For more than 20 years, Mano Borg-Pappas, PT, has witnessed a dramatic reduction in her clients’ use of painkillers—for both chronic and acute pain sufferers—with the use of cold laser therapy. “In my practice,” she says, “I commonly see anywhere from a 50% reduction to complete elimination of prescription pain-relieving drugs with low-level laser treatment.”
Joseph A. Kleinkort, PT, MA, PhD, CEAS, CIE, DAAPM, agrees. “Cold laser therapy relieves both chronic and acute pain to the point that many patients forget to take their pain medication,” he says.
This laser therapy works by increasing ATP synthesis and energy formation and repair in cells, repairing connective tissue, and enhancing collagen synthesis.
Cold laser therapy can be used to treat the pain of many conditions, such as sports-related injuries, muscle strain, and repetitive motion syndromes.
Sports injuries occur in professional athletes and everyday people. Cold laser therapy is a part of the traveling professional trainer’s tools for handling athletes’ pain and injuries. Kleinkort says, “Pretty much every professional sports team has a laser person now, to deal with tendinitis, bursitis, arthritis, sprains, and every type of inflammation. Cold laser helps with the pain of acute and chronic injuries and, for professional athletes, reinjuries as well. This modality offers rapid results. Low-level laser also helps with open wounds that need to heal quickly.”
Borg-Pappas treats professional athletes as well. “A football player—a 6-foot, 6-inch, 280-pound lineman—was referred to me after using several other types of therapy for intense quad pain,” she says. “After just two cold laser treatments, he recovered 100% and was able to resume playing.”
Low-level laser can help with pain relief of ordinary people’s sports injuries as well. Borg-Pappas sees it as a primary tool. “In the case of acute pain from a strain, I think it is primary,” she says. “Sports medicine many times includes reeducating the patient on new and better ways to move, but this cannot occur while the patient is in pain. Cold laser relieves their pain so this whole body approach can begin.”
Muscle strain pain is another area that cold laser is effective in treating. The condition most seen is back pain, and cold laser is effective in relieving this pain, while being neither invasive nor addicting. Both Borg-Pappas and Kleinkort believe that cold laser is an excellent therapy for muscle strain pain, as part of treatment that stresses activity by the patient rather than passivity.
Borg-Pappas believes that when a client has back pain, gait and posture also must be treated. “These changes in movement can’t begin until the pain is lessened, and cold laser is the best way, in my experience, to do that,” she says.
Cold laser is effective in most cases. Kleinkort has had a success record of 80%. “Most people respond well to being treated with cold laser for pain in muscle strain,” he says.
Painful repetitive motion conditions, such as carpal tunnel, tendinitis, and plantar fasciitis, can be helped with the application of low-level laser therapy.
Low-level laser, in conjunction with other modalities, has been shown to be effective in pain relief of carpal tunnel. “The noninvasiveness, or gentleness, of cold laser is helpful in the treatment of carpal tunnel,” says Borg-Pappas. She adds that many cases of carpal tunnel are misdiagnosed, due to problems with the spine and the neck.
Kleinkort says one of the important things about cold laser’s pain relief in repetitive motion conditions is “quickness.” According to Kleinkort, “If the pain is relieved quickly, the patient won’t adapt to the pain with imbalanced movement and gait. This new uneven movement can create more problems and more pain for the patient’s body.”
Ultrasound also is effective in pain relief. It works by converting electrical energy into ultrasonic waves, which are then directed to the afflicted areas for pain relief and healing. The heat from ultrasound goes deeper into the tissue than other modalities. Jonathan “Joey” Jove, PT, at the James Donaldson Fitness Center, Tacoma, Wash, believes that ultrasound is an excellent form of therapy for patients who are in pain. “Ultrasound helps to cut down the pain so they can begin a program of soft tissue work and exercise.”
For pain relief, ice and massage can be used with ultrasound therapy. Pulsed ultrasound can be utilized to “push” anti-inflammatory drugs deep into the affected area to relieve pain, be it acute or chronic. Jove has found success in treating sports injuries with ultrasound. “The ultrasound therapy helps to stop and reduce the pain in knee injuries, so that range of motion exercises can begin.”
Tatum J. Wilson, PT, at the Texas Back Institute, Plano, Tex, uses ultrasound for many different pain concerns with her clients. “I tend to use ultrasound on patients with lateral epicondylitis (tennis elbow). Ultrasound helps relieve the symptoms of pain, stiffness, inflammation, and decreased function associated with tennis elbow through its thermal and nonthermal effects.
“For example, I treated a patient with lateral tennis elbow caused by the overuse of the common extensor tendons while playing tennis. I used a combination of ultrasound to help with pain control, inflammation, and stiffness, as well as exercises to help strengthen up the elbow and shoulder joints,” she says.
Steve Ash, PT, Cedars-Sinai Orthopedic Outpatient Clinic, Beverly Hills, Calif, uses ultrasound to reduce painful scar tissue. Ash says, “I like to use ultrasound in combination with other therapies to reduce edema and postoperative pain. Also, [it] works well on reducing acute inflammation from sports injuries.”
Ultrasound works better in the smaller areas, such as the neck, ankle, etc. “Ultrasound needs to be restricted to a small area since larger areas are not practical because of the size of the ultrasound head,” says Dawn McCroy, PT, DPT, LAc, who works at Marina del Rey, Calif-based Beyond Physical Therapy. She says that back strains and lower back pain are not practical to treat with this modality.
Painful repetitive motion conditions can be treated by ultrasound. “The best tissues—from my experience and from the literature—that work well and respond well to ultrasound have high collagen density, as in tendons and ligaments,” McCroy says. “If there’s a tendon injury or a ligament sprain, then ultrasound, I think, can be very effective.” For example, she says, Achilles tendinitis can be helped by ultrasound, as it increases the blood flow, and gets the tendon to loosen up.
A combination of ultrasound and electrical stimulation has been found to be effective in controlling pain, treating muscle spasm, and increasing range of motion.
Electrical stimulation therapy works by placing electrodes on various locations to recruit muscle fibers and contracting them via electricity. With e-stim, muscles that the patient is unable to move voluntarily contract and expand. It also can relax painful spasmodic muscles, promote blood supply that assists healing, and prevent or reverse atrophy.
Several painful conditions are aided with electrical stimulation therapy, either by itself or in conjunction with other modalities. Ash likes to use a combination of electrical stimulation and ultrasound for sports injuries. “Electrical stimulation therapies best handle the pain, while the ultrasound helps to heal the scar tissue, and restore elasticity and flexibility,” he says.
Some electrical stimulation therapies, such as the portable TENS unit, offer the patient the ability to self-treat away from a clinical setting. This has two advantages: the patient does not have to travel for pain treatment, and is actively involved in their therapy. Katherine Verline, PT, a physical therapist at Cedars-Sinai Orthopedic Center, says, “I like to use the TENS unit in pain therapy for my patients as self-treatment—except in cases where they may not be able to place the electrodes properly. An example would be between the shoulder blades for back trouble.”
Wilson likes to use electrical stimulation therapy with patients in acute pain. “I have used electrical stimulation therapy (TENS) units on patients that have just had a car accident and are in a great deal of pain. I combine it with ice to help reduce swelling and inflammation to provide pain relief. I usually combine this with some sort of manual therapy to help restore range of motion until pain levels are under control, and then initiate exercises to help patients get back their prior level of function.”
Therapeutic massage, electrical stimulation therapy, and exercise are the programs that Verline prefers to use on her patients with muscle strain, particularly those presenting with low back pain.
At the Texas Back Institute, Wilson handles a variety of back problems. She says, “Since I generally see lots of chronic low back pain patients, I prefer to use electrical stimulation to help provide pain relief to allow them to perform exercises in a more pain-free environment and get them on the road to recovery faster.”
The pain of repetitive motion disorders can be treated with electrical stimulation, and reports cite a 75% reduction in pain with a TENS treatment plan that includes new movement education. Jove reports that he has had success in pain reduction for plantar fasciitis using a combination of electrical stimulation, ultrasound, massage, and exercise.
All modalities evolve and improve. Borg-Pappas and Kleinkort see cold lasers getting smaller, more portable, and able to treat more conditions. In addition, Wilson adds that she has seen ultrasound units that combine ultrasound technology with electrical stimulation.
Patient reimbursement with cold laser seems to still be a bit uneven—according to Kleinkort. “Some insurance companies and Medicare do not approve laser therapy and some do,” he says.
Wilson reports, “Patient reimbursement tends to be good for electrical stimulation and ultrasound—as long as you justify your rationale for using it and keep it condensed to a certain time frame. For example, generally after more than 10 sessions of ultrasound treatments, if the patient is not making progress, it is probably time to discontinue this treatment and search for another treatment.”
Cathy Logan is a contributing writer for Rehab Management. For more information, contact .
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