Low Level Laser Therapy in Knee Osteoarthritis
Condition: Knee Osteoarthritis
MeSH terms: Osteoarthritis; Osteoarthritis, Knee
Study type: Interventional

Summary: 
      The study will be Randomized Controlled Trial. It will be conducted in Allied Hospital
      Faisalabad. The study will be completed in four months duration. Consecutive sampling
      technique will be used for data collection. A sample size of 40 patients will be taken in
      this study. Participants will be divided into two groups. Group A will be treated by LLLT and
      conventional exercises. Group B will perform conventional exercises only. Numeric Pain Rating
      Scale will be used to measure pain. Western Ontario McMaster Universities Osteoarthritis
      Index Score (WOMAC) and Sit to stand test will be used to measure knee function. Goniometry
      will be used to measure ROM of knee. The participants will fill numeric pain rating scale and
      WOMAC as subjective measurements. Knee flexion ROM will be measured with universal
      Goniometer. Total 12 sessions will be given with three sessions per week. Post treatment
      readings will be taken at the end of 4th week. Data will be analyzed on SPSS 25.
    

Detailed description: 
      One of the most common forms of arthritis is Osteoarthritis. Approximately 15% of the
      population is affected by the disease. The prevalence of the disease increases with the age,
      with the peak incidence at fourth decade of life. Study shows that in Southern Pakistan mean
      age of the patients suffering from Osteoarthritis was 58 years. The disease was more dominant
      in women with the 3:8 male to female ratio. Study shows that 13.9% of adults aged 25 years
      and above and 33.6% of older adults aged over 65 years are suffering from osteoarthritis.

      According to Johnston County Osteoarthritis Project prevalence of symptomatic knee OA was
      recorded to be 16% and 28% for radiographic knee OA. Kellgren-Lawrence classified knee
      osteoarthritis based on the appearance of osteophytes in knee AP radiographs. Grades 0-4 were
      assigned with >2 indicating radiographic OA. Pain and stiffness are significant clinical
      features of OA which leads to reduced physical function while articular cartilage
      degeneration is considered to be important pathological feature of OA. Genetic factors,
      age-related physiological changes and biomechanical factors are considered risk factors of
      osteoarthritis. Several studies shows that increased age and BMI increases the risk of knee
      osteoarthritis. One of the important factors in knee osteoarthritis is being
      overweight.Physical inactivity is also associated with osteoarthritis. Most notable symptom
      of osteoarthritis is pain which is also determining factor of disability in patients with
      osteoarthritis. Pain increases physical inactivity which leads to increased body weight and
      eventually predispose the person to osteoarthritis.Quadriceps weakness may contribute to
      prompt clinical finding of knee osteoarthritis. Pain of osteoarthritis may causes reduced
      quadriceps strength. However some studies reveal that quadriceps weakness plays as a risk
      factor for knee osteoarthritis especially in females. Reduced muscle strength was reported in
      24% of patients with Kellgren-Lawrence grade II knee OA. It is widely accepted that among the
      patients with knee osteoarthritis quadriceps weakness is caused by muscle atrophy which
      reduces muscle strength. It is reported that age-related quadriceps weakness is linked with
      functional limitations and increased rate of falling among elders.

      Treatment options for osteoarthritis include pharmacological and non-pharmacological methods.
      The primary goal of these treatments is to relieve joint pain and improve functional quality
      of life. Non-steroidal anti inflammatory (NSAIDS) are used widely but their use is now
      limited due

      to high frequency of side effects specially side effects of gastrointestinal tracts.Therefore
      non-pharmacological treatment is preferred for elderly patients. Non-pharmacological
      treatment includes weight reduction, manual therapy, strengthening exercises, electrical
      stimulation, ultrasound, interferential current and laser therapy.

      Low level laser therapy (LLLT) is non-invasive and painless modality used for the treatment
      of knee osteoarthritis. Studies show that it markedly alleviates both acute and chronic
      conditions such as carpal tunnel syndrome, knee injuries, low back pain, chronic arthritis
      and rheumatoid arthritis. Due to its stimulatory effect on tissue metabolism and ability to
      regulate the inflammatory effect after knee injuries, LLLT is considered as a favorable
      therapeutic modality for OA. It is reported that LLLT was effective for fibroblast and
      osteoblast proliferation, bone regeneration, collagen synthesis, cellular oxygenation and
      release of neurotransmitters linked with pain modulation.

      Evidence shows that regular physical activity reduces pain and improves physical function
      among the patients with knee OA. However being inactive and disuse of affected limb may
      disturbs joint mechanics leading to softening of articular cartilage which leads to rapid
      degeneration of cartilage. This study will focus on additive effects of LLL therapy on knee
      OA patients for improving pain and function. This study will provide an insight in
      traditional methods that are used in OA patients.

      3. LITERATURE REVIEW: Osteoarthritis is the most common form arthritis which is overall
      ranked among 50 common sequelae of injuries and diseases. Almost 250 million people or 4% of
      the world's population is affected by osteoarthritis. It is generally divided into primary OA
      and secondary OA. Etiology of primary OA is not clear but some factors such as genetic
      factor, ethnicity, age related changes and biomechanical factors play an important role. Post
      traumatic, dysplastic, infectious, inflammatory or biomechanical etiologies are common cause
      of secondary OA.

      Females are more affected with hand, feet and knee OA. Women are more subjected to severe
      knee OA than men especially after menopause due to the role of estrogen. Oestrogen unmasks
      the symptoms of OA by increasing pain sensitivity(1). According to a study male to female
      ratio affected by OA in Pakistan is 3:8.

      Most significant symptom of knee OA is pain leading to increased physical inactivity which
      increases body weight and predispose the person to OA. Obesity is also a risk factor for
      developing knee OA.

      Pain in knee OA also reduces strength in quadriceps muscle. Quadriceps weakness in OA may be
      associated with the action of quadriceps during gait. Shock absorption at the knee is
      provided by eccentric contraction of quadriceps. The spontaneous loading at the knee
      resulting from inability to compensate the large compressive forces leads to quadriceps
      weakness and osteoarthritic changes.

      A number of evidence shows that exercise reduces the symptoms of OA and improves the knee
      joint function. However the most advantageous type or combination of exercises is uncertain.
      Physical inactivity and disuse of the affected limb result in loss of flexibility around knee
      joint leading to impaired joint mechanics and increased clinical findings of pain.
      Participation in physical activity and exercise has been recorded to improve joint function
      and beneficial for the treatment of knee OA.

      Physical therapy interventions for knee OA include electrical stimulation, manual therapy,
      strengthening exercises, ultrasound, interferential current therapy, laser therapy and
      orthotic devices. Low level laser therapy (LLLT) has been widely used for relieving pain in
      many

      musculoskeletal disorders. It has been considered as non-invasive and safe treatment for knee
      OA due its stimulatory effect on tissue metabolism and ability to regulate inflammatory
      process after injury Osteoarthritis is more common in females as compared to males. Pain,
      joint stiffness and reduced physical activity are prominent symptoms of knee OA. Genetic
      factors, reduced BMI, overweight, age related physical changes and quadriceps weakness are
      considered risk factors for knee OA. Physical inactivity disturbs the knee biomechanics and
      increases the symptoms of knee OA. Studies show that exercise helps to improve the symptoms
      of knee OA and enhance physical function. Low level laser therapy is non-invasive and
      painless therapeutic modality used for treating knee OA. Evidence proves that LLLT helps in
      relieving pain of OA and improving microcirculation due to its stimulatory effect on tissue
      metabolism.
    

Intervention name(s): Low level laser therapy; Conventional Exercise Therapy
Intervention type(s): Other; Other
Intervention description(s): Gallium aluminium arsenide laser device will be used with wavelength of 850nm, power 100 mW, spot size of 1.0 mm and energy of 6J/point for 60seconds. Total 8 points will be irradiated. It will take 20 minutes.
Patient will receive treatment in supine position with the affected knee(s) slightly flexed supported by the pillow or rolled towel.
On the affected knee the laser probe will placed with full contact with skin at 8 points. Three points at medial side of the knee, three points at lateral side and two points at the medial edge of the bicep femoris muscle tendon and semitendinosus muscle tendon in the popliteal fossa; Quadriceps isometric strengthening exercises.
Range of motion and active stretching exercises applied to hamstring and quadriceps muscle.
Hamstring muscle isometric exercises
Active ankle pump.
Short arc terminal extension exercises for the knee joint.
Static and dynamic strengthening exercises for the hip abductors, adductors and extensor group of muscles.
Non-weight bearing progressive resistance exercises with weighted cuffs, with progression to closed chain exercises as patient's pain allows.
Isometric exercises were applied with 6 second contractions and rest period of 2 seconds. Isotonic exercises were started as 10 repetitions with half of weight of 10 RM, 10 repetitions with three fourth of this weight and 10 repetitions with whole 10 RM
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: Single (Outcomes Assessor)
Primary purpose: Treatment
Keywords: Knee pain; Knee function; Degenerative knee disease