Treatment Rationale
Problem: Your client is a 40 yo male with Achilles tendon pain that has been present for 1 week following the Cherry Blossom 10 mile race. His longest training run was 5 miles, but had been running 2-3 times per week for 2 months prior to the race. He presents with antalgic gait and is tender to palpation over the Achilles tendon, with mild swelling.
Justification: Tumilty et al.(1) performed a systematic review on the use of low-level laser for the treatment of tedinopathy. Of the 25 control clinical trials reviewed, 12 showed positive results and 13 had inconclusive or showed no effect. In the 12 articles that showed positive results, the dosages used were similar to the currently recommended guidelines. In regards to the studies reviewed with subject who had Achilles Tendinopathy, the subjects had a 13.6 mm decrease in pain on a 100 mm VAS. Stergioulas et al.(2) performed a study that looked at the effect of adding low-level laser therapy to an eccentric exercise program for athletes with Achilles tendinopathy. The subjects were all recreational athletes who had Achilles tendinopathy and were randomized to either a group of eccentric exercise and low-level laser therapy or a group with eccentric exercise and a placebo laser for 12 weeks. Pain intensity (measured on a 100 mm VAS) during physical activity was significantly lower for the low-level laser therapy group at 4, 8, and 12 weeks. The secondary outcomes of morning stiffness, palpation tenderness, active dorsiflexion, and crepitation were also all more improved in the low-level laser group compared to the placebo group. Bjordal et al.(3) performed a study looking at the effects of low-level laser therapy on activated Achilles tendinitis and determining if the low-level laser therapy had any anti-inflammatory effects. The study had a low-laser therapy group and a placebo therapy group. The low-level laser group had significantly decreased inflammation as measured by the prostaglandin count and significantly increased pressure pain threshold compared to the placebo group.
Procedure: I will be using the procedure that was followed in the study by Stergioulas et al.(2) I will be using the low-level laser therapy and eccentric exercise group procedure, but since I am just focused on the low-level laser therapy, I will not be including the procedure of the eccentric exercises. I will use a low-level laser with a wavelength of 820 nm and apply it to 6 points along the Achilles tendon with a power density of 60 mW/cm2 and a total dose of 5.4 Joules per session. I will administer this treatment once a week for 12 weeks. The patient will be prone with his foot off the end of the plinth during the treatment sessions.
Outcome: Many outcomes were used in these studies, but I am going to use the 100 mm visual analog scale (VAS) and tenderness to palpation, both as outcome measures for pain since this seems to be my patient’s chief complaint. The outcomes will be measured at the initial visit, 4 weeks, 8 weeks, and 12 weeks.
References:
1.Tumilty S, Munn J, McDonough S, Hurley DA, Basford JR, Baxter GD. Low level laser treatment of tendinopathy: a systematic review with meta-analysis. Photomed Laser Surg. 2010;28(1):3-16. doi:10.1089/pho.2008.2470.
2.Stergioulas A, Stergioula M, Aarskog R, Lopes-Martins RAB, Bjordal JM. Effects of low-level laser therapy and eccentric exercises in the treatment of recreational athletes with chronic achilles tendinopathy. Am J Sports Med. 2008;36(5):881-887. doi:10.1177/0363546507312165.
3. Bjordal JM, Lopes‐Martins RAB, Iversen VV. A randomised, placebo controlled trial of low level laser therapy for activated Achilles tendinitis with microdialysis measurement of peritendinous prostaglandin E2 concentrations. Br J Sports Med. 2006;40(1):76-80. doi:10.1136/bjsm.2005.020842.