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What Helps Tendinosis and How?
511
Letter What Helps Tendinosis and How? I READ with interest Liz Saunders’ research paper on the use of laser versus ultrasound in the treatment of supraspinatus tendinosis (Saunders, 2003). Both groups of patients receiving the electrotherapy modalities demonstrated improvements in objective and subjective outcome measures compared to the control group. The author comments that laser and ultrasound ‘in theory reduce inflammation and promote healing and therefore should be useful in the treatment of tendinosis’ (page 366). However, recent literature supports the view that tendinosis is a noninflammatory degenerative disorder, in which inflammatory cells are absent (Benjamin and Ralphs, 1996; Khan et al, 2000; Schepsis et al, 2002). It is therefore interesting to postulate
the mechanisms underlying the improvements observed in this study. It may be that laser and ultrasound moderate the biochemical irritant model of pain in tendinosis (Khan and Cook, 2002) and promote collagen repair. It may be that there are powerful placebo effects inherent in frequent physiotherapy appointments, the therapeutic relationship that develops and the ‘hi-tech’ treatment in an environment characterised by specialised tools, uniforms and other patients waiting for attention (Harrison and Barlow, 1996). These are all part of the ritual of therapeutic encounters, which signifies the patients’ involvement in treatment, to themselves and to others, and underpins the belief that change can
occur as a result (Mitchell and Cormack, 1998). Laser treatment produced better results than ultrasound, which we can only assume were clinically significant. Since the patients receiving ultrasound also improved, the enhanced effects of laser do not refute the potential ‘non-technical’ mechanisms described above that may contribute to the efficacy of a course of treatment. Laser may also be a more effective modality in the treatment of this type of degenerative, rather than inflammatory, pathology. Liz Saunders is to be congratulated on her thought-provoking paper.
repair as Ros Johnson suggests in her letter. My earlier study (Saunders, 1995) compared dummy laser with active laser in a double-blind randomised trial of supraspinatus tendinitis, the term used for overuse tendinosis prior to the sudy by Khan et al. The laser group significantly improved in their symptoms but the dummy laser group showed no improvement. The evidence therefore is that there are no placebo effects due to laser. It is important, however, that an adequate dose of laser is applied in order that the target tissues are stimulated; the loss of laser energy in the skin and superficial tissues must be
taken into account. In both studies the degenerative nature of the tendinosis was addressed by advising patients to reduce load in the tendon, by giving appropriate ergonomic advice, in an attempt to prevent further degeneration of the tendon. Although the patients receiving ultrasound also improved, it is important to note that their improvement was not significantly different from the control group, hence my recommendation to physiotherapists to use laser rather than ultrasound to improve the symptoms of patients with supraspinatus tendinosis.
Ros Johnson MCSP University of the West of England
Dr Liz Saunders replies: Khan et al (2000) in their paper on overuse tendinosis point out that while tendinosis is the more common, partial rupture or tendinitis may occur in conjunction with primary tendinoses and does involve an inflammatory repair response. The subjects in my study (Saunders, 2003) were acute in that they had pain and secondary weakness on isometric contraction of the tendon and their tendon was tender on palpation. They may indeed have had small tears that responded to the biostimulatory effects of laser in that their symptoms significantly improved compared with the ultrasound and control groups, or laser may have promoted collagen
References for Ms Johnson and Dr Saunders Khan, K, Cook, J, Taunton, J E and Benjamin, M and Ralphs, J R (1996). Bonar, F (2000). ‘Overuse tendinosis, ‘Tendons in health and disease’, not tendonitis. Part 1: A new paradigm Manual Therapy, 1, 4, 186-191. for a difficult clinical problem’, Harrison, K and Barlow, J (1996). The Physician and Sportsmedicine, 28, 5, ‘Iatroplacebogenesis: A useful theraavailable at peutic tool?’ British Journal of Therapy www.physsportsmed.com/issues/2000/ and Rehabilitation, 3, 3, 142, 159-163. 05_00khan.htm Khan, K and Cook, J K (2002). Mitchell, A and Cormack, M (1998). ‘Overuse tendon injuries: Where does The Therapeutic Relationship in the pain come from?’ in: Bruckner, P Complementary Healthcare, Churchill and Khan, K (eds) Clinical Sports Livingstone, Edinburgh. Medicine, McGraw-Hill Education, Europe.
Saunders, L (1995). ‘The efficacy of low level laser therapy in supraspinatus tendinitis’, Clinical Rehabilitation, 9, 126-134. Saunders, L (2003). ‘Laser versus ultrasound in the treatment of supraspinatus tendinosis: Randomised controlled trial’, Physiotherapy, 89, 6, 365-373. Schepsis, A A, Jones, H and Haas, A L (2002). ‘Achilles tendon disorders in athletes’, American Journal of Sports Medicine, 30, 2, 287-305.
Physiotherapy August 2002/vol 88/no 8
Letter What Helps Tendinosis and How? I READ with interest Liz Saunders’ research paper on the use of laser versus ultrasound in the treatment of supraspinatus tendinosis (Saunders, 2003). Both groups of patients receiving the electrotherapy modalities demonstrated improvements in objective and subjective outcome measures compared to the control group. The author comments that laser and ultrasound ‘in theory reduce inflammation and promote healing and therefore should be useful in the treatment of tendinosis’ (page 366). However, recent literature supports the view that tendinosis is a noninflammatory degenerative disorder, in which inflammatory cells are absent (Benjamin and Ralphs, 1996; Khan et al, 2000; Schepsis et al, 2002). It is therefore interesting to postulate
the mechanisms underlying the improvements observed in this study. It may be that laser and ultrasound moderate the biochemical irritant model of pain in tendinosis (Khan and Cook, 2002) and promote collagen repair. It may be that there are powerful placebo effects inherent in frequent physiotherapy appointments, the therapeutic relationship that develops and the ‘hi-tech’ treatment in an environment characterised by specialised tools, uniforms and other patients waiting for attention (Harrison and Barlow, 1996). These are all part of the ritual of therapeutic encounters, which signifies the patients’ involvement in treatment, to themselves and to others, and underpins the belief that change can
occur as a result (Mitchell and Cormack, 1998). Laser treatment produced better results than ultrasound, which we can only assume were clinically significant. Since the patients receiving ultrasound also improved, the enhanced effects of laser do not refute the potential ‘non-technical’ mechanisms described above that may contribute to the efficacy of a course of treatment. Laser may also be a more effective modality in the treatment of this type of degenerative, rather than inflammatory, pathology. Liz Saunders is to be congratulated on her thought-provoking paper.
repair as Ros Johnson suggests in her letter. My earlier study (Saunders, 1995) compared dummy laser with active laser in a double-blind randomised trial of supraspinatus tendinitis, the term used for overuse tendinosis prior to the sudy by Khan et al. The laser group significantly improved in their symptoms but the dummy laser group showed no improvement. The evidence therefore is that there are no placebo effects due to laser. It is important, however, that an adequate dose of laser is applied in order that the target tissues are stimulated; the loss of laser energy in the skin and superficial tissues must be
taken into account. In both studies the degenerative nature of the tendinosis was addressed by advising patients to reduce load in the tendon, by giving appropriate ergonomic advice, in an attempt to prevent further degeneration of the tendon. Although the patients receiving ultrasound also improved, it is important to note that their improvement was not significantly different from the control group, hence my recommendation to physiotherapists to use laser rather than ultrasound to improve the symptoms of patients with supraspinatus tendinosis.
Ros Johnson MCSP University of the West of England
Dr Liz Saunders replies: Khan et al (2000) in their paper on overuse tendinosis point out that while tendinosis is the more common, partial rupture or tendinitis may occur in conjunction with primary tendinoses and does involve an inflammatory repair response. The subjects in my study (Saunders, 2003) were acute in that they had pain and secondary weakness on isometric contraction of the tendon and their tendon was tender on palpation. They may indeed have had small tears that responded to the biostimulatory effects of laser in that their symptoms significantly improved compared with the ultrasound and control groups, or laser may have promoted collagen
References for Ms Johnson and Dr Saunders Khan, K, Cook, J, Taunton, J E and Benjamin, M and Ralphs, J R (1996). Bonar, F (2000). ‘Overuse tendinosis, ‘Tendons in health and disease’, not tendonitis. Part 1: A new paradigm Manual Therapy, 1, 4, 186-191. for a difficult clinical problem’, Harrison, K and Barlow, J (1996). The Physician and Sportsmedicine, 28, 5, ‘Iatroplacebogenesis: A useful theraavailable at peutic tool?’ British Journal of Therapy www.physsportsmed.com/issues/2000/ and Rehabilitation, 3, 3, 142, 159-163. 05_00khan.htm Khan, K and Cook, J K (2002). Mitchell, A and Cormack, M (1998). ‘Overuse tendon injuries: Where does The Therapeutic Relationship in the pain come from?’ in: Bruckner, P Complementary Healthcare, Churchill and Khan, K (eds) Clinical Sports Livingstone, Edinburgh. Medicine, McGraw-Hill Education, Europe.
Saunders, L (1995). ‘The efficacy of low level laser therapy in supraspinatus tendinitis’, Clinical Rehabilitation, 9, 126-134. Saunders, L (2003). ‘Laser versus ultrasound in the treatment of supraspinatus tendinosis: Randomised controlled trial’, Physiotherapy, 89, 6, 365-373. Schepsis, A A, Jones, H and Haas, A L (2002). ‘Achilles tendon disorders in athletes’, American Journal of Sports Medicine, 30, 2, 287-305.
Physiotherapy August 2002/vol 88/no 8