High intensity laser therapy for common sports injuries and orthopedic diseases

doi:10.3969/j.issn.2095-4344.1214

Abstract

Abstract:

BACKGROUND: High energy laser therapy has good penetration and high output power, and has broad prospects in the treatment of common orthopedic diseases and common sports injuries, such as degenerative diseases of bone and joints, chronic muscle and soft tissue injuries, and spinal diseases. At present, the clinical application of this therapy lacks a unified standard, and there is a lack of evidence-based medical support in terms of indications, parameters and courses of treatment. Therefore, more randomized controlled studies are needed.

OBJECTIVE: To provide theoretical and methodological basis for high-energy laser therapy in the treatment of common sports injuries and orthopedic diseases.

METHODS: Databases of PubMed, CNKI, and WanFang were searched from May-July, 2018. The keywords were “high intensity laser therapy, sports injuries, physical therapy, osteoarthritis degenerative disease, chronic muscle soft tissue injury, spinal disease” in English and Chinese, respectively for the articles published from 2010 to 2018.

RESULTS AND CONCLUSION: (1) Twenty-one eligible articles were included in the study, including diseases such as osteoarticular degenerative diseases, chronic muscle soft tissue injuries, spinal diseases, metabolic diseases, and acute muscle and soft tissue injuries. (2) When dealing with the same disease, the parameters of high energy laser therapy have different choices. The course of the disease, the severity of the condition, and the thickness of the body’s blocking tissue may affect the adjustment of the treatment. (3) High energy laser therapy can reduce inflammation, production of painful substances, promote blood circulation and lymph circulation, and repair damaged tendons. High energy laser therapy can cure local bone loss and stimulate new bone formation. The treatment effect on common sports injuries and orthopedic diseases is expected.

Key words: high intensity laser therapy, sports injuries, physical therapy, osteoarticular degenerative diseases, chronic muscle soft tissue injury, spinal disease, orthopedic diseases, metabolic diseases

CLC Number:

R455

Lü Ting, Ding Jie, Qian Yi, He Chen, Gao Feng, Xi Rui, Zhou Jingbin, Kong Xiliang. High intensity laser therapy for common sports injuries and orthopedic diseases[J]. Chinese Journal of Tissue Engineering Research, 2019, 23(16): 2566-2572.

Figures/Tables 4

2.2 高能量激光的作用机制激光是一种特殊的人造光，产生的光具有医学治疗属性，如高亮度、高方向性等。高能量激光疗法的光源同常规激光疗法相同，为半导体激光，均可产生特定波长，如1 064 nm的光[20]。将二极管产生的光引入光纤，并将光纤的末端连接到探头上，后通过一系列透镜对光束进行处理，以确保激光光束的正确性，这种激光能输送安全稳定的功率，并且相较低能量激光可减少治疗时间[21-23]。高能量激光疗法治疗的效果由功率和波长决定，组织中的最佳激光波长应在650-1 100 nm。 2.3 高能量激光的治疗机制高能量激光疗法使用特定的波形，以减少热积累现象，更有利于穿透更深层次的组织，且热效应引起血管舒张，使更多代谢物被吸收，促使氧气和代谢物的快速交换，使更多的氧原子到达线粒体，增加线粒体氧化反应，更快的合成ATP[24-26]。大量的ATP利于RNA和DNA快速合成，促进组织快速恢复及愈合，缓解治疗区域水肿[9，27-29]。同时，高能量激光疗法治疗还可增加微循环，促进内因子分泌，并开启免疫反应和神经再生，帮助恢复组织结构和缓解疼痛[30-33]，还能在深层组织中快速诱导光化学和光热效应，可刺激肌腱内的胶原产生增加血流量、血管通透性和细胞代谢，起到镇痛作用[14，34-36]、消除炎症反应和水肿的作用[37-39]。此外，带有高能量激光束的高能量激光疗法通过发色团吸收小且缓慢的光已经得到更广泛的应用，这种吸收不是通过光的强度，而是通过传播到各个方向，增加线粒体氧化反应，三磷酸腺苷、RNA以及DNA的产生。高能量激光疗法治疗的镇痛作用基于多种作用机制，包括其减缓疼痛刺激物传播的能力和增加体内类似吗啡的产生[31-37]。 2.4 高能量激光的适应证高能量激光疗法具有极好的穿透性及多重物理治疗效应，因此被应用于多种运动损伤与骨科疾病的治疗中，如骨关节退行性疾病、慢性肌肉软组织疾病及部分常见的脊柱疾病，见表1。"

骨关节退行性疾病方面，Stigli?-Rogoznica等[35]选取Kellgren-Lawrence 评分量表分2或3级的膝骨关节病患者进行高能量激光疗法治疗，并取得了不错的疗效。慢性肌肉软组织疾病方面，有研究使用高能量激光疗法治疗肱骨外上髁炎[3，34，40]、肩峰下撞击症[17，36，41]、冻结肩[42]、斜方肌肌筋膜疼痛综合征[2]。脊柱疾病方面，颈椎病[43-44]、腰椎间盘突出症[4，27]、及广泛的腰背痛的患者都曾接受高能量激光疗法治疗并取得了不错的疗效[14，39]。甚至有研究尝试使用高能量激光疗法治疗骨质疏松(双能量X射线吸收仪T评分≤-1.5)的患者，患者疼痛和生活质量等也得到显著的改善[45-46]。但目前尚缺乏高能量激光疗法治疗急性创伤性疾病的研究，提出的高能量激光疗法治疗对急性踝扭伤的研究也相对较少[47]。上述相关文献中尚无高能量激光疗法治疗的禁忌证和严重不良反应的报道。对于常见慢性骨科与运动损伤具有镇痛、消肿和促进愈合的作用，可作为常见运动损伤的补充治疗方法[3，34-35，40-44]。 2.5 高能量激光治疗常见运动损伤和骨科疾病的使用方法及疗程相较其他激光疗法，高能量激光疗法具有特殊的波长和功率，且治疗不同骨科疾病及运动损伤选用的剂量也各不相同，见表2。高能量激光疗法通常设置的波长都是1 064 nm，但是Haladaj等[44]使用高能量激光疗法治疗颈椎病时选用的波长为980 nm。而Alayat等[43]报道中高能量激光疗法治疗颈椎病时仍延用了常规的高能量激光疗法波长1 064 nm。造成这种差异的原因可能是Halada等[44]研究中使用的高能量激光疗法型号和疗程的不同。高能量激光疗法治疗的功率和剂量在治疗不同疾病时都有所不同。功率方面，在退行性疾病中的功率使用的范围为10.5-12.0 W；慢性肌肉软组织损伤中功率的范围为6- 10 W；脊柱疾病的功率适用范围为3.8-12.0 W；骨质疏松症的患者选用的功率为0.75 W；急性肌肉软组织损伤中功率的选择为7 W。剂量方面，在退行性疾病中剂量的使用范围为510-1 780 mJ/cm2；慢性肌肉软组织损伤中剂量使用的范围为360-1 780 mJ/cm2；脊柱疾病剂量的选择范围是360-1 378 mJ/cm2；骨质疏松症的患者剂量使用的范围为510-710 mJ/cm2；急性肌肉软组织损伤剂量的选择是10 J/cm2。而值得一提的是，Karaca[17]在应用高能量激光疗法治疗肩峰下撞击综合征的时候提出，一定范围内，不同的功率和剂量都有一定疗效，然而具体产生的效应可能有所不同，在这基础上，Karaca[17]提出了2种模式——镇痛模式和生物模式：镇痛模式的功率为8 W，剂量为12 J/cm2，可以通过机械刺激自由神经末梢引起疼痛抑制，从而减轻疼痛；生物模式的功率为7 W，剂量为 100 J/cm2，能够增强愈合和恢复。总之，应对相同的疾病时，高能量激光疗法的参数也有不同的选择。毕竟，疾病的病程、病情的严重程度等都有可能影响治疗方法的调整。严格的筛选患者，把握治疗的时机，并注意与其他治疗方式的联合应用，才能够正确的使用高能量激光疗法。但这些都尚待进一步研究。"

2.6 高能量激光的疗效 2.6.1 高能量激光治疗骨关节退行性与软骨损伤的疗效骨关节炎是最常见的关节炎形式，是老年人独立性降低和生活质量变差的主要原因[24，51-56]。近年来，高能量激光疗法应用于膝关节炎取得显著的疗效。Rogoznica等[35]探讨了高能量激光疗法对膝骨关节炎患者的镇痛效果。结果显示，入选患者接受高能量激光疗法治疗后，整体疼痛减少(63±25)%。Angelova等[37]做出了相同的研究，结果显示患者在治疗7 d后目测类比评分结果显著降低，并且对疼痛的减轻效果持续了3个月。表明高能量激光疗法治疗对膝关节骨性关节炎疼痛具有强烈的即时，累积和持久效应。Kim等[38]研究了应用保守治疗(干扰电流以及超声波)对膝骨关节炎患者进行治疗，随后立即进行高能量激光疗法治疗，结果发现目测类比评分和Korean Western Ontario and McMaster Universities 骨关节炎指数都有明显改善。Alayat等[48]将高能量激光疗法结合氨基葡萄糖和硫酸软骨素治疗膝骨关节炎患者，结果发现，与对照组相比，目测类比评分和Korean Western Ontario and McMaster Universities 骨关节炎指数都有明显改善。高能量激光疗法和低水平激光治疗都能有效地降低改善患者的关节疼痛和功能，但是高能量激光疗法的治疗比低水平激光治疗更有效[24]。还有研究发现高能量激光疗法能够有效的改善膝骨关节病，可能与高能量激光疗法的渗透波长和参数也有一定的关系，1 064 nm的波长能够渗透深部组织，增加微循环，促进内因子分泌，开启免疫反应和神经再生，从而帮助恢复组织结构和缓解疼痛[38，48]。 2.6.2 高能量激光治疗慢性肌肉软组织损伤的疗效肱骨外上髁炎是常见的肌肉骨骼疾病[21，58-60]。Akkurt等[34]研究了高能量激光疗法对肱骨外上髁炎患者的治疗效果，发现疗程结束后(2周)，患者的疼痛、生活质量和功能能力等都有显著改善。徐青等[40]观察了高能量激光疗法治疗结合理筋渗透手法治疗肱骨外上髁炎的疗效，结果显示在治疗7，14 d后疼痛、肌力与基线值相比明显改善。Dundar等[3]则比较了高能量激光疗法、支具保护和安慰剂对肱骨外上髁炎患者的治疗效果，结果显示高能量激光疗法组与支具组疼痛与功能无显著性差异。以上研究结果的不同，可能是由于其研究对象和研究方法不同所致。肩痛通常表现为肩峰下撞击综合征。Kim等[42]和Karaca等[17]分别运用高能量激光疗法对冻结肩和肩峰下撞击综合征做出了研究，结果发现高能量激光疗法治疗对冻结肩和肩峰下撞击综合征患者的疼痛和功能都有明显的改善。Pekyavas等[41]比较了高能量激光疗法、肌肉胶贴带治疗和手法治疗对肩峰下撞击综合征患者的治疗效果。结果发现，高能量激光疗法治疗比肌肉胶贴带治疗和手法治疗对肩峰下撞击综合征患者的治疗效果显著。Santamato等[36]则评估了高能量激光疗法和超声波治疗肩峰下撞击综合征患者的临床疗效，结果显示与超声波组相比，高能量激光疗法治疗组治疗后肩峰下撞击综合征患者的疼痛、关节活动度、功能和肌肉力量明显改善。Dundar等[2]研究了高能量激光疗法治疗斜方肌肌筋膜疼痛综合征的女性患者的疗效，结果显示高能量激光疗法和安慰剂均能改善第4和12周的疼痛、活动范围和生活质量，且与安慰剂相比，高能量激光疗法在疼痛评分、功能方面效果更为明显。因而认为高能量激光疗法是治疗斜方肌肌筋膜疼痛综合征的有效方法。以上研究表明，高能量激光疗法治疗慢性肌肉软组织损伤能取得良好的疗效，治疗肱骨外上髁炎、冻结肩和肩峰下撞击综合征等改善明显，尤其在肩峰下撞击综合征的治疗方面优于超声波治疗，高能量激光疗法治疗慢性软组织损伤的效果优于超声波等物理治疗方式，这可能是由于高能量激光疗法治疗和超声波治疗的强度、持续时间和频率的不同造成的。 2.6.3 高能量激光治疗脊柱疾病的疗效腰椎间盘突出症的特征是腰痛，下肢疼痛和麻木或感觉缺乏[61]。Chen等[27]研究了高能量激光疗法治疗腰椎间盘突出症患者的疗效，结果显示高能量激光疗法结合脊柱减压系统可有效的改善腰椎间盘突出症。Boyraz等[50]研究了高能量激光疗法、超声和药物治疗腰椎间盘突出症的疗效。结果显示，经过10 d的治疗，3组之间与基线值相比没有明显变化，且高能量激光疗法、超声波和药物是治疗腰椎间盘的有效方法，但从辅助护理的角度来看，高能量激光疗法和超声波的疗效更长，而运动疗法是治疗和预防腰背痛的不可忽视的方法。Alayat等[14]比较了高能量激光疗法治疗结合或不结合运动疗法治疗腰背痛的临床疗效，结果显示高能量激光疗法治疗结合运动对治疗腰背痛患者更加有效，远期随访效果更好。Choi等[39]对患者先进行20 min热敷治疗，15 min干扰波治疗，5 min超声波治疗，随即进行高能量激光疗法治疗，发现高能量激光疗法治疗能显著改善腰背痛患者的疼痛和功能，提高生活质量。以上结果提示，将高能量激光疗法治疗作为腰背痛患者综合治疗的一部分，能取得良好的临床疗效。颈椎病是一种常见的与年龄相关的慢性椎间盘退变病症[62]。Alayat[43]等研究了高能量激光疗法治疗对颈椎病患者颈椎活动度、疼痛和功能活动的影响。同时接受高能量激光疗法与运动疗法的颈椎病患者，与安慰剂组相比，颈椎活动度显著改善，目测类比评分和颈部损伤指数都显著降低。有研究对比了牵引治疗和高能量激光疗法治疗颈椎病的疗效，结果发现，2种治疗方法在治疗后即刻和治疗4周后均提高了患者的疗效和镇痛效果，而高能量激光疗法治疗组在长期随访(12周后)中比牵引治疗方法更有效[44]。高能量激光疗法能够有效治疗脊柱疾病，研究表明高能量激光疗法治疗腰椎间盘突出症、腰背痛以及颈椎病的效果明显，可以有效缓解脊柱疾病症状，降低疼痛、恢复运动能力，但是高能量激光疗法治疗脊柱疾病的研究还相对较少，应不断加大对脊柱疾病的治疗样本量来加强高能量激光疗法治疗的有效性。 2.6.4 高能量激光治疗骨质疏松症的疗效骨质疏松症被定义为低骨量并且是一种全身性骨病，其特征在于骨组织微结构的退化导致骨脆性增加和容易骨折的骨[63]。尽管高能量激光疗法在骨愈合和重塑方面疗效的研究使其成为骨疾病的有价值的治疗方法，但仅有少数几项研究探索了其对骨质疏松症的作用。有研究将高能量激光疗法结合运动对疼痛、与健康有关的生活质量和降低男性骨量流失或骨质疏松风险的效果作出研究[45-46]。结果表明高能量激光疗法治疗结合运动可有效的使骨密度增加。 2.6.5 高能量激光治疗急性肌肉软组织损伤的疗效目前，关于急性踝关节扭伤的研究还相对较少，踝关节是运动损伤中最长见的部位[19，32，47，64-66]。踝关节损伤是运动和体育活动中最常见的肌肉骨骼损伤，使生活质量下降，整个生命过程中体力活动水平降低，其踝关节扭伤慢性病的发展，也可能会导致很多长期问题的发生[65]。黄思思等[47]观察了高能量激光疗法治疗急性踝关节扭伤的疗效，结果显示高能量激光疗法治疗较低水平激光治疗改善疼痛和肿胀效果更明显。据调查目前研究高能量激光疗法治疗急性创伤性疾病的报道还太少，尚缺乏证据证明高能量激光疗法的有效性。因此，还需要进一步加强对急性肌肉软组织损伤的研究。 "

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