Monday, January 23, 2012

Lessons in Laser Therapy

Low-level laser therapy uses light-emitting diodes to alter cellular function and is based on photochemical and photobiological effects of the cells and tissues. Laser light stimulates the function of cells, in particular, increasing cells' ATP (adenosine triphosphate).
"Great things will be accomplished with laser. The field is comprised of some very strong experts who are working hard to prove the overall effectiveness of the modality and in doing so, are publishing to educate the clinicians," said Paul Higgins, PT, DPT, ATC, CSCS, assistant professor, University of Hartford Physical Therapy Department, and co-owner of University Physical Therapy LLC.
As both an educator in a physical therapy program and a rehabilitation clinic owner, this clinician has a unique perspective on the evolution of laser therapy as a modality in a physical therapy setting. Dr. Higgins studies the published works of laser therapy, teaches doctorate students and conducts research on the effectiveness of light therapy.
Dr. Higgins increasingly spends more time on this modality in the classroom by having his students analyze relevant literature and complete a related lab activity.
"Laser is an up-and-coming modality," Dr. Higgins told ADVANCE. "It's a matter of producing a body of literature that supports its use and provides standard parameters and reproducible work."
Dr. Higgins would like the rehab community to understand that laser treatment is a safe modality; that literature supports its use for pain control, and that there is a lot of literature available that discusses how the body uses light during the phases of healing.
"Laser treatment is undervalued in the PT community," he said. "Although the opportunity for use has been around since 2002, there is so much to still learn about its effectiveness, the treatment parameters and the types of light therapies available."
In the Classroom
From his spot at the lectern, Dr. Higgins has had the unique experience of watching light therapy evolve as a modality. In the first course he taught, he recalled telling his students that light therapy had not yet been approved by the U.S. Food and Drug Administration. "My first lecture on the topic of light therapy lasted seven minutes or less."
Fast forward nearly 10 years, and Dr. Higgins now spends an entire class on the physics behind laser, its effects on tissue, adverse effects, recommended uses and the wide variety of parameters including dose, materials and wavelength.
When defining laser treatment to his students, Dr. Higgins turns to published works by experts including Douglas Johnson, ATC, EES, CLS. As a jumping-off point, he uses the phototherapy definition of "a therapeutic physical modality using photons (light energy) from the visible and infrared spectrum for tissue healing and pain reduction."1
"My goal is for students to gain exposure to the topic of light therapies," Dr. Higgins shared. "I want them to be able to go out into the clinical setting and make their own judgment of if, how and when to use light therapies."
Dr. Higgins would like his students to make their decisions based on the literature. "I do my best not to bias my students and instead allow them to make clinical judgments based on the rationale behind laser (light therapy) use," he said.
"At the very least, I feel that my students are able to join in on the conversation around light therapy with other professionals, support their own theories behind whether they feel light therapy is an effective modality, and most importantly, provide a platform for their own clinical decision making," he observed.
In a Clinical Setting
In his own clinic, Dr. Higgins uses this modality because the literature supports it as a safe modality with little or no adverse effects. "I do not believe that light therapy's true potential has been reached, but the literature is inching forward," he said.
Dr. Higgins acknowledged that there are reimbursement issues that may prevent providers from making the treatment available to clients. "Having the opportunity to travel and teach different courses, I ask clinicians about billing codes for light therapy and if they are being reimbursed," he said. "On the practice management side of things, why would a PT want to purchase equipment that will not eventually pay for itself and the clinician's time of use? On the clinician side of things, however, PTs generally will use a modality if they have seen that it works."
Dr. Higgins believes that literature has not yet shown this modality to be more effective than current care due to the variance in parameters. This modality is thought to be most effective in the treatment of painful conditions. Recent research is beginning to whittle down the long list of claims.
At first glance, the literature and several text books suggest that laser therapy is best suited for: carpal tunnel syndrome, soft tissue injuries, arthritis, muscle strains, tendonitis, swelling / edema, tennis / golfer's elbow, nerve regeneration, fibromyalgia, repetitive stress injuries, bone healing, and joint sprains.1,2
More recent literature seems to support light therapy when used for pain control (decreasing pain) and possibly pain due to fibromyalgia. According to Dr. Higgins, pain control is a broad brush.
"I know I'm not going to get deep penetration, plus the fact that I have a cluster probe that is more diffuse and less directional than a laser diode, so an elbow epicondlyitis, infrapatellar tendonitis, plantar fasciitis and wrist pain due to over-use are common examples where I would use the LED and have some success with its use," he said. "I'm only one clinician who has been working with light therapies for four years, so my sample size is too small to have measurable clinical outcomes."
"When I lecture, I refer to Douglas Johnson as 'the expert,' given his body of work and the intricate details of his work," Dr. Higgins relayed.
In the book Phototherapy 101, author Douglas Johnson, ATC, EES, CLS, explains that light alters cell membrane function, cell permeability, intercellular function and can act as a trigger for cellular reactions. He further writes about how light can improve ATP synthesis and promote active transport across the cell. Injured tissue has photo acceptors which increases their ability to encourage the receipt of photons, more readily than uninjured tissue. Single oxygen is formed which enhances the development of ATP.1
The author also lists stabilization of the cellular membrane, enhancement of ATP production and synthesis, stimulated vasodilatation and histamine response, increased leukocyte response and increased angiogenesis. Dr. Higgins points out that these factors occur without an increase in tissue temperature.
Dr. Higgins believes that the rehab sector would benefit from more research in the area of light therapies. "Light therapies can be an effective tool for the clinician for pain control, but there needs to be more consistency with the treatment parameters," he explained.
"It is an exciting time for modalities, knowing that this is new and on the horizon," shared Dr. Higgins. "As clinicians and educators promoting evidence based medicine, once the parameters are understood, there may be no limit to the use of laser as a physical modality."
1. Johnson, D. (2007). Phototherapy 101. Sports and Industrial Rehab: Taylor, MI.
2. Cameron, M. (2009). Physical Agents in Rehabilitation, From Research to Practice. Elsevier, St. Louis, MO.
Rebecca Mayer is senior regional editor of ADVANCE
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