Joint rehabilitation remains challenging for patients in pain and physical therapists alike. When pain impacts deep tissue, various interventions and modalities such as ultrasound or electrical stimulation may not elicit a response. Laser therapy, said Michael J. Velsmid, DPT, MS, president/director of Boston Sports Medicine, has the depth of penetration needed to reach these deep-tissue areas.
Low-level laser therapy (LLLT) is a pain-free, non-invasive, affordable tool used by physical therapists throughout the healing process that is becoming more prevalent in PT practices nationwide. Unlike surgical lasers, which produce heat and cut tissue, low-level cold lasers are absorbed into the skin to increase cellular activity in tissues, which can bring healing to injured areas.
In musculoskeletal dysfunction, one of the most commonly used lasers-actually an acronym for "light amplification by stimulated emission of radiation"-is a 3b low-level laser with power output of less than 500mW (milliwatts) per diode. A charge is applied to an atom (electricity), which signals a cascade of reactions with an end result of photons (light) being absorbed in the cell mitochondria. This, in turn, produces anti-inflammatory effects, increasing cellular recovery as a pain modulator via its role as a nociceptor inhibitor, according to Lee Howard, PT, PhD, ATC, LAT, CSCS, owner of Carolina Physical Therapy Specialists in Kernersville, NC.
In order for a unit to be true laser, it must produce a monochromatic (one color, one wavelength, one frequency), coherent (photons are in phase and well organized) and collimated beam (minimal divergence), Dr. Howard explained. In turn, the photons are thought to be absorbed into the cell, triggering biostimulatory or bioinhibitory responses. Some of these responses related to musculoskeletal dysfunction include increased cell metabolism and cell proliferation, enhanced DNA and RNA synthesis, improved range of motion (ROM), as well as decreased edema, pain and scar-tissue formation.
Through the amazing transformation of energy, lasers power metabolic processes, creating beneficial proteins and enzymes needed for cellular repair, Dr. Velsmid told ADVANCE. "This leads to the regeneration and repair of damaged tissues and the modulation of pain, which can be used as part of a comprehensive treatment approach when appropriate," he said. "As always, we design and implement treatment plans that are tailored to each individual's needs and personal goals."
While the primary goal of physical therapy is to decrease joint complex pain, decrease inflammation, reduce swelling and achieve an overall therapeutic response-often defined by improved ROM and strength-there's little agreement about the best laser dosage, power and application techniques, explained Dr. Howard, who notes tailoring to the patient is key. "Laser dosing decision-making should be based on condition status (acute versus chronic), the depth of tissue damaged and targeted and stimulatory (cell repair) versus inhibitory desires (decreased swelling)."
"The greatest challenge with joint rehabilitation is overcoming pain and addressing limited joint mobility," added William M. Siegel, PT, DPT, Cert. MDT, clinic supervisor at Burke Rehabilitation Outpatient Clinic in Mamaroneck, NY. "LLLT appears to be a safe and effective modality used for many diagnoses and is worth trying before subjecting a patient to more invasive or less conservative procedures."
The orthopedic and sports medicine patient is an ideal candidate for laser therapy, said Dr. Howard, noting that patients presenting with ecchymosis, edema, muscular "spasm," pain, limited ROM, inflammation, arthritis or joint stiffness often benefit quickly from laser therapy. He estimated that 25 percent of patients in his clinic opt for laser treatment, and are routinely and successfully treated for shoulder tendonitis, pes anserine bursitis, knee pain from meniscus tears, post-operative pain and edema control, migraines, plantar fasciitis, low-back pain and muscle strains.
"Patients often respond within one to two applications given optimal application parameters. We have had instances where patients have literally not been able to walk in the clinic with foot flat (heel and toe down in midstance) because of pain from a calf strain, yet after a laser treatment-without any other intervention-achieve foot flat with 75 percent pain reduction upon leaving. This is a 'better than average' response but other modalities don't produce this type of rapid result," Dr. Howard reported.
At Boston Sports Medicine, laser therapy has been effective in treating ligament sprains, tendonitis, muscular strains, joint pain, reflex sympathetic dystrophy (RSD) and post-operative healing. "The results have been faster injury and wound healing, decreased inflammation and a reduction in pain," said Dr. Velsmid. "Patients who have failed with other non-invasive therapies often have demonstrated remarkable results with laser therapy. We have noted good clinical results with laser therapy on joint injuries. We have seen patients with non-healing foot stress fractures and even chronic shin splints who tried everything else, finally heal with laser therapy."
While the effects of laser on improving joint ROM, decreasing pain and improving strength in the knees with osteoarthritis diagnoses have been reported in the literature, Dr. Howard pointed out there's a lack of comparable studies because heterogeneous laser dosing parameters make it difficult to draw conclusions toward promising outcomes.
Dr. Velsmid suggested contacting an equipment vendor to acquire a demo unit for a month-long trial, then use it frequently with joint injury patients to make your own assessment of efficacy. "The research has not been done. But I would not exclude laser therapy from practice simply due to the deficiency in research in support of it. We are basing our evidence on clinical experience," he said.
This lack of research supporting low-level lasers in physical therapy makes David Jeter, MPT, CMPT, a physical therapist at Acceleration Physical Therapy in Spokane, WA, skeptical about its use in PT treatment. He believes addressing the underlying cause of pain is a more worthy pursuit than applying a modality to the area of complaint.
"My job as a physical therapist is to make sure that all joints and muscles in that system above and below that area are working appropriately so the damaged area can heal. A great example is patellar tendonitis in the knee. One of the biomechanical causes of patellar tendonitis is restriction and weakness at the hip/pelvis. If the hip is not able to load correctly because of restriction and weakness, then the knee is placed at a disadvantage. This creates excessive stress on the tendon, which in turn creates inflammation and pain," Jeter said.
The key to resolving this patellar tendonitis is to improve the ability of the hip to load, thus taking stress off of the knee and allowing the great healing potential of the body to work, he added.
"The hip should be the knee's best friend," concluded Jeter. "Failure to address the hip will do nothing for the patient's knee in the long run, even if you can make it calm down in the short run. We must address the culprit, not the victim. At best it feeds into a cycle of dependency on the professional, and at worst it feeds into a placebo effect that ultimately costs the system without any actual long-term benefits."
Weighing the Costs
Cost of laser therapy is certainly a concern. While the U.S. Food and Drug Administration has approved it for joint rehabilitation, it's not commonly covered by health insurance. Dr. Howard shared an excerpt from a major insurance company's 2012 clinical policy manual: "[We] consider cold laser therapy (also known as low-level laser therapy or class III laser) experimental and investigational because there is inadequate evidence of the effectiveness of cold laser therapy in pain relief (e.g., acute and chronic low-back pain/neck pain), wound healing, or for other indications such as carpal tunnel syndrome, colorectal cancer, lymphedema, musculoskeletal dysfunction, myofascial pain syndrome, neurological dysfunctions, physical therapy, rheumatoid arthritis, shoulder impingement syndrome and tinnitus."
Dr. Velsmid noted that manufacturers have found a sometimes successful "work around," bundling in the applicator laser diodes with ultraviolet diodes-a treatment more commonly approved by insurance carriers. The patient gets the benefit of both therapies and insurance coverage.
Dr. Howard mentioned this isn't really "good practice" and is actually incorrect coding if the intent of treatment is for the use of laser. "Reimbursement for the ultraviolet code 97028 per the 2012 Medicare fee schedule is roughly $7. UV light and laser costs are dramatically different as is the intent for treatment. Furthermore, we do not want to devalue the services that PTs deliver and continue to promote practice that may hinder unfair reimbursement. Many people will elect to pay for 'add-on' services that help them if they are reasonably priced," according to Dr. Howard.
Dr. Siegel's patients at Burke likewise have received limited insurance reimbursement, but he suggested that patients inquire with their carrier directly to ask about the benefit. Some clinics charge patients directly for laser therapy, but then help them seek reimbursement. At his facility, they provide the service as a non-billable modality such as ice or heat.
A common misconception is that laser therapy is expensive, but Dr. Howard reported that a 10- to 15-minute treatment should not exceed $30 when using a good-quality class 3b laser.
"Patient cost is always a factor in healthcare, but it is not us who determine these expenses," Dr. Howard said. "As a provider, it is frustrating to pass additional cost to patients during this economy, but it would be even more frustrating if the patient wasn't given an option that may lead to better outcomes or at least contribute to quicker recovery."
Laser therapy will not become a standard of care until several high-powered, credible research studies are published-and funding remains a challenge. Despite that grim reality, physical therapists are optimistic after a solid decade of experience with lasers, just scratching the surface of understanding how to adjust parameters to achieve the optimal therapeutic outcomes.
As trends and new experiences emerge, so does excitement about this modality. "Improvement in research design coupled with clinical input will help determine best-practice guidelines, and for those who feel it important, insurance recognition," Dr. Howard concluded.
Kerri Reeves is a freelance writer based in Ambler, PA, and was formerly on staff at ADVANCE.