achilles tendinopathy treatment with triple therapy
TRANSCRIPT
ACHILLES TENDINOPATHY TREATMENT WITH TRIPLE THERAPY: A
PILOT STUDY
School of Specialities in PRM “G. d’Annunzio” University, Chieti-Pescara, Italy
R. G. BELLOMO, F. CAPOGROSSO, D. PORTO, L. DI PANCRAZIO, S. SANTINI, R. SAGGINI
ACHILLES TENDINOPATHY
- One of the most frequent pain diseases - Especially from the amateur sport - 11% from the runners - Average onset age: between 28 and 55 years old - Can be acute or chronic (3 weeks)
(Alfredson H, Cook J. A treatment algorithm for managing Achilles tendinopathy:new treatment options. Br J Sports Med 2007;41:211–6.)
ACHILLES TENDINOPATHYCLINIC
1. Heel pain: sudden, gradual or insidious 2. Increased pain just after inactivity 3. Functional limitation in foot dorsiflexion and plantarflexion 4. Tendon and pre-insertional pain 5. Swelling increased at pre-insertional portion 6. Antalgic lameness
ACHILLES TENDINOPATHY
HISTOPATHOLOGY • Opacification of the triangle of Kager • Tendon thickening • Degeneration of collagen tissue • Outbreaks of hyaline degeneration • Increased neovascularization • Increase in PGE2 • Increase of neurogenic inflammatory factors
(substance P; calcitonin gene-related peptide) • Increased fibroblasts proliferation
(Bjur D, Alfredson H, Forsgren S. The innervation pattern of human Achilles tendon: studies of the normal and tendinosis tendon with markers for general and sensory innervation. Cell Tissue Res 2005;320:201–6.)
DIAGNOSIS • CLINICAL EXAMINTAION • ULTRASONOGRAPHY • RMN
DIFFERENTIAL DIAGNOSIS
1. Os trigonum syndrome 2. Peroneal tendons deseases 3. Tenosynovitis of plantar flexors 4. Stress fractures in the hindfoot 5. Accessory soleus muscle miofascial syndrome 6. Tumors (Achilles tendon xantoma) 7. Bursitis 8. Sural neuroma COMPLICATIONS Tendon rupture
(Alfredson H. Conservative management of Achilles tendinopathy: new ideas. Foot Ankle Clin 2005;10:321–9.)
CURRENT THERAPIES • Corticosteroids inflitrations • Eccentric exercise • ESWT • Sclerotherapy • Electrocoagulation • Topic Trinitrato Glycerole (GTN)
• Triple Therapy : 2 laser sources • Source 1:
• Source 2:
• Scan time: 10-15 minutes • You can set Time, Power, Frequency, Spot
üGa Al As (Gallio, Alluminio, Arsenurio) üPower: 10 W üWavelenghts: 805-811 nm üFrequency: 1-10000 Hz üDuty cycle: 50%
üGa Al As (Gallio, Alluminio, Arsenurio) üPower: 15 W üWavelenghts: 1061-1067 nm üFrequency: 1-10000 Hz üDuty cycle: 50%
TRIPLE – THERAPY BY LEVEL
THERAPEUTIC EFFECTS
• Active hyperemia (increase in size
and decrease in the permeability of the blood and lymph vessels)
• Stabilization of the cell membrane
of mast cells • Activation of phagocytes
ANTI-INFLAMMATORY/EDEMA EFFECTS
wash-out effect on pro-inflammatory substances (histamine, bradykinin, cytokines, lymphokines)
greater supply of oxygen and nutrients
decreased histamine production
removing harmful substances
Barberis – 1996; Honmura – 1992-93; Sato – 1994.
THERAPEUTIC EFFECTS
• On the surface of the block, potential actions in nociceptive endings are inducted through changes in axonal membrane permeability (Belkin– 1994; Jimbo – 1998);
• The active hyperemia promotes the wash-out of the
algogenic substances; • Pain modulation by interaction with the large caliber
myelinated fibers; • Increase in morphine-mimetic substances (endorphins,
enkephalins) (Walker– 1983 Corti – 1986, Ponnudurai – 1988, Zati - 1997).
ANALGESIC EFFECT
THERAPEUTIC EFFECTS
• Increased production of ATP from ADP at the mitochondrial level;
• Promotion of cell replication; • Promotion of the RNA and proteins (collagen) synthesis with facilitation of repair processes (Smolianova– 1990; Manteifel’v – 2004, 2005, 2009).
BIOSTIMULANT EFFECT
CONTROINDICATIONS
ABSOLUTE • Areas that are near the
eye; • Bleeding diathesis area; • Areas that are near the
uterus (in women of childbearing potential);
• Cancer patients; • Epilepsy.
RELATIVE
• Cardiac area in cardiac
patients; • With infectious
inflammation or allergy in progress;
• Patients with very dark skin.
It is important that both the patient and the operator use the appropriate protective eyewears that filter the light in an appropriate manner to the wavelength of the laser source
CLINICAL INDICATIONS:
• Analgesic and anti-inflammatory therapy for
musculoskeletal (tendonitis, bursitis, bruising, injury, muscle spasms)
• Trigger points: miofascial syndrome • Tender points: fibromialgy • Neuralgia (trigeminal and post-herpetic neuralgia) • Ulcers
TRIPLE – THERAPY BY LEVEL
MATERIALS AND METHODS
5 PATIENTS (average 49 years; 3 M and 2 F) ENROLLMENT: between February 2012 and May 2012 INCLUSION CRITERIA: • Chronic tendinopathy present at least 3 months • Clinical and ultrasonography diagnosis • Between 28 and 55 years • Usual non competitive sports activities • Drug therapy not in progress EXCLUSION CRITERIA: • Ongoing pregnancy • Cancer patients • Bleeding diathesis area
MATERIALS AND METHODS 1. 3 treatments per week for 3 weeks T0/T1 2. Treatment duration: 15 minutes 3. 41 J for each session 4. 8 W at 200 Hz (10J) for the diode of 808 nm and 12 W
in continuos mode (31J) for the diode of 1064 nm
MATERIALS AND METHODSPre- and post-treatment evaluation :
1. VAS 2. Fischer algometer 3. Ultrasonography 4. Termography
RESULTSVAS Pre-treatment: 8.2 (range between 6 and 9) Post-treatment: 1.4 (range between 1 and 2) REDUCTION OF 83%
RESULTS
0
2
4
6
8
10
PRE POST
8,2
1,4
VAS
RESULTSFISCHER
ALGOMETER Pre-treatment: 5 kg/cm2
(range between 3 and 7)
Post-treatment: 18 kg/cm2
(range between 16 and 20)
RESULTS
0 5 10 15 20
POST
PRE
18
5
FISCHER ALGOMETER (kg/cm2)
RESULTS
ULTRASONOGRAPHY Pre-treatment: accentuation of
hypoechogenicity Achilles tendon and peritendinous components
Post-treatment: significant reduction of
ultrasonographic hypoechogenicity of evaluated structures
Pre-treatment T0= 30.1° C
THERMOGRAPHY
Post-treatment T0= 34.4° C
27.1°C<30°C<31°C
Pre T0
Post T0
27.7°C<33.1°C<34.3°C
Pre-treatment at sessione 5 =29.3° C
• Pre T 1/2
26.8°C<29.3°C<30.1°C
Pre-treatment T1=28.1° C
27.1°C<28.7°C<30.8°C
Pre T1
RESULTS
THERMOGRAPHY T0: Δt= 4.3° C
RESULTS
THERMOGRAPHY T0= 30.1° C T1= 28.2° C
RESULTS
THERMOGRAPHY T0: Δt= 4.3° C (with inflammation) T1: Δt= 4.1° C (healthy)
4,3
4,14
4,1
4,2
4,3
PRE POST
THERMOGRAPHY (ΔT) C°
CURRENT PROTOCOL • Treatment duration of 15 minutes • 41 J for each session • 8 W at 200 Hz (10J) for the diode of 808 nm • 12 W in continuos mode (31J) for the diode of 1064
nm
DISCUSSION At the end of 9 sessions of treatment, carried
out over a period of 3 weeks, a significant reduction of the inflammatory Achilles framework has been highlighted, resulting in reduction of pain symptoms (assessed by VAS and Fischer algometer) and improvment of the ultrasound and thermografic framework.
None of the 5 patients experienced adverse reactions.
CONCLUSIONSBased on the obtained results, even considering
the small number of treated patients, we can consider the Triple Therapy appropriate in Achilles tendinopathy, even without combination with any other therapeutic aids, taking less time than using other methods.
Today we are testing it in larger and heterogeneous groups of patients.
Thanks