This case study comparison will provide three examples of patients we successfully treated using CW low-level laser therapy (LLLT) in conjunction with manual therapy (using either myofascial release techniques and/or Maitland-based joint mobilizations). These cases include a post-surgical patient, a non-surgical patient with a similar chronic pathology, and a patient with an acute pathology. All three patients are highly active individuals who desired a full, unrestricted return to their respective recreational activity.
This article will briefly review each patient's past and current medical history, and a provide a synopsis of two months of treatment provided using CW LLLT and manual therapy (appropriate therapeutic and neuromuscular exercises were also a portion of the plan of care for each patient, but are not relevant in the discussion of this comparison), along with the results of treatment with respect to improvements in both physical impairments and functional abilities.
Case #1: History and Treatment
Our 59-year-old female post-surgical patient arrived at our facility with a unique history. The patient was status post a right knee arthroscopic medial and lateral meniscectomy, pick chondroplasty of the medial femoral condyle and synovectomy, who was two and a half months out of surgery and had already received physical therapy services at a different facility. With her case, subjective evaluation revealed pain lingered in a diffuse manner throughout the knee, primarily residing at the medial compartment, and still escalating from a constant 3 out of 10 to 8 out of 10 on a McGill Pain Questionnaire when rotational shear forces were experienced at the right knee.1 This individual also had complaints of intermittent bouts of joint effusion/edema, most often situated at the infrapatellar region of the right knee. She reported that currently she experienced difficulty ambulating longer than 15 minutes and descending stairs both secondary to pain, as well as an inability to participate in or teach Zumba class, which she does several days a week.
A review of systems and past medical history was unremarkable. Physical examination showed several pertinent physical impairments. These impairments included moderate bilateral genu valgum, impaired active range of motion (AROM) limited to 122 degrees of right knee flexion with pain at end range, strength deficits at the right quadriceps and adductor muscle groups equivalent to 4 out of 5, right hamstrings strength equivalent to 3 minus out of 5, and bilateral gluteus medius muscular strength of 3 plus out of 5 via manual muscle testing (MMT), along with active trigger points palpated in the rectus femoris, vastus lateralis, gluteus medius and maximus, and hypomobile joint play of the right patellofemoral and tibiofemoral joints.
In treating this patient, as well as the other two mentioned later on in this comparison, we used a CW laser system (class 3b) that administered an 830nm wavelength, delivering 1 joule per laser diode with 3 diodes present on the probe for a total of 3 joules per a preset 33 second treatment cycle. During the patient's two-month stretch of physical therapy received at my facility, we provided once weekly manual treatment and biweekly LLLT for the first six weeks of care and one time per week for the final two weeks of treatment. To address this patient's physical impairments with manual therapy techniques we used a combination consisting of strain-counterstrain and ischemic compression-based myofascial release methods at the trigger points previously indicated, as well as a medial glide grades II and III (in accordance with the Maitland approach) at the patellofemoral joint, and a posterioanterior glide consisting of the same grades at the tibiofemoral joint. Our objective with LLLT with this patient was to promote an enhanced circulatory effect into the remodeling tissue in an attempt to clean up any residual exudates, and with proper joint mobilization avoid improper crosslinks in the collagen tissue from forming, limiting proper arthrokinematic function of the knee.2
For the first six weeks biweekly, LLLT was applied to the right knee at two points along both the medial and lateral joint lines, for a total of 4 points. A dosage of 3 j/cm2 was administered at each point. During the last two weeks of treatment once weekly, at the same points and with the same parameters, LLLT was applied to the right knee.
Case #2: History and Treatment
Our chronic pain patient possessed similar underlying pathology as that of our surgical patient, but opted for a non-operative approach to treatment for his condition. The patient is a 70-year-old male with a diagnosis of a right posterior horn medial meniscal lesion and medial femoral condyle osteoarthritis. Subjective examination disclosed this individual to suffer from morning joint stiffness and pain, as well as constant dull pain throughout the course of the day that ranges from 3 out of 10, to 6 out of 10 during periods of exacerbation.
Location of the patient's symptoms always resided at the medial compartment of his right knee. His signs and symptoms typically increased after prolonged static positioning, like sitting or standing for greater than 30 minutes, excessive squatting positions required for certain activities of daily living (ADLs), or after walking 18 holes of golf, as well as with hitting out of sand traps or the rough. No diagnostic testing was conducted at the time, and a review of systems and past medical history was unremarkable.
The patient's physical examination provided the following; moderate bilateral genu varum, a positive McMurray's test for a potential medial meniscal lesion, AROM to be within functional limits with pain at the end range of both flexion and extension, strength deficits at the right quadriceps, hamstrings and adductor muscle groups equivalent to 4 plus out of 5, and bilateral gluteus medius muscular strength of 3 plus out of 5 via MMT, fair dynamic single-leg stance balance (assessed via multi-directional perturbations with patient in single-leg stance) at the right lower extremity was present, active trigger points in the right gluteus minumus, medius, maximus, tensor fasciae latae (TFL) were detected, and moderate increased tissue density at the right iliotibial band (ITB) was observed, along with a hypomobile right tibiofemoral joint.3
The treatment of this patient was very similar to that of our operative patient. This golf enthusiast was able to make biweekly treatments of both LLLT and manual techniques. Manual treatment for this patient revolved around a combination also consisting of strain-counterstrain and ischemic compression based myofascial release methods at the trigger points previously reported. Only a posterioanterior glide of the right tibiofemoral joint was required in the treatment of this patient's knee, also using grades II and III as administered in a similar manner to that of our surgical case.
Biweekly LLLT was directed at this patient's right knee in the exact same manner as used in treating our post-surgical Zumba instructor, except biweekly treatments remained the course of care for the complete eight weeks of treatment. Again, our objective in using LLLT was to improve the circulation and fluid dynamics present in the joint.
Case #3: History and Treatment
The final candidate arrived at our clinic with a completely different pathology. In including this patient, one can obtain a flavor for the diverse use of CW LLLT in treating orthopedic patients.
The last case involves a 60-year-old female who presented with acute rotator cuff tendonitis of both the supraspinatus and infraspinatus tendons of her dominant hand. Subjective examination of this avid tennis player revealed that the mechanism of injury in this patient's case was repetitive microtrauma sustained during the learning of new mechanics for her forehand. She complained of a constant 4 out of 10 dull ache at the anterior aspect of her right shoulder that could elevate up to an 8 out of 10 sharp pain with overhead or quadrant-based movements of the right shoulder girdle. Signs and symptoms would also be aggravated by sleeping in right sidelying, lifting greater than 5 pounds with her right upper extremity, as well as with any participation in her three time a week tennis clinic or matches. Diagnostic testing (X-ray) was inconclusive, and a review of systems and past medical history was unremarkable as well.
A postural screen demonstrated minimal forward head positioning with a moderated amount of rounded shoulder position bilaterally, with bilaterally protracted scapulae; a positive Neer test for impingement syndrome at the right shoulder; AROM testing at the right shoulder was within functional limits throughout all planes of motion, except a painful arc transpired at 90 degrees of shoulder flexion and pain was elicited with overpressure at end range flexion, abduction, external rotation (ER) and the overhead quadrant position (combined flexion, abduction and ER); strength deficits at the right rotator cuff muscles were equivalent to a 3 plus out of 5 via MMT, and the patient exhibited severe tenderness to palpation (with accompanying trigger points in the muscle tissue) at the supraspinatus and infraspinatus tendons, along with hypomobile joint play at the right glenohumeral joint and T2 though T6 thoracic segments.3
In treating acute inflammatory conditions with CW LLLT our experience has shown that the frequency of treatment initially is critical. Our objective is to reduce the inflammatory cycle while simultaneously diminishing the patient's subjective interpretation of pain. A three-times a week regimen of LLLT would be most beneficial, but is not always ideal based on the patient's schedule. With this individual (based on availability with both parties), I decided that biweekly treatments of both manual techniques and LLLT would suffice, but it would be necessary for the first four weeks to be rendered without interruption.
Our primary goal during the first four weeks of treatment was to slow the process of exudation of cells and chemicals that result in swelling and pain during the acute phase of inflammation, while enhancing the typically impaired circulation to the injured tissue and thus promoting fibroblastic cell activity.2 During the last four weeks of treatment, which involved the patient going from subacute to chronic stages of inflammation, I decrease the dosage of LLLT per point, trying to support connective tissue growth with the laying down of collagen and ultimately the remodeling of said connective tissue.2 Biweekly LLLT was applied to three points at the right shoulder/glenohumeral joint, one each at the location of the supraspinatus and infraspinatus tendons, and the third at the anterior portion of the joint capsule. A dosage of 8 j/cm2 was used for the first four weeks, and then 6 j/cm2 was administered for the final four weeks of PT. Manual treatment involved similar myofascial release methods to her infraspinatus and supraspinatus trigger points that were performed on our two prior patients, along with distraction, inferior, posterioanterior and eventually quadrant mobilizations of the right glenohumeral joint grades II, III and IV, as well as posterioanterior glides to the hypomobile T2 through T6 thoracic segments.
With all three cases, a significant reduction of pain was achieved after two weeks of treatment. Our surgical patient, after eight weeks of care, is pain-free during ambulation, stair negotiation and executing ADLs, and has only intermittent medial right knee pain of 2 out of 10, occurring only with her modified return to Zumba classes (we are still limiting the duration of time she participates in class). Her physical impairments have all resolved, with full right knee flexion restored, strength within normal limits (WNL) at all previously impaired musculature, and normal arthrokinematic function present at the right patellofemoral and tibiofemoral joints.
Our golfer has resumed unrestricted play and reports no pain during, or after a round. His AROM is now pain-free with overpressure with both flexion and terminal extension, strength of his impaired right lower-extremity musculature is WNL.
Our tennis player has also progressed well, and at discharge resumed participation in her tennis group's clinic and match play three times a week without limitations (her pro will do a re-assessment of the stroke mechanics which most likely attributed to her tendonitis). She remains pain-free and able to sleep on her right side. Her physical impairment has resolved with no painful arc observed prior to discharge.
As evidenced, CW LLLT offers the therapist a solid option in the treatment and management of both chronic and acute orthopedic-based pathologies. CW LLLT should be viewed as a legitimate modality that can help treating clinicians meet treatment objectives.
References are available at www.advanceweb.com/pt
Darren Riccio is owner of Achieve Physical Therapy & Performance Enhancement in Scarsdale, NY.