One of the biggest innovations in rehabilitative medicine is silent, quiet, and virtually undetectable by the patient during treatment. Low-level laser therapy (LLLT) is a systematic application of a low-powered, pulsed laser designed to aid in recovery from injury. While it is understood that the laser stimulates cell function, exactly why it is so successful is unclear. However, the fact that it is successful is evident, if something of a mystery.

"You can see the laser, but you can't feel it, yet it's very, very effective," says Todd Forman, managing partner of Integrative Therapeutics, Natick, Mass. "For 80% to 90% of the people we use it on, we see a very positive result."

Those positive results often come in the form of pain relief for patients on whom conventional treatments and manual therapies have been ineffective. Like physical therapy itself, LLLT is not as much about treating the pain specifically as it is about targeting the source.

"Whether or not you're using a laser, physical therapy is about getting to the underlying cause of the problem and not just treating the pain itself. To some, this might sound like a semantic difference, but I believe it is a very important operational difference," Forman says. "If a shoulder hurts due to a tendon that is inflamed because the shoulder can't move properly, then you treat the restriction in the range of motion first, and then the inflammation—and then the pain is going to go away."

SEEING THE (LASER) LIGHT

The PTs at Integrative, a privately owned practice that opened in 2000, have had access to the LLLT system for about 18 months. But the science wasn't initially welcomed with open arms. Coming from a strong manual therapy and therapeutic exercise background, Forman was a self-described skeptic of the technology—cynicism that was quickly allayed.

"The company's representative started to use the laser on the staff, and I was seeing results. We would test strength six times, and it came out as the same grade; then he did the laser treatment, tested again, and it was a full muscle grade higher," he says, discussing a presentation he attended at the urging of one of his colleagues. "This is an objective finding you can put a measurement on, and it is literally changing in 1 or 2 minutes, right before your eyes. I am very confident that what we are seeing is not, and cannot, be placebo."

After a 3-month trial period, the decision was made to purchase the LLLT system. Integrative's four PTs provide benefits to its patients with a laser system manufactured by Erchonia Medical, McKinney, Tex.

As a result of current reimbursement structures in place by most insurance providers, those benefits are paid for "out of pocket" by the patients. A great variance in the types and quality of lasers on the market is one reason for the hesitance on the part of payors; also factoring in is the fact that it was only cleared by the FDA less than 5 years ago.

Because there is currently no CPT code for a laser, practices are left with only two choices: either to provide treatments free of charge or to offer it on a pay-for-service basis. The cost of the unit—which ranges between $9,000 and $12,000—usually rules out the first option.

As the majority of their patients do not have unlimited resources, the PTs at Integrative only recommend use of the laser if they are confident it will generate positive results for patients.

"Physical therapy is not ineffective; it works very well. So we will try regular physical therapy first, and if we are not meeting these goals within a reasonable time frame, then I will bring the laser in," Forman says. Knowing the laser sessions can be costly for some patients, the business provides a safety net. "We guarantee the first visit, meaning if we recommend it and it doesn't work, we will refund the full cost of the visit."

In the 18 months since the laser has been in use, only one refund has been given. This level of success is made possible because of the immediacy associated with the laser.

"You can see range of motion go from 90° of shoulder abduction and pain at the end of the range to 180° of shoulder abduction with no pain—in only about 3 minutes," Forman says.

Conversely, the PT knows right away if it is not going to work, according to Forman, who has never experienced an instance in which the laser was completely ineffective on the first session and then miraculously started to work during the second session.

PRECISE PARADIGM

Even with such high success rates, it is important that the laser not be used as a "broad stroke" tool and that therapists perform a standard physical therapy evaluation before administering the laser. LLLT is a modality accompanied by a treatment protocol that must be followed in order to obtain optimum results, Forman says.

Simply shining the laser on a painful shoulder for about 10 minutes, without following the paradigm, will yield modest results, if any. But applying the laser, following a test of the neck's range, to the cervical spine for 90 to 120 seconds in a specific pattern will result in marked improvements.

"It's a very criteria-based paradigm, and it is a fairly lengthy process: You establish a given finding, you treat that finding, you retest that finding, and only when that is resolved do you go on to the next one," Forman says. "The unit itself is impressive, but to obtain the best results, you really need the unit plus the treatment paradigm."

Exactly how much time the patient experiences with the laser is based on the particulars of their injury. One option is a "laser adjunct session," which is performed in the context of a normal physical therapy treatment. Applied in 5- to 10-minute segments, these add-on treatments target individual problems, such as supraspinatus strength that is persistently weak.

Not only will these mini-applications dramatically increase the strength in patients who are responsive to the laser, but the improvements are maintainable. According to Forman, it is typical to maintain about 75% to 80% of the gains obtained with the laser.

Read expert advice on laser therapy in our March 2007 article, "Seeing the Light."

The second approach is full-length therapy sessions, which normally last about 45 minutes. A much more extensive treatment with a laser, these treatments are generally recommended for patients with multiple or complicated physical ailments.

ADDING OPTIONS

For Integrative, LLLT has provided the practice the opportunity to expand its already-comprehensive services.

"First and foremost, we wanted the laser to give us another tool to help us with the patients who we were already being successful with—that was the first priority. Everything else really become secondary to that," Forman says. Almost since its introduction to the practice, the laser has been a good fit, allowing them to provide a range of services, which already included acupuncture, chiropractic, and massage therapy. "What makes Integrative unique is its ability to bring a number of different diagnostic perspectives to a problem. Not every patient gets every discipline, but when necessary to coordinate on a patient, it starts to give us the ability to develop truly coordinated multidisciplinary care."

Laser therapy has had an impact not only on patients' lives, but also on the business, bringing with it increased revenue and increased patient volume.

"I don't like to create expectations that we are going to resolve all problems in one fell swoop with this modality, so we have been a little bit slow to advertise it," Forman says. "Even so, it is definitely bringing in new patients and more revenue; that number has been climbing steadily for a year, and now it is happening even more quickly."

For example, when full-laser sessions were first made available, the practice was performing one or two each month. The last tally put the number closer to 20 each month. Aside from listing it as a service on its Web site, the practice doesn't do any external advertising, so most of the boost comes from word of mouth—a direct result of the system's successes. Referrals are not only being made by patients, but are also coming from physicians who are seeing noteworthy advances in their patients' progress.

One of Forman's patients came to the practice after suffering through a 2-year history of sciatica that was a result of birth complications. Despite trying numerous modalities and therapies, her condition was not improving.

"We had such marked results after the first time I used a laser, one of her clinicians called me and asked what I had done," he says. The patient was even more delighted. "She literally came in and said, 'I don't care if I have to get down on my knees and beg you. Will you do that again?' Of course, she didn't have to get down on her knees and beg."

Due to the woman's long-standing, complicated problems, she was treated for about eight sessions. At the conclusion of treatment, her sciatica was roughly 95% resolved.

"This is a woman who was in her early 30s with a newborn, and she could not be on her feet for more than 30 minutes. Now she is back to yoga, she's got an active lifestyle again—she has gotten her life back," recalls Forman, who notes that in addition to the LLLT, she was treated with traditional physical therapy. "In her case, it is not a pure laser case, but the help that the laser gave was undeniable. She just did very, very well."

REALITY CHECK

Despite such "miracle" recoveries, Forman emphasizes that LLLT is not a silver bullet.

"Like everything else in life, it is really good but it is not universally applicable," he says. "I don't think there is an orthopedic condition you couldn't use the laser on, but I think extremity problems are a little bit faster to treat than spine problems. Though, that has less to do with the laser and more to do with the fact that spinal problems tend to be a little bit more complex."

For practices contemplating bringing lasers into their practice, he recommends setting expectations before a purchase is even made.

"[Physical therapy] practice administrators and directors need to answer the question: What exactly is it you want a laser to do for your practice? If you don't really know what you want it for, it's difficult to determine whether or not it has ultimately done the job a year or two out," Forman says. "You need to define what deficiency you are trying to manage, and see if the laser is going to fill that niche or not. We were eager to use it to solve more problems, and ultimately that is what it has done."

It's also imperative that therapists who will be administering LLLT invest the time required to truly master the modality. Forman goes as far as to say that, after purchasing the laser unit, it should remain in the box until staff has been trained and fully understands the paradigm. Rushing to use the modality too quickly is likely to generate substandard results, frustrating both the patient and the therapist.

"Once you understand the treatment paradigm, then go ahead and start playing with it so that you get an idea about how it responds," Forman says. "The treatment protocol is a guideline, not a cookbook. There is a fair amount of thought process that goes into that, and it takes practice to get proficient at it."

The customer demand for Integrative's LLLT services is not waning, and Forman expects it to become a much larger part of the practice.

"As the modality starts to become more available to the public, people who have been dealing with chronic problems—and just living with them—will seek out that new and effective therapy," Forman says. Still, the focus will stay on providing the best treatment option possible, regardless of how it's delivered. "I am in the business of treating patients. I am not in the business of trying to hawk a specific treatment."

Dana Hinesly is a contributing writer for Physical Therapy Products. For more information, contact .