamento de Fisioterapia,
Fonoaudiologia e Terapia Ocupacional. Rua Cipota
ˆnea, 51,
Cidade Universita
´ria, Sa
˜o Paulo (SP) 05360-160, Brazil
Email: patriciaalfredo@usp.br
Clinical Rehabilitation
26(6) 523–533
ÓThe Author(s) 2011
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DOI: 10.1177/0269215511425962
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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 (P¼0.03). No
other significant differences (P>0.05) were observed in other variables. In intragroup analysis, partici-
pants in the laser group had significant improvement, relative to baseline, on pain (P¼0.001), range of
motion (P¼0.01), functionality (P¼0.001) and activity (P<0.001). No significant improvement was seen
in the placebo group.
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.
Keywords
Osteoarthritis, low level laser therapy, exercises, knee
Received: 18 May 2011; accepted: 15 September 2011
Introduction
Osteoarthritis is a rheumatologic disorder char-
acterized by pain, joint inflammation, impair-
ment of muscular stability and functional
incapacity. It is a primary cause of impaired
quality of life and is associated with morbidity
and increased mortality risk.
1
The most
common form of osteoarthritis affects the
knee, and its prevalence is secondary to longer
life expectancy and population ageing.
2
In Brazil, osteoarthritis is a cause of 7.5% of
all temporary absenteeism from work, as well as
of 6.2% of all illness-related retirements.
3
Although commonly seen as a progressive and
chronic disorder, the early therapeutic approach
can minimize its symptoms.
4
The European League Against Rheumatism
(EULAR) suggests that low level laser therapy
and exercises should be considered when plan-
ning optimal treatment for osteoarthritis.
2
Indeed, low level laser therapy induces photo-
chemical physiological actions in living tissues
at the cellular level. Some of these effects include
cellular oxygenation, release of neurotransmit-
ters associated with pain modulation and release
of anti-inflammatory, endogenous mediators.
5
Nonetheless, the clinical efficacy of low level
laser therapy in the treatment of osteoarthritis
is still debatable; while some authors have
reported pain relief,
6,7
others have not.
8,9
These discrepancies may be associated with the
parameters (wave length, dose, time, area, tech-
nique) used in treatments by different studies.
Thus it is necessary to define which parameters
should be used to achieve optimum therapeutic
response in patients with osteoarthristis.
Strong evidence suggests that joint exercises
reduce pain and disability in patients with oste-
oarthritis.
10
There is evidence that exercise is
responsible for muscular strengthening and
better flexibility, improved global function as
well as better performance of activities of daily
living (ADL).
11
The efficacy of low level laser therapy in the
treatment of osteoarthritis, as well as its associ-
ation with exercise therapy has previously been
questioned.
6–9
The aim of this investigation is to
evaluate the effectiveness of this low level laser
therapy and exercise in reducing pain, improving
functionality, range of motion (ROM) and qual-
ity of life (QOL) in an osteoarthritis population.
Methods
Participants
Participants were recruited from the Special
Rehabilitation Services in Taboa
˜o da Serra-SP
Brazil.
524 Clinical Rehabilitation 26(6)
To be included in the study, participants had
to have knee osteoarthritis with osteoarthritis
levels 2–4 according to Kellgren–Lawrence
grade,
12
be aged between 50 and 75 years, both
genders, have knee pain and functional disability
for at least three months, and according to the
criteria of the American College for
Rheumatology.
13
The Kellgren and Lawrence
grading of knee osteoarthritis is as follows:
none (0), doubtful (1), minimal (2), moderate
(3) and severe (4).
The ACR criteria of knee osteoarthritis are as
follows:
.Using history and physical examination: knee
pain and three of the following – over 50
years old; less than 30 minutes of morning
stiffness; bony tenderness; bony enlargement;
no palpable warmth of synovial.
.Using history, physical examination and
radiographic findings: knee pain and one of
the following – over 50 years old; less than 30
minutes of morning stiffness; crepitus on
active motion; and osteophytes.
.Using history, physical examination and
laboratory findings: knee pain and five
of the following – over 50 years old;
less than 30 minutes of morning stiffness;
bony tenderness; bony enlargement; no
palpable warmth of synovial; crepitus on
active motion; ESR <40 mm/h; rheumatoid
factor <1: 40; synovial fluid sign of
osteoarthritis.
Participants were excluded if they had cancer,
diabetes, symptomatic hip osteoarthritis, or used
antidepressants, anti-inflammatory medications
or anxiolytics during six months prior to
enrolment.
The study was approved by the Research
Ethics Committee and all participants signed
informed consent forms.
Randomization
Forty-six participants with osteoarthritis were
randomized into one of two groups (laser or
placebo) by an investigator not involved in
assessment, diagnosis or treatment.
Randomization was performed by using sealed,
randomly filled envelopes describing the treat-
ment group. Patients and the physiotherapist
responsible for the evaluation were unaware of
randomization results.
Sample size
Sample size was calculated assuming 80% power
to detect a 20% improvement in pain (VAS),
with a standard deviation of 2 points and a sig-
nificance level of 5%. The required sample
would be 17 patients per group.
Assessment
All participants were evaluated by the same
blinded physiotherapist at three different mea-
surement intervals: baseline (T1), following the
end of laser therapy after three weeks (T2) and
the end of exercise therapy after 11 weeks (T3).
The physiotherapist was trained to evaluate the
same way all patients at all times.
.Pain was assessed using a visual analogue
scale (VAS)
14
consisting of a 10 cm rule (with-
out numbers). At the left side, ‘no pain’ is
written, while on the right side, ‘unbearable
pain’. Patients were instructed to mark on the
rule what their level of pain was.
.Functionality was measured using the
Lequesne questionnaire,
15
which consists of
11 questions about pain, discomfort and
function. Scores range from 0 to 24 (from
‘no’ to ‘extremely severe’ dysfunction).
.Range of motion for flexion of the knees were
measured with the universal goniometer
(AESCULAP), according to the methods
described by Marques.
16
.Muscular strength was estimated at maximal
isometric force for the quadriceps, using a
portable dynamometer (Lafayette, USA).
Under stabilized conditions, patients, sitting
with knees flexed at 60(measured by a goni-
ometer),
17
were asked to extend the legs as far
Alfredo et al. 525
as they could. Three trials were conducted
and the mean value was obtained.
.Activity was measured using the Western
Ontario and McMaster Universities
Osteoarthritis (WOMAC) questionnaire,
18
which is self-administered and measures
pain, frozen joints and physical activity.
Increased scores suggest decreased activity.
In this study the most affected knee joint of
each participant was included.
Intervention
All patients were treated by the same physio-
therapist who had not taken part in the
evaluations.
Participants in the laser group received low
level laser therapy while the placebo group
received placebo therapy three times a week
for three weeks following initial assessment.
Both groups exercised three times a week for
the remaining eight weeks of the programme.
In the laser group, energy was irradiated over
the joint line onto five points of the synovial
region of the medial side of the knee and in
four points at the lateral side, at 3 J per point.
Total dose per knee was 27 J per treatment and
used previously calibrated equipment (Irradia
Class 3B; Stockholm, Sweden). In the placebo
group, procedures were identical but without
emission of energy.
The laser equipment had two identical pens,
one for the active treatment and one for the pla-
cebo treatment (sealed). The pen’s semi-conduc-
tor consisted of gallium arsenide with wave
length of 904 nm, frequency of 700 Hz, average
power of 60 mW, peak power of 20 W, pulse
duration 4.3 ms, 50 seconds per point (area 0.5
cm
2
). The parameters followed the recommen-
dation of the World Association of Laser
Therapy (WALT)
19
for osteoarthritis.
Exercises
All patients followed the same training pro-
gramme (Table 1). The intervention was divided
into three phases: P-1, P-2 and P-3 during eight
weeks with three sessions a week. Each session
lasted 45 minutes:
.10 minutes warming-up (treadmill, ergometer
bike or rowing machine);
.30 minutes 2–3 sets with P-1, P-2 or P-3;
.5 minutes stretching (hamstrings, quadriceps,
adductors, and gastrocmenius).
Statistical analysis
Data normality was assessed using the Shapiro–
Wilk test; homogeneity of data was estimated
using the Levene’s test. For the intergroup anal-
ysis the values were standardized as follows: For
variables where reduction meant improvement
(pain, function, WOMAC), we used the for-
mula: (T1–T2) 7AV1 and (T1–T3) 7AV1.
For variables where increase meant improve-
ment (range of motion and muscle strength),
we used the formula: (T1–T2) 7AV1 and
(T1–T3) 7AV1. To compare the two groups,
laser and placebo, we calculate the difference of
their means. Negative values mean that laser is
better than placebo and positive values mean
that placebo is better. Analyses between groups
were performed using the independent t-test for
the conditions T1 T2 and T1 T3. For
intragroup analysis, evaluation times were com-
pared by repeated-measures ANOVA (single
effect), followed by the Tukey post-test.
Analyses were conducted using the Statistical
Package for Social Sciences (SPSS version 17;
SPSS Inc., Chicago, IL, USA). An alpha level
of 0.05 was set for all comparisons.
Results
Sixty-one subject were eligible to take part in
study and 15 were excluded. Forty-six patients
were assessed at baseline and randomly allo-
cated in two different groups (laser group ¼24
and placebo group ¼22). Forty patients com-
pleted the treatment and attended the last assess-
ment (Figure 1).
526 Clinical Rehabilitation 26(6)
Table 2 displays the demographics of partic-
ipants in each group. There were no statistically
significant differences (P>0.05) for age, weight,
height, body mass index, gender and osteoar-
thritis degree between the two groups.
Table 3 shows that there was no significant
difference in any of the variables of both groups
at the time of the baseline (P>0.05).
The intergroup analysis showed that the laser
group presented significant improvement in the
variables of WOMAC, as pain (P¼0.033), func-
tion (P¼0.002) and total score (P¼0.008) at T2
compared to T1 and pain (P¼0.001), function
(0.002) and total score (0.003) in T3 compared
to T1. No other statistically significant differ-
ences were found in the other variables
(P>0.05) (Table 4).
Table 5 shows the intragroup analysis at the
different measurement intervals. The laser group
had significant improvement in pain scores
(P<0.05) and activity (P<0.001) between T1
and T2 and between T2 and T3 (P¼0.001) as
well as range of motion (P¼0.01) and function-
ality (P¼0.001) between T2 and T3. In the pla-
cebo group, no significant improvements were
seen for any of the variables (P>0.05).
Table 1. Exercise programme conducted over the eight weeks of treatment
Phases Exercises
P1 Each exercise had 30 repetitions and 2 sets:
(week 1–week 2) Sitting in the chair with a weight on the ankle, knee and stretch the
foot to rotate alternately in and out then change legs
Objectives:
Range of Motion
Lying prone. Bend the knee slowly as much as possible. Stretch
the knee slowly
Standing with support. Bend the knees to approximately 60
degrees. Push up again
Walk on a 3 m line without stepping off the line
Motor Learning
Balance Coordination
Walk–standing. Transfer your body weight from one leg to the
other
P2 Each exercise had 20 repetitions and 3 sets:
(week 3–week 5)
Objective:
Standing. Bend your knees to approximately 60 degrees, and
up again
Walk sidewards by crossing legs. To right and left
Strengthening Standing on a balance board. Hold the balance
Lying prone. Bend one knee as much as possible
One foot-standing on a step. Bend your knee until the other foot
touches the floor, push up again
P3 Each exercise had 20 repetitions and 3 sets:
(week 6–week 8) Walk sideward by crossing steps. To right and left
Objective:
Strengthening
Standing on one leg. Bend the knee to approximately 60 degrees,
and up again
Standing on a balance board. Keep the balance. More difficult if
eyes are closed
Standing on the floor. Get up on your toes, hold 1–2 seconds, and
get down again
Sitting with weight around the ankle. Stretch the knee slowly, hold
the stretch 3–4 seconds, and slowly down again
Alfredo et al. 527
Assessed for eligibility (n=61)
Excluded (n=15)
n=9)
n=6)
Analysis
Analysed (n=40)
Assessed after active LPL (n=24) Assessed after placebo LPL (n=22)
Randomized and registered (n=46)
Placebo group
Receive allocated to intervention (n= 22)
Placebo LPL 3 days a week, in 3 weeks
Laser group
Receive allocated to intervention (n=24)
Active LPL 3 days a week, in 3 weeks
Exercises 3 days a week, in 8 weeks
Assessed after exercise (n=20)
Discontinued
intervention (n=4)
Discontinued
intervention (n=2)
Assessed after exercise (n=20)
Baseline assessment (n=46)
Figure 1. Participant flow diagram.
528 Clinical Rehabilitation 26(6)
Discussion
The effects of low level laser, in combination
with a programme of exercises in patients with
knee osteoarthritis was assessed in this study.
Positive results were found in low level laser
therapy when associated with exercises in yield-
ing pain relief, improvement function and activ-
ity compared to the placebo group.
We postulate that analgesia in the laser group
after laser therapy may have been a consequence
of the anti-inflammatory properties of the low
level laser at 3 J, applied onto specific points,
suggested by WALT,
19
on the articular capsule.
Similar results were found by Bjordal et al.,
20
including the pain relief and improvement in
global health status of knee osteoarthritis
patients. In a meta-analysis, Brosseau et al.
6
sug-
gested that the significant pain relief associated
with low level laser may have been due to
increase in neurotransmitter levels, including
serotonin, which is important in endogenous
Table 2. Clinical and demographic characteristics of the participants in both groups
Characteristics
Laser group (n¼20)
Mean (SD)/n (%)
Placebo group (n¼20)
Mean (SD)/n (%) P-value
Age (years) 61.15 (7.52) 62.25 (6.87) 0.63
Weight (kg) 76.27 (10.32) 74.9 (15.73) 0.74
Height (m) 1.59 (0.08) 1.59 (0.09) 0.94
BMI (kg/m
2
) 30.16 (4.12) 29.21 (4.95) 0.51
Gender
Female 15 (75%) 16 (80%) 0.71
Male 5 (25%) 4 (20%) 0.71
Osteoarthritis degree
2 4 (20%) 9 (45%) 0.09
3 9 (45%) 4 (20%) 0.09
4 7 (35%) 7 (35%) 1.00
SD, standard deviation; BMI, body mass index.
Table 3. T-test among the variables pain, functionality, range of motion, muscle strength and activity at the time of
the baseline
Laser group (n¼20) Placebo group (n¼20)
Variables Mean (SD) Mean (SD) P-value
Pain (cm) 5.32 (3.55) 3.54 (3.06) 0.098
Functionality 11.88 (3.98) 11.55 (3.18) 0.776
Range of motion (degrees) 91.50 (13.79) 91.80 (20.42) 0.992
Muscle strength (H/kg) 11.63 (4.87) 9.96 (3.58) 0.207
Activity-WOMAC
Pain subscale 9.10 (4.92) 7.30 (3.54) 0.192
Stiffness subscale 3.05 (1.96) 2.95 (2.14) 0.878
Function subscale 33.85 (16.93) 27.15 (11.32) 0.188
Total score 46.05 (22.99) 38.00 (14.91) 0.196
SD, standard deviation; P-value for t-test; WOMAC, Western Ontario and McMaster Universities Osteoarthritis Index.
Alfredo et al. 529
pain modulation. Hegedus et al.
21
and Montes-
Molina et al.
22
carried out clinical trials accord-
ing to the recommendations of WALT, using
830 nm laser with average power of 50 and 100
mW, respectively, with a dose of 6.0 J/point.
Effective results were recorded in pain relief
and improvements in microcirculation in the
irradiated area in patients with osteoarthritis
knee.
There is strong evidence that exercise reduces
pain and improves function in patients with
osteoarthritis,
23,24
and this may explain the
maintained benefits even after laser therapy
was discontinued. Our findings suggest that
analgesia induced by low level laser resulted in
improved exercise performance and this combi-
nation resulted in prolonged analgesic effects.
We also demonstrated the functional
improvement in the laser group in relation to
placebo. Similar results were found by Stelian
et al.,
25
who observed significant functional
improvement and pain reduction in the laser
group but not in placebo group in patients
with osteoarthritis. However, Brosseau et al.
26
found no significant improvement in pain reduc-
tion and functional status for hand osteoarthri-
tis patients for laser therapy versus placebo.
These results may be because the laser was
Table 4. Comparison between the groups for the variables pain, functionality, range of motion, muscle strength and
activity. Negative value suggests laser is better than placebo group
Laser group placebo group P-value
Variables Mean change score (95% CI) (intergroup)
Pain
T1 T2 0.43 (0.04) 0.071
T1 T3 0.31 (0.08) 0.120
Functionality
T1 T2 0.08 (0.22) 0.602
T1 T3 0.27 (0.04) 0.087
Range of motion (degree)
T1 T2 0.04 (0.16) 0.404
T1 T3 0.02 (0.08) 0.632
Muscle strength (H/kg)
T1 T2 0.07 (0.25) 0.395
T1 T3 0.12 (0.09) 0.266
Activity – WOMAC
Pain subscale
T1 T2 0.29 (0.02) 0.033*
T1 T3 0.33 (0.15) 0.001*
Stiffness subscale
T1 T2 0.24 (0.11) 0.173
T1 T3 0.31 (0.17) 0.202
Function subscale
T1 T2 0.35 (0.14) 0.002*
T1 T3 0.34 (0.13) 0.002*
Total score
T1 T2 0.30 (0.08) 0.008*
T1 T3 0.31 (0.12) 0.003*
95% CI, 95% confidence interval; P-value for t-test; WOMAC, Western Ontario and McMaster Universities Osteoarthritis Index.
530 Clinical Rehabilitation 26(6)
applied on painful osteoarthritis-affected finger
joints (chronic stage) as well as three superficial
nerves innervating the painful area and not in
specific regions of the joint capsule.
In our study, parameters associated with
activity also improved in the laser group, cor-
roborating the findings of Gur et al.
27
in a sim-
ilarly conducted study (low level laser and
exercises also improved pain, functionality and
activity of patients with osteoarthritis).
Tascioglu et al.
28
however, did not find signifi-
cant improvement in the activity assessed by
WOMAC of patients receiving laser with a
wavelength 830 nm, 50 mW of mean power,
with doses ranging from 1.5 to 3 J. They believe
that this fact may be related to the laser modal-
ity, dosages and wavelength selection used.
In patients with knee osteoarthritis, quadri-
ceps strength is decreased by 50–60%, mainly
because of atrophy and arthrogenic inhibition.
29
It has been suggested that sensorimotor dysfunc-
tion of the quadriceps may be relevant to oste-
oarthritis progression
30,31
as a risk factor for
disability. We did not demonstrate improve-
ments in quadriceps muscle strength, however
functionality improved in the laser group follow-
ing the exercise therapy. We believe these results
are due to the fact that the exercise programme
was focused not only on quadriceps muscle
strength gain, but on the overall strengthening
of the lower limb. Montes-Molina et al.
22
used
830 nm laser at a dose of 6.0 J per point and
concluded that low level laser associated with
quadriceps exercise was effective in reducing
pain, a conclusion supported by our study.
Similar results were found by Hurley and
Scott,
32
who suggested that the improvement
of strength and functionality in knee
Table 5. Within-group difference in change score (T1, T2 and T3) for laser and placebo groups
Groups T1 T2 T3
Variables (n¼20/group) Mean (SD) Mean (SD) Mean (SD) P-value
Pain (cm) Laser 5.32 (3.55)
a
3.36 (3.47)
b
2.58 (3.27)
b
0.001*
Placebo 3.54 (3.06) 3.15 (2.94) 2.30 (2.25) 0.230
Functionality Laser 11.88 (3.98)
a
10.78 (4.62)
a
8.37 (4.27)
b
0.001*
Placebo 11.55 (3.18) 10.68 (3.08) 10.40 (3.91) 0.400
Range of motion (degree) Laser 91.50 (13.79)
a
91.40 (12.11)
a
99.45 (12.89)
b
0.010*
Placebo 91.80 (20.42) 95.65 (17.25) 96.55 (15.28) 0.180
Muscle strength (H/kg) Laser 11.63 (4.87) 11.8 (4.86) 12.52 (4.50) 0.700
Placebo 9.96 (3.58) 11.51 (6.62) 9.68 (3.65) 0.230
Activity – WOMAC
Pain subscale Laser 9.10 (4.92)
a
6.55 (3.32)
b
4.80 (4.36)
b
0.000*
Placebo 7.30 (3.54) 6.55 (3.98) 6.35 (3.48) 0.370
Stiffness subscale Laser 3.05 (1.96) 2.35 (2.30) 2.35 (2.21) 0.720
Placebo 2.95 (2.14) 2.65 (2.23) 2.6 (2.11) 0.200
Function subscale Laser 33.85 (16.93)
a
24.15 (13.58)
b
19.50 (14.04)
b
0.000*
Placebo 27.15 (11.32) 27.40 (13.88) 23.35 (12.18) 0.190
Total score Laser 46.05 (22.99)
a
33.05 (18.62)
b
26.65 (20.17)
b
0.000*
Placebo 38.00 (14.91) 36.60 (18.34) 32.30 (16.82) 0.22
*P-value for ANOVA.
a,b
Identify which values are statistically different between after multiple comparison test.
WOMAC, Western Ontario and McMaster Universities Osteoarthritis Index.
Alfredo et al. 531
osteoarthritis was so substantial that it could
postpone or totally avoid surgical interventions.
Although no significant difference was
observed between groups for range of motion,
in intra-group analysis improvement in the laser
group after exercise was observed.
Corroborating our findings, Gur et al.
27
also
found statistical significant improvement in the
flexion of the knee in all groups treated with
laser except the placebo group. However,
Bulow et al.
9
failed to demonstrate significant
improvement in pain and range of motion
when comparing laser and placebo. However,
they used very low doses of laser (less than 3 J)
over pain points, and not necessarily over the
soft periarticular tissues.
Our findings suggest that low level laser ther-
apy when associated with exercises is effective in
yielding pain relief, function and activity in
patients with knee osteoarthritis.
The major study limitations were the small
number of patients, the absence of a control
group, which would allow us to assess the natural
course of the disease, and the absence of follow-
up. Future studies should increase the number of
patients, include a control group, add a group
which receives low level laser therapy and exercise
simultaneously from the very beginning and a
long-term follow-up assessment.
Clinical messages
.The application of low level laser three
times per week for three weeks can assist
in the execution of exercises in patients
with knee osteoarthritis.
.The combination of laser and exercise can
improve pain, function and activities in
subject with knee osteoarthritis.
Disclosure statement
No competing financial interests exist.
Clinical trials
[Low power laser and exercise in osteoarthritis of the
knee: a randomized clinical trial, CT01306435.]
Conflict of interest
There is no conflict of interest.
Funding
This study was supported financially by: Fundac¸ a
˜ode
Amparo a
`Pesquisa do Estado de Sa
˜o Paulo
(FAPESP) – Foundation of Research Support of
Sa
˜o Paulo State and Coordenac¸ a
˜ode
Aperfeic¸ oamento de Pessoal de Nı
´vel Superior
(CAPES) – Coordination for the Improvement of
Higher Level – or Education – Personnel.
Biostatistics Support Group, Department of
Dentistic, School of Odontology, University of Sa
˜o
Paulo, Sa
˜o Paulo, Brazil.
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... Finally, 16 articles remained. [22][23][24][25][26][27][28][29][30][31][32][33][34][35][36][37] ...
... When the change of pain was examined according to the VAS, 2 articles examined changes of pain according to the VAS and found no statistical or clinical difference. 26,28 Alfredo et al 26 found a change of pain to be 0.4 cm. Bennel et al 28 did not report any difference in pain. ...
... 24 One study compared laser plus exercise and placebo laser plus exercise with control. 26 One study compared 4 intervention groups: heat application, exercise, exercise after heat application, and control, 37 and one study compared strengthening exercise and electromyography-biofeedback-assisted strengthening exercise. 25 The duration of the exercise sessions ranged from 30 to 90 minutes. ...
Article
Objective: This systematic review aimed to evaluate and summarize the effects of therapeutic exercise clinically in reducing pain intensity in patients with knee osteoarthritis. Methods: A search of PubMed, Web of Science, Scopus, EBSCO, and Cochrane Central Register of Controlled Trials (CENTRAL) databases from the date of inception to December 15, 2019, was conducted. Primary outcome of interest was pain measurement using the visual analog scale. The methodological quality of the studies was assessed using the Physiotherapy Evidence Database (PEDro) scale. Results: Sixteen studies were included in this systematic review. These studies reported that therapeutic exercise is clinically effective in reducing pain intensity in patients with knee osteoarthritis. In addition, compared with a short-term and low-intensity therapeutic exercise, there was strong evidence that therapeutic exercise, in combination with pain inhibition interventions, may play a significant role in reducing pain intensity. Conclusion: The systematic review provides evidence for the use of therapeutic exercises, which is high-intensity, long-term, and combined with other interventions, for reducing pain intensity clinically.
... Interestingly, PBM did not produce any extra positive effect in the exercised patients. Data from the literature do not corroborate the findings of the present study demonstrating a superior effect measured by WOMAC in exercised and irradiated patients with OA [35][36][37]. Kheshie et al. [36] also observed a decrease in WOMAC subscales in patients with OA treated with physical exercises and PBM. One hypothesis that can be raised is that the PBM parameters used in this study were not sufficient to produce an additional effect in the exercised patients. ...
... Data from the literature do not corroborate the findings of the present study demonstrating a superior effect measured by WOMAC in exercised and irradiated patients with OA [35][36][37]. Kheshie et al. [36] also observed a decrease in WOMAC subscales in patients with OA treated with physical exercises and PBM. One hypothesis that can be raised is that the PBM parameters used in this study were not sufficient to produce an additional effect in the exercised patients. ...
Article
Full-text available
Background The knee osteoarthritis (OA) is a joint disease characterized by degradation of articular cartilage that leads to chronic inflammation. Exercise programs and photobiomodulation (PBM) are capable of modulating the inflammatory process of minimizing functional disability related to knee OA. However, their association on the concentration of biomarkers related to OA development has not been studied yet. The aim of the present study is to investigate the effects of PBM (via cluster) with a physical exercise program in functional capacity, serum inflammatory and cartilage degradation biomarkers in patients with knee OA. Methods Forty-two patients were randomly allocated in 3 groups: ESP: exercise + sham PBM; EAP: exercise + PBM and CG: control group. Six patients were excluded before finished the experimental period. The analyzed outcomes in baseline and 8-week were: the Western Ontario and McMaster Universities Osteoarthritis (WOMAC) and the evaluation of serum biomarkers concentration (IL-1β, IL-6, IL-8, IL-10 e TNF-α, and CTX-II). Results An increase in the functional capacity was observed in the WOMAC total score for both treated groups (p < 0.001) and ESP presents a lower value compared to CG (p < 0.05) the 8-week post-treatment. In addition, there was a significant increase in IL-10 concentration of EAP (p < 0.05) and higher value compared to CG (p < 0.001) the 8-week post-treatment. Moreover, an increase in IL-1β concentration was observed for CG (p < 0.05). No other difference was observed comparing the other groups. Conclusion Our data suggest that the physical exercise therapy could be a strategy for increasing functional capacity and in association with PBM for increasing IL-10 levels in OA knee individuals. Trial registration : ReBEC (RBR-7t6nzr).
... 44 physical therapy such as transcutaneous electrical nerve stimulation (tens), laser therapy, magnetic fields and neuromuscular electrical stimulation are not uniquely recommended by any guideline in the management of Oa, lacking of solid scientific evidences. Despite this, in scientific literature there are many studies that deepen the beneficial synergic role of physical therapy combined with therapeutic exercise [51][52][53] at the same time, the combination of pharmacological and physical therapies seems to represent the optimal Oa management, since it could be able to enhance the beneficial effects of each treatment, significantly limiting any side effect. 54 ...
... Low-level laser therapy (LLL) combined with exercise has been shown to alleviate pain while improving mobility and movement in patients with knee OA. Radiation also increases local microcirculation and is highly recommended as a supplement to other treatments for OA [50,61]. ...
... Low-level laser therapy (LLL) combined with exercise has been shown to alleviate pain while improving mobility and movement in patients with knee OA. Radiation also increases local microcirculation and is highly recommended as a supplement to other treatments for OA [50,61]. ...
Article
Full-text available
The rising prevalence of osteoarthritis (OA) in the general population has necessitated the development of novel treatment options. It is critical to recognize the joint as a separate entity participating in degenerative processes, as well as the multifaceted nature of OA. OA is incurable because there is currently no medication that can stop or reverse cartilage or bone loss. As this point of view has attracted attention, more research is being directed toward determining how the various joint components are impacted and how they contribute to OA pathogenesis. Over the next few years, several prospective therapies focusing on inflammation, cartilage metabolism, subchondral bone remodelling, cellular senescence, and the peripheral nociceptive pathway are predicted to transform the OA therapy landscape. Stem cell therapies and the use of various biomaterials to target articular cartilage (AC) and osteochondral tissues are now being investigated in considerable detail. Currently, laboratory-made cartilage tissues are on the verge of being used in clinical settings. This review focuses on the update of clinical prospects and management of osteoarthritis, as well as future possibilities for the treatment of OA.
... It is noteworthy that the moderate or high intensity resistance training protocols are extremely sufficient and effective for promoting gains on muscle strength and muscle mass [20,21], which will, consequently, lead to improvement in the functionality. In addition, the strengthening of lower limb muscles plays an important role in muscle strength, muscle mass, functionality [22][23][24][25] and pain relief [78] for these populations. On the other hand, it is known that some patients with chronic arthropathies usually avoid physical activities for having fear of exacerbating the symptoms of the disease [79] or for ending up getting discomfort when performing high-load exercises [32,80]. ...
Article
Full-text available
Introduction: Rheumatoid arthritis(RA) and osteoarthritis(OA) patients showed systemic manifestations that may lead to a reduction in muscle strength, muscle mass and, consequently, to a reduction in functionality. On the other hand, moderate intensity resistance training(MIRT) and high intensity resistance training(HIRT) are able to improve muscle strength and muscle mass in RA and OA without affecting the disease course. However, due to the articular manifestations caused by these diseases, these patients may present intolerance to MIRT or HIRT. Thus, the low intensity resistance training combined with blood flow restriction(LIRTBFR) may be a new training strategy for these populations. Objective: To perform a systematic review with meta-analysis to verify the effects of LIRTBFR on muscle strength, muscle mass and functionality in RA and OA patients. Materials and methods: A systematic review with meta-analysis of randomized clinical trials(RCTs), published in English, between 1957-2021, was conducted using MEDLINE(PubMed), Embase and Cochrane Library. The methodological quality was assessed using Physiotherapy Evidence Database scale. The risk of bias was assessed using RoB2.0. Mean difference(MD) or standardized mean difference(SMD) and 95% confidence intervals(CI) were pooled using a random-effects model. A P<0.05 was considered statistically significant. Results: Five RCTs were included. We found no significant differences in the effects between LIRTBFR, MIRT and HIRT on muscle strength, which was assessed by tests of quadriceps strength(SMD = -0.01[-0.57, 0.54], P = 0.96; I² = 58%) and functionality measured by tests with patterns similar to walking(SMD = -0.04[-0.39, 0.31], P = 0.82; I² = 0%). Compared to HIRT, muscle mass gain after LIRTBFR was reported to be similar. When comparing LIRTBFR with low intensity resistance training without blood flow restriction(LIRT), the effect LIRTBFR was reported to be higher on muscle strength, which was evaluated by the knee extension test. Conclusion: LIRTBFR appears to be a promising strategy for gains in muscle strength, muscle mass and functionality in a predominant sample of RA and OA women.
... Their findings suggest that low level laser therapy when associated with exercises is effective in yielding pain relief, function and activity in patients with knee osteoarthritis. 16 In present study there is significant improvement was observed in control group and experimental group in respect to all parameters taken in WOMAC scale such as pain, stiffness and physical function. There was also significant decrease in swelling by both conventional and additional low level laser therapy. ...
Article
Full-text available
Purpose: The main purpose of the study was to find out the effects of Low Level Laser Therapy in patients presenting with diagnosis of bilateral patellofemoral knee osteoarthritis. The objective of our research is: To improve functional outcome. Methodology: A split-body-experimental design was done by random sampling for 4 weeks. A minimum of 20 subjects (i.e., 40 knees) were assigned for the study and low level laser therapy was applied to the right 20 knee (experimental group) and left 20 knee (control group) received conventional treatment in bilateral osteoarthritis, therefore number of knees tested were 20 for low level laser therapy and other 20 will receive conventional treatment Result: Statistically significant improvement was indicated in respect to all parameters taken in WOMAC scale such as pain, stiffness and physical function. There was also significant decrease in swelling by both conventional and additional low level laser therapy. Improvements in all parameters of the experimental group were more statistically significant when compared to parameters of control group (p <0.05). Conclusion: This study suggests that there is significant improvement with additional Low Level Laser therapy as well as with conventional treatment in patients with patellofemoral knee osteoarthritis but there is more significant improvement in experimental group in which Low level laser therapy was given along with exercise program. There is decrease in pain, swelling and stiffness. Hence, addition of Low Level laser therapy in patella-femoral knee osteoarthritis is more effective than conventional treatment. Keywords: Patellofemoral osteoarthritis, Low Level laser therapy, knee joint, isometric strengthening.
... In clinical practice, the use of ultrasound and photobiomodulation in the treatment of a variety of musculoskeletal disorders has yielded mostly positive results. These therapies are advantageous in the treatment of osteoarthritis because they are considered safe, have few or no adverse effects, are easy to use, and have significant analgesic effects [2,11,12]. ...
Article
Full-text available
Pain is the most common symptom of osteoarthritis, and spinal glia is known to contribute to this symptom. Therapeutic ultrasound and laser therapy have been used to effectively treat osteoarthritis, with few adverse effects. Thus, this study aimed to investigate the effects of ultrasound and photobiomodulation on the symptoms and evaluate the participation of spinal glia in osteoarthritis-induced nociception in mice. Male Swiss mice were subjected to osteoarthritis induction with a 0.1-mg intra-articular injection of monosodium iodoacetate. Additionally, the mice received chronic ultrasound or photobiomodulation treatment for 21 days or a single treatment at day 14. Nociception was evaluated using von Frey filaments, and osteoarthritis symptoms were assessed by analysis of gait, joint temperature, and knee joint diameter. The role of spinal microglia and astrocytes on nociception was evaluated via an intrathecal injection of minocycline or fluorocitrate, and the spinal release of IL-1β and TNF-α was assessed by ELISA after chronic treatment with ultrasound or photobiomodulation. Our data showed that both single and chronic treatment with ultrasound or photobiomodulation attenuated the osteoarthritis-induced nociception. No differences in gait, knee joint temperature, or knee joint diameter were found. The intrathecal injection of minocycline and fluorocitrate decreased the osteoarthritis-induced nociception. There was an increase in the spinal levels of TNF-α, which was reverted by chronic ultrasound and laser treatments. These results suggest that osteoarthritis induces nociception and glial activation via spinal release of TNF-α and that the chronic treatment with ultrasound or photobiomodulation decreased nociception and TNF-α release.
... Photobiomodulation was performed using the low level laser (Laserpulse -Indústria Brasileira de Equipamentos Médicos -IBRAMED ® , Amparo, São Paulo, Brazil) with a Gallium Arsenide (AsGa) probe with a wavelength of 904 nm, with a dose of 3 J per point, totaling 9 points, 15 total energy of 27 J per session, peak power of 70 W, pulse repetition frequency of 9500 Hz, pulse duration of 60 ns, average power of 40 mW, application time of 75 seconds per point, and beam cross-sectional area of 0.5 cm². 23 The intervention of the placebo photobiomodulation was performed with the device switched on, with the energy emission button not activated. The panel light of equipment was constantly on. ...
Article
Objectives: To evaluate the effects of interferential current and photobiomodulation in patients with knee osteoarthritis. Design: A randomized, placebo-controlled, double-blind clinical trial. Setting: Physiotherapy Clinic of City University of São Paulo. Subjects: A total of 184 patients with knee osteoarthritis were recruited and, of these, 168 were included and randomized into four groups with 42 each: interferential current, photobiomodulation, interferential current plus photobiomodulation or placebo groups. One hundred and sixty-four patients completed the study. Intervention: Patients received 12 sessions (three times a week) of treatment: 30 minutes of interferential current (active or placebo) followed by photobiomodulation (active or placebo). Main measures: Primary outcome: pain intensity at rest and during movement (numeric rating scale) after 12 sessions. Secondary outcomes: functional capacity (Timed Up & Go and Sit and Lift tests and Lequesne and WOMAC questionnaires), pressure pain threshold, conditioned pain modulation, and muscle strength production (isokinetic evaluation). Patients were assessed at baseline, after 12 sessions, and three and six months after the end of the treatment. Results: Interferential current plus photobiomodulation reduced pain intensity at rest and during movement compared to placebo and interferential current at all time points (P < 0.05). Photobiomodulation reduced pain intensity at rest compared to placebo at all time points (P < 0.05) and compared to interferential current at six months follow-up (P < 0.05). Photobiomodulation reduced pain intensity during movement compared to placebo at six months follow-up (P < 0.05). Conclusion: Interferential current plus photobiomodulation or isolated photobiomodulation improve pain intensity in knee osteoarthritis.
Article
Objectives To investigate the laser effect associated with stretching exercise on pain and functionality in patients with knee osteoarthritis. Design A randomised controlled trial Setting Special Rehabilitation Services. Subjects We enrolled 215 knee osteoarthritis patients (430 knees were treated). Intervention Group Laser + Stretch ( n = 43), Placebo + Stretch ( n = 43), Stretch ( n = 43), Laser ( n = 43) and Control ( n = 43) were treated with active laser and stretching exercises; placebo laser and stretching exercises; stretching exercises; active laser, and control, respectively. Interventions were conducted 3 times a week for 8 or 11 weeks. Main outcome measures The primary outcome was the change in knee pain and disability. Secondary outcomes included severity of osteoarthritis, mobility, knee range of motion, flexibility, activity, severity of osteoarthritis and medication intake for pain relief. Results The patients’ average age was 63.52 (6.8) years. Pain scores at baseline and post treatment ( p < 0.001) were 7.43 (2.10) and 2.79 (1.92) for group Laser + Stretch, 7.39 (1.98) and 4.47 (2.82) for group Placebo + Stretch, 6.83 (1.42) and 4.24 (2.43) for group Stretch, 6.61 (1.68) and 2.94 (2.65) for group Laser, 6.74 (1.75) and 6.47 (2.29) for group Control, respectively. Disability score at baseline and post treatment ( p = 0.000237) were 12.36 (5.02) and 8.08 (4.64) for group Laser + Stretch, 12.71 (5.12) and 9.90 (4.95) for group Placebo + Stretch, 11.83 (2.77) and 7.20 (5.28) for group Stretch, 11.58 (5.59) and 8.21 (6.18) for group Laser, 11.23 (4.68) and 11.45 (4.83) for group Control, respectively. Conclusion Laser therapy combined with stretching exercises improves pain during rest, activities of daily living, stiffness, muscle shortening and range of motion in patients with knee osteoarthritis.
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This study was designed to compare the prevalence of shoulder-arm morbidity, patient satisfaction with surgery and the quality of life of women submitted to breast-conserving therapy or modified radical mastectomy and immediate breast reconstruction . This study was a cross-sectional study of women who underwent breast-conserving therapy (n = 44) or modified radical mastectomy and immediate breast reconstruction (n = 26). Quality of life was evaluated with the SF-36 Health Survey Questionnaire. No differences were found in the prevalence of lymphedema. The movements that were most commonly affected by these procedures were abduction, flexion and external rotation. When the two groups were compared, however, we only found a statistically significant difference for the prevalence of restricted internal rotation, which occurred in 32% of women in the breast-conserving therapy group and 12% of those in the modified radical mastectomy and immediate breast reconstruction group (OR: 7.23; p = 0.03 following adjustment for potential confounding factors). No difference in quality of life or satisfaction with surgery was found between the two groups. These data suggest that the type of surgery did not affect the occurrence of lymphedema. Breast-conserving therapy, however, increased the risk of shoulder movement limitation. No differences were found between the two surgical techniques with respect to quality of life or satisfaction with surgery.
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Physiotherapy is one of the most important components of therapy for osteoarthritis of the knee. The objective of this prospective case series was to assess the efficiency of a guidance manual for patients with osteoarthritis of the knee in relation to pain, range of movement , muscle strength and function, active goniometry, manual strength test and function. Thirty-eight adults with osteoarthritis of the knee (>or= 45 years old) who were referred to the physiotherapy service at the university hospital (Santa Casa de Misericórdia de São Paulo) were studied. Patients received guidance for the practice of specific physical exercises and a manual with instructions on how to perform the exercises at home. They were evaluated for pain, range of movement, muscle strength and function. These evaluations were performed before they received the manual and three months later. Patients were seen monthly regarding improvements in their exercising abilities. The program was effective for improving muscle strength, controlling pain, maintaining range of movement of the knee joint, and reducing functional incapacity. A review of the literature showed that there are numerous clinical benefits to the regular practice of physical therapy exercises by patients with osteoarthritis of the knee(s) in a program with appropriate guidance. This study shows that this guidance can be attained at home with the use of a proper manual. Even when performed at home without constant supervision, the use of the printed manual for orientation makes the exercises for osteoarthritis of the knee beneficial.
Article
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Low-level laser therapy (LLLT) is thought to have an analgesic effect as well as a biomodulatory effect on microcirculation. This study was designed to examine the pain-relieving effect of LLLT and possible microcirculatory changes measured by thermography in patients with knee osteoarthritis (KOA). Patients with mild or moderate KOA were randomized to receive either LLLT or placebo LLLT. Treatments were delivered twice a week over a period of 4 wk with a diode laser (wavelength 830 nm, continuous wave, power 50 mW) in skin contact at a dose of 6 J/point. The placebo control group was treated with an ineffective probe (power 0.5 mW) of the same appearance. Before examinations and immediately, 2 wk, and 2 mo after completing the therapy, thermography was performed (bilateral comparative thermograph by AGA infrared camera); joint flexion, circumference, and pressure sensitivity were measured; and the visual analogue scale was recorded. In the group treated with active LLLT, a significant improvement was found in pain (before treatment [BT]: 5.75; 2 mo after treatment : 1.18); circumference (BT: 40.45; AT: 39.86); pressure sensitivity (BT: 2.33; AT: 0.77); and flexion (BT: 105.83; AT: 122.94). In the placebo group, changes in joint flexion and pain were not significant. Thermographic measurements showed at least a 0.5 degrees C increase in temperature--and thus an improvement in circulation compared to the initial values. In the placebo group, these changes did not occur. Our results show that LLLT reduces pain in KOA and improves microcirculation in the irradiated area.
Article
The aim of this study was to investigate the analgesic efficacy of low power laser therapy in patients with knee osteoarthritis (OA). The study design was randomised, placebo-controlled and single blinded. Sixty patients with knee OA according to the American College of Rheumatology criteria were included and randomly assigned to three treatment groups: active laser with dosage of 3J/per painful point, active laser with a dosage of 1.5/J per painful point and placebo laser treatment groups. A Gal-Al-As diode laser device was used as a source of low power laser with a power output of 50 mW and a wavelength of 830 nm. The patients were treated 5 times weekly with 10 treatments in all. The clinical assessments included Western Ontario and McMaster Universities osteoarthritis index (WOMAC) pain, stiffness and physical function subscales. In addition, the intensity of pain at rest and on activation was evaluated on a visual analogue scale. Compared to baseline, at week 3 and at month 6, no significant improvement was observed within the groups. Similarly, no significant differences were found among the treatment groups at any time. With the chosen laser type and dose regimen the results that we obtained in this study, suggest that low-level laser therapy has no effect on pain in patients with knee OA.
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Osteoarthritis, the most common rheumatic disease, always focused treatment on physical measures and symptomatic therapy with analgesics and antiinflammatory agents. New therapies with long-acting symptomatic drugs or structure/disease-modifying agents are now being available with the potential to reverse the structural or biochemical abnormalities of osteoarthritis. The authors summarized a revision of these therapeutic advances.
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The purpose of this study was to determine the effects of laser therapy in pain reduction and/or recovery of patients at the onset of Rheumatoid Arthritis (RA), comparatively with the traditional nonsteroidal anti-inflammatory drugs (NSAIDs). Fifty-nine patients with RA of 6-12 months duration were included in the study. The patients were divided into 3 groups: Group 1 (21 patients) received laser therapy; Group 2 (18 patients) was submitted to placebo laser therapy and NSAIDs medication; Group 3 (20 patients) was treated only with NSAIDs. Physical therapy was instituted in all three groups. GaAIAs diode laser of 830 nm wavelength and 200 mW maximum output power was used. Group 1 received laser therapy once each day, eight days per month, for a total of 32 treatments during a four-month period. The parameters used were 2-4 J/cm2 energy density, and a frequency of 5 Hz or 10 Hz depending on the number and severity of pain in the affected joints. Placebo laser treatment was given to group 2. The functional activity score, the acute phase reactants (ESR and C - reactive protein), T - lymphocytes and NK (natural killer) - cells were estimated. Synovial biopsies and Magnetic Resonance Imaging (MRI) of the synovial membrane were performed as well. The analysis of the clinical and biological parameters at the end of treatment showed a statistically significant decrease of duration of morning stiffness, of pain at rest and during movements, and improved acute phase reactants. The overall efficacy rate in these studies was 86% in the fttst group, 50% in laser placebo group and 40% in the NSAIDs-treated third group. After four months of treatment, our investigations showed that 830 nm infrared laser therapy promoted the restoration of function, relieved pain and limited the complications of RA.
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For the purposes of classification, it should be specified whether osteoarthritis (OA) of the knee is of unknown origin (idiopathic, primary) or is related to a known medical condition or event (secondary). Clinical criteria for the classification of idiopathic OA of the knee were developed through a multicenter study group. Comparison diagnoses included rheumatoid arthritis and other painful conditions of the knee, exclusive of referred or paraarticular pain. Variables from the medical history, physical examination, laboratory tests, and radiographs were used to develop sets of criteria that serve different investigative purposes. In contrast to prior criteria, these proposed criteria utilize classification trees, or algorithms.
Article
To determine if clinical guidelines recommending therapeutic exercise for people with knee osteoarthritis (OA) are supported by rigorous scientific evidence. To explore whether the magnitude of treatment benefit reported in randomized controlled trials (RCT) is associated with exercise dosage or study methodology. We conducted a metaanalysis of RCT comparing some form of land-based therapeutic exercise with a nonexercise group using pain and self-reported physical function outcomes. The 32 included studies provided data on almost 3800 participants. Metaanalysis revealed a beneficial treatment effect: standardized mean difference (SMD) 0.40 [95% confidence interval (CI) 0.30 to 0.50] for knee pain; SMD 0.37 (95% CI 0.25 to 0.49) for physical function. While the pooled beneficial effects of the 9 RCT evaluating exercise programs providing fewer than 12 direct supervision occasions or the 9 RCT judged to have a low risk of bias remained significant and clinically relevant, the magnitude of treatment benefit pooled from these RCT was significantly smaller than the comparator group (12 or more supervision occasions, moderate to high risk of bias, respectively). The mode of treatment delivery (individual treatments, exercise classes, home program) was not significantly associated with the magnitude of treatment benefit. There is evidence that land-based therapeutic exercise has at least short-term benefit in terms of reduced knee pain and physical disability for people with knee OA. The magnitude of the treatment effect was significantly associated with the number of direct supervision occasions provided and study methodology (assessor blinding, adequate allocation concealment).