Effect of Laser in osteoarthritis of knee
DISSERTATION SYNOPSIS
SUBMITTED TO
RAJIVGANDHI UNIVERSITY OF HEALTH SCIENCES, KARNATAKA
BANGALORE
TOWARD PARTIAL FULFILMENT OF
MASTER OF PHYSIOTHERAPY DEGREE COURSE
By
UNDER THE GUIDANCE OF
S NATARAJAN
VIKAS COLLEGE OF PHYSIOTHERAPY
MARYHILL, KONCHADY, MANGALORE-575006
2010-12
RAJIVGANDHI UNIVERSITY OF HEALTH SCIENCES, KARNATAKA
BANGALORE
REGISTRATION OF SUBJECTS FOR DISSERTATION
| | | |
|1. |Name of the Candidate |GODASE RANJITH VIJAY KUMAR |
| |and Address | |
| | |VIKAS COLLEGE OF PHYSIOTHERAPY |
| | |AIRPORT ROAD |
| | |MARYHILL, KONCHADY |
| | |MANGALORE – 575008 |
| | | |
|2. |Name of the Institution |VIKAS COLLEGE OF PHYSIOTHERAPY |
| | |Mangalore. |
| | | |
|3. |Course of study and subject |Master of Physiotherapy (MPT) |
| | |Physiotherapy in Musculoskeletal Disorders and Sports Physiotherapy |
| | | |
|4. |Date of admission to Course |01-03-2010 |
| | |
|5. |Title of the Topic |
| | |
| |EFFECT OF LOW LEVEL LASER THERAPY IN OSTEOARTHRITIS OF KNEE JOINT |
| | |
|6. |BRIEF RESUME OF THE INTENDED WORK |
| | |
| |6.1 Need for the study |
| | |
| |Osteoarthritis (OA) is a major cause of disability and is among the most frequent forms of musculoskeletal disorders.1 It|
| |is characterized pathologically by both focal loss of articular cartilage, and marginal and central new bone formation.2 |
| |It is a complex disease whose etiology bridges biomechanics and biochemistry. Evidence is growing for the role of |
| |systemic factors (such as genetics, dietary intake, estrogen use, and bone density) and of local biomechanical factors |
| |(such as muscle weakness, obesity, and joint laxity). These risk factors are particularly important in weight-bearing |
| |joints.3 |
| | |
| |OA is strongly associated with aging, and with the increasing proportion of elderly populations, large joint OA, |
| |particularly of the knee, will become an even more important healthcare problem.2,4,5 Knee osteoarthritis (KOA) is |
| |associated with symptoms of pain and functional disability. Physical disability arising from pain and loss of functional |
| |capacity reduces quality of life and increases the risk of further morbidity and mortality.2,6 |
| | |
| |The objectives of the management of KOA are pain relief, maintenance and improvement of mobility and minimizing |
| |disability. There are several guidelines on the management of OA. They are mostly based on the evidence of the various |
| |interventions like patient education, pharmacological and nonpharmacological therapy and surgery.7-10 |
| | |
| |Although non-steroidal anti-inflammatory drugs (NSAIDs) are widely used to treat the pain and stiffness associated with |
| |knee OA, the high incidence of serious upper gastrointestinal side effect with NSAIDs can limit their use.11 To avoid or |
| |to reduce the side effects associated with NSAIDs, physical therapy agents such as ultrasound, transcutaneous electrical |
| |nerve stimulation therapy and muscle strengthening exercises are frequently used.12-15 |
| | |
| |Regular participation in physical activity has been recognized for several years as being beneficial in the management of|
| |knee osteoarthritis (OA).16-18 While there is agreement that exercise therapy can be helpful, the effect of exercise |
| |therapy on pain, quadriceps strength, and physical function appears to be small to moderate in most clinical |
| |trials.13-15, 19-22 These findings suggest that there are likely subgroups of individuals who continue to have pain, |
| |muscle weakness, and disability even after participating in an exercise therapy program. Individuals with knee OA must |
| |often overcome a variety of problems, such as joint pain, stiffness, limitations in motion, motor and sensory |
| |dysfunctions, and functional limitations that prevent them from participating in regular physical activity.18 |
| | |
| |Puett and Griffin in a review of the efficacy of nonmedicinal, noninvasive therapies in hip and knee osteoarthritis |
| |report that exercise reduces pain and improves function in patients with osteoarthritis of the knee. They further |
| |conclude that no support exists for ultrasound treatment and sparse or inconsistent evidence exist for transcutaneous |
| |electrical nerve stimulation, pulsed electromagnetic fields and acupuncture, while single, well-designed studies suggest |
| |that topically applied capsaicin and laser treatment reduce pain associated with knee osteoarthritis.23 |
| | |
| |Low-level laser therapy (LLLT) was added 20 years ago to existing physical therapy agents used in physiotherapy in the |
| |treatment of OA. LLLT is a light source that generates extremely pure light of a single wavelength. The effect is not |
| |thermal but rather related to photochemical reactions in the cells. The effectiveness of laser therapy is still unclear |
| |and needs to be examined more rigorously.24,25 |
| | |
| |Low-power laser therapy has been used to control pain in different musculoskeletal conditions. Despite its widespread |
| |use, the results of the experimental and clinical studies are conflicting. The results of some placebo-controlled studies|
| |suggest that low-power laser treatment may be useful for reducing the pain in cervical osteoarthritis 19 and medial and |
| |lateral epicondylitis.20 On the other hand, a number of placebocontrolled, randomised and double blind studies have not |
| |been able to demonstrate any significant or convincing clinically relevant effects over placebo in the treatment of |
| |lateral epicondylitis,21 rotator cuff tendinitis22 and rheumatoid arthritis.26 However, very few controlled clinical |
| |studies of low-power laser applied for the treatment of knee OA have been reported and the findings from these studies |
| |are also contradictory.27 The results obtained from the trial of Stelian et al. suggest that laser treatment may be |
| |useful in reducing the pain and disability associated with knee OA.27 In contrast, in a double blind, placebo controlled |
| |study Bülow et al. detected no difference between the actively and the placebo treated groups.28 Since the results of low|
| |power laser therapy effectiveness studies in knee OA show considerable variation, I aim to evaluate the effect of low |
| |power laser treatment in patients with knee OA in the present study. |
| | |
| | |
| |6.2 Review of Literature |
| | |
| |Bjordal et al in a literature search investigated if low level laser therapy (LLLT) of the joint capsule can reduce pain |
| |in chronic joint disorders. The results showed a mean weighted difference in change of pain on VAS and Global health |
| |status improved for more patients in favour of the active LLLT groups. They concluded that Low level laser therapy |
| |significantly reduces pain and improves health status in chronic joint disorders, but the heterogeneity in patient |
| |samples, treatment procedures and trial design calls for cautious interpretation of the results.29 |
| | |
| |Brosseau et al conducted a systemic review to assess the effectiveness of LLLT in the treatment of OA. Seven trials were |
| |included, with 184 patients randomized to laser, 161 patients to placebo laser. Three of the trials showed no effect and |
| |two demonstrated very beneficial effects with laser. Only one study found significant results for increased knee range of|
| |motion. Other outcomes of joint tenderness and strength were not significant. Lower dosage of LLLT was found as effective|
| |as higher dosage for reducing pain and improving knee range of motion. They concluded that for OA, the results are |
| |conflicting in different studies and may depend on the method of application and other features of the LLLT |
| |application.30 |
| | |
| |Hegedűs et al designed a study to examine the pain-relieving effect of LLLT and possible microcirculatory changes |
| |measured by thermography in patients with knee osteoarthritis (KOA). Patients with mild or moderate KOA were randomized |
| |to receive either LLLT or placebo LLLT. Results showed a significant improvement in pain, increase in temperature-and |
| |thus an improvement in circulation and knee flexion, reduced knee circumference and pressure sensitivity in the LLLT |
| |group compared to the placebo group. They concluded that LLLT reduces pain in KOA and improves microcirculation in the |
| |irradiated area.31 |
| | |
| |Yurtkuran et al in a study investigated the effects and minimum effective dose of laser acupuncture in knee |
| |osteoarthritis (KOA). Results showed a statistically significant improvement in pain on movement, 50-foot walking time, |
| |and knee circumference (KC) in experimental group and pain on movement, 50-foot walking time and Western Ontario and |
| |McMaster Universities osteoarthritis index (WOMAC), in the placebo controlled group. When groups were compared with each |
| |other, the improvement observed in KC was superior in Laser group than in placebo group. They conclude that Laser |
| |acupuncture is effective only in reducing periarticular swelling when compared with placebo laser.32 |
| | |
| |Tascioglu et al in a randomised, placebo-controlled and single blinded study investigated the analgesic efficacy of low |
| |power laser therapy in patients with knee osteoarthritis (OA). Results showed no significant improvement in the Western |
| |Ontario and McMaster Universities osteoarthritis index (WOMAC) pain, stiffness and physical function subscales and, the |
| |intensity of pain at rest and on activation. They concluded that low-level laser therapy has no effect on pain in |
| |patients with knee OA.33 |
| | |
| |Gur at al compared the efficacy of two different laser therapy regimes in patients with knee osteoarthritis in a |
| |prospective, double-blind, randomized, and placebo controlled trial. Results showed statistically significant |
| |improvements in respect to all parameters such as pain, function, and quality of life (QoL) measures in the post-therapy |
| |period compared to pre-therapy in both active laser groups compared to placebo group. They concluded that applications of|
| |LPLT in different dose and duration do not affect results and laser therapy is a safe and effective method in treatment |
| |of knee OA.34 |
| | |
| |Shen et al in a placebo controlled pilot study assessed the effect of combined laser acupuncture on knee osteoarthritis. |
| |The results showed there was significant difference between the two groups in the Western Ontario and McMaster |
| |Universities (WOMAC) osteoarthritis index pain score and pain reduction. They concluded that combined laser treatment |
| |seems beneficial to patients with knee OA. However, due to the small sample size and the high drop-out rate of patients |
| |in the placebo group, a large sample-size clinical trial is warranted to determine further the therapeutic efficacy of |
| |the device.35 |
| | |
| |Pisters et al conducted a systematic review to determine the long-term effectiveness of exercise therapy on pain, |
| |physical function, and patient global assessment of effectiveness in patients with osteoarthritis (OA) of the hip and/or |
| |knee. Results showed strong evidence for no long-term effectiveness on pain and self-reported physical function, moderate|
| |evidence for long-term effectiveness on patient global assessment of effectiveness, and conflicting evidence for observed|
| |physical function. For exercise programs with additional booster sessions, moderate evidence was found for long-term |
| |effectiveness on pain, self-reported physical function, and observed physical function.36 |
| | |
| |Iversen in review of managing hip and knee osteoarthritis with exercise reports that therapeutic exercise is a component |
| |of all major rheumatologic society guidelines, yet the frequency, dose, duration, and therapeutic threshold for exercise |
| |are not clearly delineated and exercise is provided as a complex intervention combining multiple modes and provided in |
| |various settings under a range of conditions. He concludes that regardless of the variability in results and inherent |
| |biases in trials, exercise appears to reduce pain and improve function for persons with knee osteoarthritis and provide |
| |pain relief for persons with hip osteoarthritis.37 |
| | |
| |Bellamy et al conducted a double blind randomized controlled parallel trial to validate WOMAC, a new multidimensional, |
| |self-administered health status instrument for patients with osteoarthritis of the hip or knee. The results showed that |
| |the pain, stiffness and physical function subscales fulfill conventional criteria for face, content and construct |
| |validity, reliability, responsiveness and relative efficiency. They concluded that WOMAC is a disease-specific purpose |
| |built high performance instrument for evaluative research in osteoarthritis clinical trials.38 |
| | |
| |Davies et al compared the responsiveness and relative effect sizes of the Western Ontario and McMaster Universities |
| |Osteoarthritis Index (WOMAC) with the Medical Outcomes Study Short Form Health Survey (SF-36) in a randomized clinical |
| |trial for treatment of osteoarthritis (OA) knee or hip. Patients completed the WOMAC and SF-36 at baseline and days 7, |
| |14, and 28 of the trial. Results showed significant improvement in WOMAC pain, physical functioning, and the total score,|
| |while improvement was detected only for bodily pain on the SF-36. They concluded that the WOMAC has greater power to |
| |detect treatment differences than the SF-36, with respect to pain and physical functioning, in OA clinical trials.39 |
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| |6.3 Objectives of the study |
| | |
| |The main objective of the study is to find out the effects of Low Level Laser Therapy in patients presenting with |
| |osteoarthritis knee. |
| | |
|7. |Materials and methods |
| | |
| |7.1 Source of data |
| | |
| |Data will be collected from patients, who are referred to the outpatients Physiotherapy department of Vikas College of |
| |Physiotherapy, Mangalore, with diagnosis of osteoarthritis of knee joint after obtaining informed consent. |
| | |
| |7.2 Method of collection of data |
| | |
| |Hypothesis: |
| | |
| |There are significant decrease in pain and disability in osteoarthritis of knee joint with application of Low Level Laser|
| |Therapy. |
| | |
| |Null Hypothesis: |
| | |
| |There are no significant decrease in pain and disability in osteoarthritis of knee joint with application of Low Level |
| |Laser Therapy. |
| | |
| |Research Design: |
| | |
| |Experimental design will be used in this study. |
| | |
| |Sampling method |
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| |Random sampling method |
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| |Methodology |
| | |
| |Patients who are diagnosed to have osteoarthritis of knee joint and fulfilling the following inclusion and exclusion |
| |criteria will be selected for the study after obtaining informed written consent. |
| | |
| |Inclusion Criteria: |
| | |
| |1. Idiopathic knee OA according to American College of Rheumatology criteria were recruited for the study.40 |
| | |
| |2. Grade II to III bilateral knee OA confirmed radiologically according to the Kellgren-Lawrence grading system.41 |
| | |
| |3. Average pain intensity of 40 or more on a 100-mm Visual Analoque Scale (VAS) |
| | |
| |4. Age group 50-60 years |
| | |
| |5. Both males and females |
| | |
| |Exclusion Criteria: |
| | |
| |1. Kellgren-Lawrence Grade I and IV41 |
| | |
| |2. Knee joint disease other than OA |
| | |
| |3. OA of the hip, ankle and foot joints |
| | |
| |4. Serious concomitant systemic diseases |
| | |
| |5. Intra-articular fluid effusion |
| | |
| |6. Previous physical therapy and intra-articular corticosteroid or hyaluronic acid injections |
| | |
| |7. Previous knee surgery |
| | |
| |8. Serious valgus or varus deformity or who had hormonal, metabolic, or systemic rheumatologic problems |
| | |
| |9. Local-oral analgesic or nonsteroid antiinflammatory drug use in the previous 4 weeks |
| | |
| |10. Patient having a systemic disease (cardiac-cerebrovascular pulmonary system or malignancy) that contraindicated to |
| |physiotherapy and exercise |
| | |
| |Study Design |
| | |
| |The selected subjects will be randomly assigned into one of two groups. Each group will consist of 15 patients of both |
| |genders within the age group of 50-60 years. |
| | |
| |Group I: This will consist of 15 patients and they will undergo Low Level Laser Therapy. |
| | |
| |Group II: This will consist of 15 patients and they will undergo Placebo Laser. |
| | |
| |Interventions |
| | |
| |Patients will attend five weekly physical therapy sessions during a two-week period. Both groups will undergo an exercise|
| |session consisting of 10 sets of isometric contraction to quadriceps muscle and 20 repetitions of active range of motion |
| |exercises for knee joint after completing 10 minutes of LLLT or Placebo Laser application. |
| | |
| |LLLT Group: A low power laser, with a power output of 1 mW, wavelength of 830 nm and a laser beam diameter of 1 mm will |
| |be used. Continuous laser energy will be applied to both sides of the knee on the tenderest points, which will be |
| |determined by clinical examination. The dose per tender point will be 3 joule. |
| | |
| |Placebo group: The patients in the placebo group will be treated with placebo laser. For the placebo laser application, |
| |the same laser device will seem to be work but with no laser beams transferring to the two tender most points on either |
| |side of knee. |
| | |
| |Evaluation: Before the beginning and after the 2 week intervention period, all patients will be evaluated in the |
| |following outcome measures. |
| | |
| |1. Pain using a 10 cm Visual analogue scale |
| | |
| |Pain measured in a 10 cm Visual Analog scale. VAS is a 10 cm line with pain descriptors marked “no pain” at 1 end and |
| |“the worst pain imaginable” at the other. The patients will be asked to report their perceived pain level, both at rest |
| |and on most painful movement, by marking the VAS with a perpendicular line. |
| | |
| |2. Disability using the WOMAC (Western Ontario McMasters) Osteoarthritis Index |
| | |
| |The WOMAC is a disease-specific measure for hip and knee osteoarthritis. It is designed to provide a standardised |
| |assessment of self-reported health status while incorporating activities relevant to patients. The WOMAC consists of 24 |
| |items: 5 pain, 2 stiffness, and 17 physical function items. It produces three subscale scores (pain, stiffness, and |
| |physical function) and a total score. |
| | |
| |The WOMAC can be self-administered and takes approximately 5 minutes to complete. Patients were asked to answer each |
| |question with regard to the pain, stiffness, or difficulty experienced in the previous 48 hours. It is simple to use and |
| |offers 5 response options ranging from 'none' to 'extreme'. A response of 'none' is scored as 0, 'mild' as 1, 'moderate' |
| |as 2, 'severe' as 3, and 'extreme' as 4. Scores for each section are summed to produce pain, stiffness, and physical |
| |function subscale scores. The WOMAC is scored on a best to worst scale, so that lower subscale scores represent less |
| |pain, less stiffness, or better physical function. A total WOMAC score can also be produced and is commonly transformed |
| |to a 0-100 scale for ease of interpretation and comparison with other studies. |
| | |
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| | |
| | |
| |Statistical tests: |
| | |
| |The following statistical tests will be used to analyze the collected data: |
| | |
| |The pain score data collected using VAS will be analyzed using non-parametric tests as the data are ordinal in nature. |
| |The intra group pre and post-test data will be analyzed using Wilcoxon sign rank test, while the post-test inter group |
| |data will be analyzed with Mannwhitney U test. |
| | |
| |The disability data collected using WOMAC Osteoarthritis Index will be analyzed using parametric tests as the data are |
| |interval in nature. The intra group pre and post-test data will be analyzed using Unpaired t-test, while the post-test |
| |inter group data will be analyzed with Paired t-test. |
| | |
| |7.3 Nature of Investigations and Interventions: |
| | |
| |The study requires non-invasive investigations and interventions to be conducted on patients. They include physical |
| |examination like inspection, palpation, and measurement of range of motion, etc. Treatment interventions include |
| |application of LLLT and knee exercises. |
| | |
| |7.4 Ethical clearance: |
| | |
| |Ethical clearance has been obtained from the ethical committee of our institutions to carry out the investigations and |
| |interventions on patients necessary for this study. |
| | |
|8. |References |
| | |
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| |Stelian J, Gil I, Habot B, Rosenthal M, Abramovici I, Kutok N, et al. Improvement of pain and disability in elderly |
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| |Bülow PM, Hensen J, Danneskiold-Samsoe B. Low power Ga- Al-As laser treatment of painful osteoarthritis of the knee. |
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| |location-specific doses for pain from chronic joint disorders. Aust J Physiother. 2003;49(2):107-16. |
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| |measuring clinically important patient relevant outcomes to antirheumatic drug therapy in patients with osteoarthritis of|
| |hip or knee. J Rheumatol. 1988; 15(12):1833-40. |
| |Davies GM, Watson DJ, Bellamy N. Comparison of the responsiveness and relative effect size of the Western Ontario and |
| |McMaster Universities osteoarthritis Index and the short-form Medical Outcomes Study Survey in a randomized, clinical |
| |trial of osteoarthritis patients. Arthritis Care Res. 1999;12(3):172-9. |
| |Altman R, Asch E, Bloch D, Bole G, Borenstein D, Brandt K, et al. The American College of Rheumatology criteria for the |
| |classification and reporting of osteoarthritis of the knee. Arthritis Rheum. 1986;29:1039-1049. |
| |Kellgren JH, Lawrence JS. Radiological assessment of osteo-arthrosis. Ann Rheum Dis. 1957;16(4):494-502. |
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|9. |Signature of the candidate : |
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|10. |Remarks of the Guide |
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|11. |Name and Designation of |
| | |
| |Guide : S NATARAJAN |
| |Professor |
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| |Signature : |
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| |Co-Guide : - |
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| |Signature : - |
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| |Head of the Department : Prof. S. NATARAJAN M.P.T. |
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| |Signature : |
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|12. |12.1 Remarks of the Chairman and Principal |
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| |12.2 Signature : |
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