Rehab professionals go to work against such forces with a combination of manual therapy, activity-based procedures and a healthy dose of patient education.
Occasionally, modern technology lends a hand, in the form of physical modalities. Low-level laser therapy (LLLT) uses light with specific characteristics to treat medical conditions. Low-level laser devices produce therapeutic effects by non-thermal absorption of photons by cells.
LLLT has been shown to hasten the inflammatory process through mitochondrial chromophore stimulation. This increases respiratory chain activity, which enhances ATP synthesis, cellular repair and reproduction. While the science is there, the clinical community has been slow to adopt laser treatment as standard protocol, and insurers are even more reluctant to pay for it.
However, many clinicians-even skeptical ones-are finding that laser therapy has a definite place.
"I'm not really a 'modalities' guy," stated Matt Contino, DPT, therapist and partner at Sleepy Hollow Physical Therapy, a 3-location practice outside New York City. "I'm primarily manual-therapy and exercise based, and often reluctant to use modalities in practice."
But even Dr. Contino became interested in learning more after an in-office demo of equipment and a 60-day trial period by the manufacturer in 2003. "We were neutral in our approach [during the trial period]," Dr. Contino said. "We didn't tell patients one way or the other that it would help them-just that this is something new that we're trying out. The majority of people reacted positively, and we felt it would be an excellent addition to the practice."
Now, Dr. Contino and colleagues will suggest a course of laser treatment for many inflammatory and pain-generating orthopedic conditions, such as tendonitis, bursitis, nerve entrapment, plantar fasciitis and acute sports injuries.
"I like that there are very few contraind-ications," related Dr. Contino, adding that many "stubborn" conditions respond, such as chronic tennis elbow that hasn't resolved through prior therapy. "You can use it over hardware, over a knee replacement-you won't have the side effects of some other treatments. It's fast-acting for many patients and people are excited about it so it creates a buzz in the community."
Jake Gleason, MPT, OCS, has a similar story. Gleason became interested in laser therapy as a therapeutic modality when his co-workers at the clinic he worked in after PT school began offering it. When Gleason went on to open his own business-Free Motion Physical Therapy in San Juan Capistrano, CA-he arranged for an in-office demo and began offering the service in 2008.
Approximately 80 percent of Free Motion's patients arrive via their primary care provider, many of them with acute-stage orthopedic and sports injuries that may or may not require surgery down the line. These are the cases that can often be relieved through a round of low-level laser therapy in combination with established manual therapy and activity-based protocols.
"Your typical [laser therapy] conditions will be tendonitis, joint injuries and swelling that results in difficulty bending, rotator cuff, tennis elbow, the sprains and strains that you sustain from sports participation," said Gleason, whose two other staff therapists also provide laser therapy. "We'll aim for 2-3 times per week, and generally we'll see some improvement pretty quickly." Gleason offers a free trial of LLLT to patients with a condition that may respond to it, and is careful to explain the physiologic response to patients during treatment.
In suburban Detroit, physical therapists and clinicians at Sports and Industrial Rehab cater to a largely industrial client base at their headquarters in Taylor, MI.
"We can pull from Dearborn and many of the automotive manufacturing sites south of Detroit," said owner Doug Johnson, ATC, EES, LAT, CLS. "About 50 percent of our patients are low-back [cases], 20 percent acute trauma. The majority of our cases are on-the-job [injuries]. Our patients are generally active and need to get back to work quickly." In addition to physician referrals, Johnson also maintains direct contracts with employers to rehab their injured workers.
"Michigan is a rough market for the private practitioner," he said. "We started to shy away from a lot of our insurance contracts. Insurers were starting to lower their rates to the point that it was actually costing us money to treat their patients."
As a result, Johnson had to go into his community and "sell his ideas." From his days as a regional director for occupational medicine provider Concentra, Johnson new that numbers would have to be on his side. This meant proving to case managers, companies and clients through objective analyses that he could save them money.
"We were a small clinic, maybe 700 feet," Johnson said. "We had to compete. We had to have a niche and a reason for companies to go with us."
Part of that specialization, Johnson feels, is offering laser therapy treatment to his clients.
"We were one of the first laser therapy clinics in the country," he said. "We bought our first unit in 2002. In our niche, time is money. We have to keep them 'in the game', and on the job. We have to be able to prove it to our referral sources."
The rapid return to work and life is what draws clinicians to the modality.
"My usual course of laser therapy is from 6 to 8 treatments, and we'll know by then if it's worth continuing," said Dr. Contino. "It's nice not to have to tell patients that they need to keep coming back indefinitely-generally we'll see some improvements after just one or two sessions."
Regarding reimbursement, laser therapy remains a work in progress. As it currently stands, laser therapy in most rehab centers remains either a cash-pay or unbilled service. Though many insurance companies balk at covering it, many clinicians are satisfied with the clinical outcomes and patient response to continue providing it. Many promote the modality in their promotional efforts.
Laser proponents hope and expect reimbursement to improve, as evidence continues to validate its role in rehab. Part of the effort involves reaching out to the clinical community, to insurers and to the public.
In the last few years, Johnson has delegated many of his clinical duties to his staff therapists and has hit the road to teach other clinicians the evidence and the physiology behind laser therapy in addition to his hands-on approach to worker rehabilitation. Many professional sports teams are bringing laser units in to treat their injured professional athletes, Johnson said. All of this is a positive for the profession.
"Physical therapists are in a dire situation," he said. "Their services are being undervalued by insurers. If you can offer a service that's objectively proven to reduce treatment times and time off the job, you've gone a long way toward validating the skill you provide."
Jonathan Bassett is on staff at ADVANCE, and can be reached at firstname.lastname@example.org