By Perry Nickelston, DC, FMS, SFMA
Joint rehabilitation requires a strategic and comprehensive treatment approach, integrating soft-tissue techniques, fascial manipulation and functional movement patterning. Restoring optimal range of motion and reducing pain by transitioning a client from passive to active care should be the primary goal. Decreasing time spent in the passive phase of care and empowering patients with painless functional active rehab of the kinetic chain helps improve compliance.
What if you could use a modality to significantly increase recovery times and heal chemically damaged cells while strengthening surrounding tissue? Or decrease passive therapy and accelerate the natural regeneration process of injured joints? Laser therapy can be the answer you have been searching for to enhance clinical outcomes and patient satisfaction.
Understanding the therapeutic mechanisms of action involved with laser therapy and treatment protocols are essential. Successful use of any modality in clinical practice ultimately depends on the skill of the practitioner. Let’s take an in depth look at the physiological benefits of laser therapy and how it can be integrated into acute and chronic joint rehabilitation programs.
Physiological Benefits of Lasers
The US Food and Drug Administration (FDA) approved the first low-level Class III laser (LLLT) in 2002 and the first Class IV therapy laser in 2003. The most significant clinical and therapeutic difference between Class IV lasers and Class III is that the Class IV can produce a primary biostimulative effect on deeper tissues. Reaching deep tissue structures is critical to joint rehabilitation and recovery. If you cannot reach the intended target tissue with adequate therapeutic laser dosages, your overall clinical results will diminish.
Laser therapy excites the kinetic energy within cells by transmitting healing energy known as photons. The skin absorbs these photons via a photo-chemical effect, not photo-thermal; therefore it does not cause heat damage to the tissues. As such, laser can be safely used on patients who have metal joint replacements without the risk of injury. Laser light does not excite or interact with the molecules in metal or plastic.
Once photons reach the cells of the body, they promote a cascade of cellular activities. They can ignite the production of enzymes, stimulate mitochondria, increase vasodilatation and lymphatic drainage, synthesize ATP and elevate collagen formation substances to prevent scar formation. This is a critical step in reducing long-term disabling chronic myofascial pain syndromes and joint restrictions.
Photobiomodulation, also known as laser biostimulation, is the medical technique in which exposure to laser light enhances tissue growth and healing. Here is a partial list of positive effects of photobiomodulation on the body, all of which are a crucial part of long-term healing.
• Increased leukocyte activity (acceleration of tissue repair and decrease of pain);
• Increased neovascularization (new vessel growth and increased oxygenation);
• Increased fibroblast production (speeds tissue repair);
• Increased tensile strength (helps prevent re-injury);
• Stabilization of cellular membrane of damaged cells;
• Enhancement of ATP production and synthesis;
• Decreased C-Reactive protein Neopterin and acceleration of leukocytic activity;
• Enhanced lymphocyte response with reduction of Interleukin 1 (IL-1);
• Increased prostaglandin synthesis;
• Enhanced superoxide dismutase (SOD) levels;
• Stimulation of vasodilation with increased angiogenesis (new blood vessels).
Principal factors of success with deep-tissue laser therapy for fascial restrictions and joint rehabilitation include optimal dosage, power, wavelength and accurate clinical diagnoses.
Maintaining or restoring movement of specific segments is the key to preventing or correcting musculoskeletal pain. Fundamentally, joint rehabilitation is about movement, and lots of it. The base foundation of functional movement is proper joint mobility and stability.
Without adequate mobility and stability of joints in the kinetic chain, you end up with dysfunctional movement. Activities of daily living are then built on dysfunctional movement patterns, resulting in compensation and injury.
Microtrauma results from small amounts of stress imposed on the body over time caused by poor biomechanics; the body compensates with suboptimal joint alignment, muscle coordination and posture. Joints begin approximating in an effort to gain stability lost from muscular weakness and compensation.
This process, known as “joint centration,” is an inherent protective mechanism of the body which, if left uncorrected, may cause osteoarthritis, degeneration and decreased mobility.
Postural movement patterns are learned early in life by the central nervous system (CNS). However, structural or functional body stressors (e.g., tension, trauma, genetics), may prevent optimum posture. Faulty postures from physical compensations alter joint mechanical behavior, flexibility and range of motion. The increase in mechanoreceptor stimulation from locked joints results in neuro-reflexive muscular changes. Long-standing over-activation of abnormal joint reflexes causes changes in spinal cord memory that eventually “burns a neural groove” in the CNS as the brain and cord are unknowingly saturated with a constant stream of inappropriate proprioceptive information.
Inherently, the brain comes to rely on this faulty information about where it is in space to determine how to establish perfect posture. The brain simply forgets what its alignment should be. In other words, the body now makes the abnormal its new normal. Neurology wins every time. The silent progression of faulty postures and dysfunctional movement patterns are part of the reflexogenic relationship between muscles and joints. Neurogenic muscle activation patterning by combining laser therapy and functional movement rehabilitation is an effective way to “reprogram” the CNS for optimal function and reverse abnormal patterning.
Joint Mobility vs. Stability
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To understand the relationship between mobility and stability, we must look at human movement. Mobility in terms of human movement is a measure of the ability of a joint or a series of joints to move through a range of motion. Stability represents body control through strength, coordination, balance and efficiency of movement; stabilization is the control of mobility. Mobility must first be established before you can have adequate stability. Every joint in the body requires a ratio of both. However, some joints are meant to be more mobile and some more stable. There must be a symbiotic relationship between these two patterns for optimal performance.
There is a basic alternating series of joint movements where a loss of function in the joint below will affect the joint above. Compromised kinematic chain mobility secondary to one joint’s relative immobility often results in compensatory movement patterns in order to recover function; this is referred to as a compensatory or dysfunctional movement pattern.
Let’s look at how a joint movement dysfunction in the ankle and hip can cause compensatory pain related symptoms. After an injury the body tries to splint and guard movement. It wants to “immobilize” you as a protective mechanism for healing (and not simply where the site of pain is). Ankles lose mobility, knees lose stability and hips lose mobility.
For example, the ankle loses mobility, then the body takes it from the knee, which is supposed to be stable. The result is knee pain from overuse and lack of stability. The hip loses mobility and “locks down,” and the body increases movement in the lower back and pelvis. The result is lower back and sacroiliac joint pain. If a patient comes to you with a loss of hip mobility, the complaint will generally be one of lower back pain. But it can also cause knee compensation pain. This is why you should be evaluating the joints above and below the site of pain. The fix is usually increasing the mobility of a nearby joint.
However, the hip can be both immobile and unstable. How can a joint be both immobile and unstable? Let’s take a look. Weakness of the hip in either flexion or extension causes compensation at the lumbar spine, while weakness in abduction (prevention of adduction) causes stress on the knee. Remember, a muscle has two actions of joint movement, initiation and resistance. For example, the gluteus medius initiates hip external rotation, but also prevents hip internal rotation.
So in order to fully optimize muscle function, you must exercise that muscle in both movement actions. Poor psoas and iliacus strength or activation will cause lumbar flexion as a substitute for hip flexion. Poor strength or activation of the glutes will cause compensatory extension recruitment of the hamstrings and lumbar spine to replace the motion lost in hip extension.
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Perry Nickelston is clinical director of the Pain Laser Center LLC in Ramsey, NJ. He is a member of the board of directors and medical staff advisor for the American Institute for Medical Laser Application. He is medical director of Clinical Laser Application for LiteCure LLC. Contact Dr. Nickelston at www.stopchasingpain.com
Example Case: Laser for Knee Osteoarthritis
Laser therapy on the affected joint and surrounding tissue following current research protocols can ease the symptoms of osteoarthritis.
Depth of Tissue-superficial: 4-6J/cm2
Deep: 10-12J/cm2 (Joules is the measurement of photon energy in J/cm2).
Apply laser therapy of 4,000J on the knee joint-anterior, medial, lateral, and posterior-while the patient actively flexes and extends the knee. You may also integrate passive range of motion if active is too painful. Joint motion while treating with laser therapy ensures all cells are exposed to the photon energy.
All joint-related laser therapy treatments should include active and passive ranges of motion to stimulate optimum effects of photon energy into target tissues.
Laser the proximal and distal rectus femoris, biceps femoris, and gastrocnemius in relationship to fascia trigger points. As per the kinetic chain protocol, assess and laser the ankle joint and hip joint in combination with other chosen modalities.
If incorporating manipulative therapies use laser therapy immediately prior, to assist with muscle relaxation and edema reduction. You may discover manipulative therapy will last longer, be more comfortable, and require fewer treatments. Most joint rehabilitation cases require 6 to 10 laser therapy sessions for maximum benefit, depending on the individual. Each case is different.
There is no cookie cutter program for pain syndromes. The history of each patient makes the program specific. The above dosage range is a good benchmark to begin with. Reassess after the fourth laser therapy session to document progress and the possible need for change in therapy protocols.