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Low Level Laser and Tennis Elbow MADAM - In the study by Ottar Vasseljen ‘Low level laser versus traditional physio- therapy in the treatment of tennis elbow’ (May, pages 329-334), it is perhaps under- standable that the laser group fared no better than the traditional physiotherapy group.

The experimental design was different for each group. The laser group was double-blind with neither subject nor physiotherapist knowing whether treatment was being given, but for the traditional group both subjects and therapists knew that the treatment was real.

Presumably the physiotherapy assessor also was only sure that the traditional group had received treatment, as the laser group was part of a double-blind study carried out earlier.

All this was bound to bias any results in favour of the traditional group, especially where subjective tests are being used, and objective tests that require motivation.

I suspect people involved in blind studies where only a gradual improvement is expected will not appear to respond as well as a matched group aware that they are receiving treatment, and furthermore treatment that the physiotherapist is having to work hard at (deep friction massage).

The author used laser parameters to produce a skin surface dose of 3.5 J/cm2 in 10 minutes. As this same dose can be produced in 12 seconds using 50 mW diode (Omega, 1989), laser is potentially a cost-effective treatment compared with the ultrasound and friction massage used in the traditional group which took 17 minutes of physiotherapy time, not to mention the wear and tear on the physiotherapists’ fingers!

Further research is necessary to evaluate laser therapy as there are so many parameters and possible dosages, but the design must be the same for the groups to be compared, otherwise there is really no comparison at all. Liz Saunders MSc MCSP Derby

Reference Omega Universal Technologies Ltd (1989). Sales literature, Omega House, 211 New North Road, London N1 6UT.

MADAM -With reference to the research report appearing in the May issue of Physiotherapy which compared low level laser and traditional physiotherapy in the treatment of tennis elbow, I would like to make the following comments: 1. Why combine two traditional physiotherapy modalities, ie ultrasound and deep frictions? Especially when in the discussion the author refers to a study showing that ultrasound in combination with friction massage was no better than ultrasound alone. 2. As Mr Vasseljen’s article states, to be effective deep friction massage should be carried out for 15-20 minutes. The author says that ‘many physiotherapists find this exhausting’ and so ten minutes was the chosen time. I am sure I am not alone

in finding this attitude insulting, implying that we are happy to carry out less than effective treatment in order to avoid our own exhaustion.

3. The author says that the laser irradiation to the skin was 3.5 J/cm’. Studies have shown that 4 J/cm‘ is the optimum dose and this should be the dose delivered to the tissues concerned, not to the skin (Mester et a/ , 1985; Lam ef a/ , 1986). Only 20% of the skin dose reaches beyond the dermis and thus the author’s chosen treatment dose was patently too low to be effective.

I suggest that these points alone must call into question the validity of the conclusion.

While I firmly believe that research for physiotherapy should be conducted by members of our profession, to be taken seriously both by ourselves and members of the other medical professions it must be carried out in a scentifically rigorous manner. C L Potter MCSP Worthing

References Mester, E et a/ (1985). ’The biomedical effect of laser application’, Lasers in Surgery and Medicine, 5, 31-39. Lam, T S et a/(1986). ‘Laser stimulation of collagen synthesis in human skin fibroblast cultures’, Lasers in the Life Sciences, 1, 1, 41.

MADAM - Having read Mr 0 Vasseljen’s research report on the treatment of tennis elbow in your May issue, we would like to draw his attention to certain ambiguities and clarify his Cyriax references: 1. Deep friction massage is not the treatment of a tennis elbow but a preliminary measure to produce hyper- aemia at the painful scar formed at the tenoperiosteal junction of extensor carpi radialis brevis, thus acting as a local anaesthetic and softening the scar tissue prior to treatment.

The treatment is Mills manipulation, which pulls apart the scar surfaces, resulting in permanent lengthening and thus initiating spontaneous recovery. 2. Preliminary deep friction must be applied for 15 minutes in order to be effective. 3. Dr Cyriax indicated a result of treatment, ie deep friction and Mills manipulation, within 12 treatments, not eight. 4. Cyriax stated that spontaneous recovery takes one year if the patient is less than 60 years old, but stresses that injection of any steriod actually inhibits spontaneous recovery. Bob de Conninck Director Deanne lsler MCSP European Teaching Group of Orthopaedic

Geneva, Switzerland Medicine

Mr 0 Vasseljen comments: In reply to Ms Saunders, our patients

were randomised continuously to either the placebo laser (PL), active laser (AL) or the traditional physiotherapy (TP) group; thus the results are based on one study yielding two publications. The first looked at the effect of AL versus PL in a double-blind fashion (vasseljen eta/, 1992), whereas the other also looked at the AL group, but this time compared the results to the TP group (vasseljen, 1992). Ms Saunders’ comments refer to the latter article. As stated in this article and correctly

pointed out by Ms Saunders, the patients in the AL group had no way of knowing whether they were receiving the AL or the PL, whereas it was obvious to the patients in the TP group that they received treatment. This might set up a bias. However, our design is stated clearly and should be interpreted as such. In spite of possible improvements in further research, we feel that the evidence put forward in our study and a great part of the general literature does not yet support an extensive use of this new regime in favour of more traditional methods used by many physio- therapists. If Ms Saunders feels that a different design would put forward more convincing evidence for the efficacy of low level laser therapy (and of course it may), then this effort should be welcome.

The matter of optimal dosage is not very well understood. It is premature to assume any linearity in the dose/effect curve. In other words, there is no evidence in the literature to support the notion that ‘if some is good, then more is better’. We chose to use a dosage similar to one used in a previous Norwegian study with favourable results of laser therapy for tennis elbow (Gudmundsen and Vikne, 1987).

It is quite misleading of Mrs Potter to argue that a dose of 4 J/cm2 is more effective than 3.5 J/cm2 (as used in our study) in the treatment of tennis elbow. She refers to an article by Mester eta / (1985) which does not deal with tennis elbow or the effects of infra-red lasers at all. I thus find Mrs Potter’s argument puzzling, and strongly feel one should treat references with greater respect.

The dosage calculation is a difficult matter. Many parameters influence the light dosage to the skin and the attenuation of the light intensity through the skin and subdermal tissues. Pulse peak effect or output, pulse width and frequency, irradiation area, beam collimation and treatment time are important parameters in order to calculate the dosage on the skin. Penetration depth in the tissue varies according to the type of tissue. We chose to use an IR laser with peak effect in the watt as opposed to the milliwatt area, since this gives a greater penetration depth in the tissue (the laser used in our study had a 10 W peak effect). This is illustrated in the figure.

It is essential that the researcher adheres to appropriate nomenclature regarding laser energy when reporting results. Not just values given in the sales literature by the manufacturer but measured or calibrated readouts should be provided. In our study we have reported measured values. It is our experience that the technical specifications provided by

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the manufacturers might vary considerably from measured readouts. Very often the sales literature lacks adequate technical specifications in order to calculate dosimetry (personal material, unpub- lished). For more information on appropriate nomenclature and calibration procedures, an article by Arndt eta1 (1981) is recommended.

This short reply cannot include the issue’ of dosage, nor the importance of proper calibration routines. It should be kept in mind that the technical specifications provided by manufacturers are often inadequate for the immaculate researcher.

Finally, technical failure of laser equipment does happen, and in the infra-red spectrum this might be difficult to detect. Efforts in establishing proper calibration routines are thus important both for the researcher and the clinician.

References Vasseljen, 0 (1992). ‘Low-level laser versus traditional physiotherapy in the treatment of tennis elbow’, Physiotherapy, 78, 5,

Vasseljen jr, 0, Hoegh, N, Kjeldstad, B, Johnsson, A and Larsen, S (1992). ’Low- level laser versus placebo in the treatment of tennis elbow’, Scandinavian Journal of Rehabilitation Medicine, 24, 37-42. Gudmundsen, J and Vikne, J (1987). ‘Laserbehandling av epicondylitis humeri og rotatorcuffsyndrom’, Norsk Tidsskriff for Idrettsmedisin, 2, 6-15 (in Norwegian). Arndt, K A, Noe, J M, Northam, D B C and Itzkan, I (1981). ‘Laser therapy - Basic concepts and nomenclature’ Proceedings of the American Academy of Dermatology,

Svaasand, L 0 and Ellingsen, R (1983). ‘Optical properties of human brain’, Photochemistry and Photobiology, 38,

329-334.

5, 6, 649-654.

293-299.

0 .- c 2 c

W/cm2 rnW/crn2 Light intensity

Above: Light intensity from two lasers with equal wavelength and different peak effect (10 W versus 30 mW) attenuating through tissue. Both lasers have an irradiation area of 0.5 c d . Light intensities at the skin surface are 20 W/cmZ and 60 mW/cm2 respectively, i f the reflection is ignored (personal communication with Or Philos Befit weldstad, Institute of Physics, AVH, University of Trondheim, Norway). Results are adapted from Svaasand and Elllingsen 1983)

Physiotherapists Board Disciplinary Committee

In June 1992, the Disciplinary Com- mittee of the Physiotherapists Board heard a case against Mr P S Fitchett, a State registered physiotherapist. This followed the finding by the Society’s Professional Conduct Committee that he had committed serious professional misconduct (Physiotherapy, July 1991, page 457). Mr Fitchett was charged that he did not confine himself to practice in those fields of physiotherapy in which he had been trained, in that he performed an X-ray investigation on a patient.

The Disciplinary Committee found that this was a breach of its code of conduct which constituted infamous conduct in a professional respect. The Committee was

informed that since this incident, due to changes in regulations concerned with X-rays, Mr Fitchett had ceased to use his X-ray apparatus. It was also informed that he intended to retire from practice shortly. In the circumstances, judgement on whether his name should be retained on the register was postponed for a year.

Comment Both the Society and the Board have

now, therefore, found that taking X-rays forms no part of the practice of physio- therapy. Physiotherapists should satisfy themselves that, if they are to undertake innovative techniques, they have the support of a significant section of the profession. A leaflet on the implications of Rule 1 (Scope of Practice) of the CSP’s Rules of Professional Conduct is available from the Professional Affairs Department.

Retirement Thanks MADAM - May I through the medium of the correspondence column of Physiotherapy thank all those involved in making my farewell party on June 5 a resounding success. Gifts and many fond wishes added to the sense of occasion.

I particularly noted that at the party there were at least three individuals who were in the first class I ever taught. Presumably they were in the ‘I’ve started, so I’ll finish’ category.

My thanks to all for their attendance and the good wishes from those unable to attend. Jack Britton BA MCSP DipTP Former Principal Bristol School of Physiotherapy

Franka’s Fund for War Victims

Relief to all victims of the war in the republics of former Yugoslavia is offered by Franka’s Fund, which includes a physiotherapy project initiated by Vivian Grisogono MA MCSP, who is a descendant of the oldest surviving noble family in Dalmatia.

Well known for her books and articles, mainly on treatment of sports people, Miss Grisogono has visited the countrv and is organising teams of physiotherapists to help the war victims - there were more than 16,000 wounded people in Croatia at the beginning of the year, and their numbers rise daily.

The existing rehabilitation services are stretched to the limit. There is a need for physiotherapists to help treat the injured, and a need for specialist training of physio- therapists in the treatment of amputations, head injuries and spinal damage. There is also urgent need for physiotherapy and rehabilitation equipment.

The Croatian Ministry for Health has identified the immediate needs as: 1. The development of treatment centres for spinal and head injuries. 2. Equipment for rehabilitation treatment. 3. Equipment and facilities for disabled sport. 4. Help with the organisation of social and professional rehabilitation, to follow the completion of the medical rehabilitation phase.

British physiotherapists can help these needs, through providing volunteers to help in the day-to-day treatment of the injured, and through setting up educational courses, linked to clinical practice, to help teach the local practitioners the specialist treatments for various types of patients.

An initial appeal has brought an excellent response from physiotherapists keen to volunteer their services to help the war wounded (see Physiotherapy, December 1991, page 816.)

Any other members wishing to offer help in any form can contact Miss Grisogono at 62 Lulworth Avenue, Hounslow, Middlesex TW5 OTZ (telephone and fax 081-570 2082).

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