High-intensity versus low-level laser therapy in

the treatment of patients with knee

osteoarthritis: a randomized controlled trial

Pembimbing : dr. Nyoman Murdana, SpKFR(K)

Presentan : Merie Octavia
Introduction
• Knee osteoarthritis (KOA) common musculoskeletal
joint disease that affects the elderly
• Begin after age of 40
• Degeneration of the articular cartilage and its underlying
bone as well as bony overgrowth
• Major causes of physical disability  pain, stiffness, joint
instability, and muscle weakness
• 1/3 aged 65 years and older have KOA, evidenced by
radiography
• In Saudi Arabia, KOA affects 53.3% males and 60.9%
females (age 30-90) , mean age of 49 years with bilateral
affection about 80%
Introduction
• The treatment of KOA involves both pharmacological and non-
pharmacological interventions
• Physical therapy modalities are commonly used for pain
management that may include ultrasound, and low-level laser
therapy (LLLT)

Laser  non LLLT Recently, HILT

invasive, easily significantly was
administered reduces both introduced. The
acute and advantage of
chronic HILT is able to
conditions such reach and
as RA, OA, CTS stimulate
large/deep
joints
Objective

Compare the effects of LLLT and

HILT on pain relief and functional
improvement in patients with
KOA
Methods

Subjects recruited
were from the Were examined
outpatient by orthopedic
single-blinded
department of
randomized
physical therapy
specialists and
controlled trial and rehabilitation underwent
department of AL- imaging before
Noor hospital.
Methods
Inclusion Criteria Exclusion Criteria

1. Had painful KOA at least 6 months
2. OA grade 2-3
3. Had no limitation ROM except minimum
tightness in the knee joint
4. Had not undergone any specific treatments 3
months before entering the study
5. WOMAC ≥ 25
6. VAS ≥ 4
1. Had any other musculoskeletal problems such
as fracture, tendon or ligament tears,
meniscus injury, RA or knee surgery
2. Problems with hip/ankle-foot joints
3. Central/ peripheral neuropathy
4. Received physical therapy / intra-articular
corticosteroid/ hyaluronic acid injection last 6
months
 Randomized into three groups 
Methods were randomized using the SPSS
program
Group 1

Group 2

Group 3
HILT and LLLT and Placebo
exercise exercise laser plus
(HILT+EX (LLLT+EX exercise
group) group) (PL+EX
group)
Methods  Intervention protocols
HILT
High-intensity laser
therapy
1. pulsed Nd:YAG laser
2. Probe positioned in contact and
perpendicularly
3. Patient in a supine lying position with the
knee flexed at 30° to open the joint surfaces
to the laser beam (optical windows)
4. The scanning was performed transversely and
longitudinally in the anterior, medial, and
lateral aspects of the knee joint
5. Total energy delivered in one session 
1250J (3 phases of treatment) for 15 minutes
6. HILT was applied for a total of 12 sessions
(two sessions/week for 6 weeks).
Low-level laser
therapy
1. Gallium-arsenide diode (GaAs) laser
2. Wavelength of 830 nm, output power of 800
mW, average energy density of 50 J/cm2,
frequency of 1 KHz, and duty cycle of 80 %.
3. Supine position lying on the treatment bed
while the affected knee was slightly flexed
and supported with a pillow
4. Total energy 1250 J in 32 minutes
5. Total of 12 weeks (two sessions/week for 6
weeks).
Methods  Intervention protocols
Plasebo Laser
1. Patient attended the physical therapy clinic
two times a week for 6 weeks and received
sham laser.
Exercise
1. all treatment groups received an exercise
program which consisted of active range of
motion (ROM) exercises, muscle
strengthening,and flexibility exercises
2. Started the exercise session with a 10-min
warm-up exercise on the treadmill. Then,
each patient performed the quadriceps
muscle strengthening exercise 10times/set, 3
sets, 2 min rest between set , followed by 5
min of self-stretching for the hamstring and
calf muscles
3. These exercises were repeated at home.
Outcomes Measured

• Demographics  age, gender, weight, body mass index (BMI),

marital status, and disease duration
• Pain levels and disability scores. Pain level was measured by VAS and
knee function by WOMAC.
SEMESTER 2\TANGERANG\womac-osteoarthritis-index.pdf
• Baseline evaluation and repeated after 6weeks of treatment
Data analysis

• SPSS for Windows, version16

• Analysis of variance (ANOVA) was used for comparing mean values of
patient’s age, weight, height, and BMI
• For non-parametric measures like VAS and WOMAC  Wilcoxon
signed ranks test. (differences between baseline and post-treatment)
• Difference between each treatment group was performed by the
Kruskal-Wallis test
• The level of statistical significance was set as P<0.05.
RESULTS
-baseline characteristics-
• There were no significant differences between groups
RESULTS
-baseline characteristics-
RESULTS
• All treatment groups showed a significant reduction in VAS and
WOMAC in post- treatment as compared with baseline values

5,65 4,71 3,94

Discussion
Discussion
• From this study the main findings were that HILT and LLLT
combined with exercise are effective in decreasing the VAS and
WOMAC scores after 6 weeks of treatment
• HILT combined with exercises was more effective than LLLT combined
with exercises
• Both treatment modalities were better than exercises alone in the
treatment of patients with KOA.
Discussion
• Effects of LLLT on KOA  reduction of pain , stiffness , knee swelling ,
and inflammatory process  increase microcirculation  increase
functional performance
• HILT applications include recovery of nerve paralysis , wound repair
and pain relief.
• HILT superior effect  leading to the possibility of treating deep
tissues and structures
• Very good and quick analgesic effect of HILT in patients with KOA
Conclusion
• Laser is an effective physical therapy modality
• Laser(either LLLT or HILT) combined with exercise was more effective
than placebo laser with exercise
• Effect of HILT combined with exercise is more effective in decreasing
pain and increasing functional performance.
• Exercise the most important
• The combined use of exercise and laser especially HILT  clinical
significance in providing a rapid and potent effect in pain reduction
and functional improvement.
 I
P
HILT + exc
patients with KOA
LLLT + ecx

PICO
O
C VAS
Plasebo laser +exc WOMAC
 1a. R- Was the assignment of patients to
treatments randomised? √

1b. R- Were the groups similar at the start of the trial? √

2a. A – Aside from the allocated treatment,
were groups treated equally? √

2b. A – Were all patients who entered the trial

accounted for? And were they analysed in the groups
to which they were randomised?
No. Drop out 6,7%
 3. M - Were measures objective or were the
patients and clinicians kept “blind” to which
treatment was being received?
What were the results?
How precise was the estimate of the
treatment effect?
• P<0,05

Will the results help me in caring for my

patient?
• Is my patient so different to those in the study that the results cannot
apply? NO
• Is the treatment feasible in my setting? ? NO
• Will the potential benefits of treatment outweigh the potential harms of
treatment for my patient? YES, theres no serious harm for patient
HILT

• Recommended for 8-10 sessions for 10-

15 minutes, depending on the underlying
clinical condition
• Rapid and permanent wound healing, and
reduced recovery time
• Important physiological effects of HILT are
the involvement of intracellular enzyme
activity (especially in the Krebs cycle),
increased oxygen transport and oxygen
use, stimulation of DNA synthesis,
activation of Na / K pumps, fibroblast
activity, phagocytosis, metabolic
processes, inflammatory mediator
suppliers (histamine and prostaglandins)
and endorphin levels
• Research conducted by Diana et al. OA patients were given 6 single
therapy sessions, 3 sessions in 1 week. In phase I, laser applications
are given in a circular and continuous manner. HILT is regulated by
power of 10 W, frequency of 25 Hz, dose of 12 J / cm2, total energy of
300 J, wavelength of 1064 nm, area of 25 cm2, for 2 minutes. After
phase I, the tool is adjusted to phase II with continuous movement.
Power of 5 W, density 120 J / cm2, total energy of 300 J, wavelength
1064 nm, area of 25 cm2, duration 2-4 minutes.
• During the procedure, the patient should feel a warm sensation in the
area of the skin.
• Pause time intervals to reduce heat accumulation in tissues so as to
accelerate the photochemical, photothermal, and photomechanical
effects
• The recommended duration of therapy ranges from 5-15 minutes
with a total energy of 1000-2000 J and knee flexion position of 30°.
The advantage of HILT compared to LLLT is that it increases the
penetration power of tissues, giving a broader and deeper
therapeutic effect  is able to penetrate up to the bones and
cartilages