Arthroplasty Today 19 (2023) 1e9

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Arthroplasty Today
journal homepage: http://www.arthroplastytoday.org/

Original Research

Low-Level Laser and Light Therapy After Total Knee Arthroplasty

Improves Postoperative Pain and Functional Outcomes: A Three-Arm
Randomized Clinical Trial
Homa Bahrami, PhD, Alireza Moharrami, MD, Peyman Mirghaderi,
Seyed Mohammad Javad Mortazavi, MD *
Joint Reconstruction Research Center, Tehran University of Medical Sciences, Tehran, Iran

a r t i c l e i n f o a b s t r a c t

Article history: Background: We examined the effect of low-level laser therapy (LLLT) and Bioptron light therapy on pain
Received 22 July 2022 and function following primary total knee arthroplasty.
Received in revised form Methods: A single-center, single-surgeon, prospective randomized clinical trial was performed with 3
2 October 2022
groups of 15 patients: LLLT (804 nm), light (Bioptron; Bioptron AG, Wollerau, Switzerland), and controls.
Accepted 29 October 2022
Range of motion (ROM), visual analog scale pain, opiate consumption (oxycodone in milligrams), knee
Available online xxx
swelling, and the Knee Society Score (KSS) were assessed before the surgery and on postoperative day 2,
postoperative day 3, month 3, and month 12 after the operation.
Keywords:
Enhanced recovery after surgery
Results: The preoperative scores were similar between groups. A higher ROM was observed with the LLLT
Laser therapy group at all follow-ups except at the 12-month follow-up (3-month ROM: 116.8
vs 104.0
vs 92.3
; P <
Low-level light therapy .001). The knee swelling at 3 months was similar between the LLLT and light groups (2.1 cm), which was
Postoperative care lower than that in controls (2.1 cm, P < .001). Furthermore, visual analog scale pain decreased more in
Total knee arthroplasty the LLLT group than in other groups (8.5 vs 7.2 vs 6.0 points) at 3 months (P ¼ .04) but was similar at 12
months (P > .05). Also, the LLLT group consumed fewer opiate painkillers during the first month (48.3 vs
60.3 mg of oxycodone, P ¼ .02). In the LLLT group, the KSS at 3 and 12 months and the KSS function score
at 3 months exceeded minimally clinically important differences (P < .05).
Conclusions: In the early stages of recovery after total knee arthroplasty, LLLT and Bioptron light therapy
could be helpful to control immediate and acute knee pain and swelling, reduce the need for opioids,
improve ROM and functional scores, and improve recovery.
Level of Evidence: Therapeutic level I.
© 2022 The Authors. Published by Elsevier Inc. on behalf of The American Association of Hip and Knee
Surgeons. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/lice
nses/by-nc-nd/4.0/).

Introduction are major concerns for orthopedic surgeons. A multimodal anal-

gesic approach is generally used, including nonsteroidal anti-
Knee degenerative processes may eventually worsen, develop inflammatory drugs (NSAIDs), opioids, periarticular injections,
osteoarthritis (OA), and lead to patient limitations. Patients with and peripheral nerve blocks [2,3]. Nevertheless, adverse effects of
advanced knee OA may benefit from total knee arthroplasty (TKA) extended use, such as gastrointestinal bleeding and ulcers [4] and
to restore function and improve quality of life [1]. The management renal failure, are harmful to patients, especially the elderly [5].
of acute postoperative pain and the early recovery following a TKA Prolonged use of NSAIDs prevents local inflammation, which plays
a key role in healing, destroys osteoblasts through apoptosis in-
duction, and interferes with a successful healing response [6].
Homa Bahrami, Alireza Moharrami, and Peyman Mirghaderi contributed equally Moreover, an increase in the consumption of opioids leads to a rise
to this work (Co-first author). in postoperative hospitalization length and complications during
* Corresponding author. Joint Reconstruction Research center, Imam Khomeini recovery [7].
Hospital, Tehran University of Medical Science, End of Keshavarz Blvd, Tehran, Iran.
Low-level laser therapy (LLLT) facilitates musculoskeletal reha-
Tel.: þ98 21 6658 1586.
E-mail address: [email protected] bilitation with a focused beam of low-power light of wavelength

https://doi.org/10.1016/j.artd.2022.10.016
2352-3441/© 2022 The Authors. Published by Elsevier Inc. on behalf of The American Association of Hip and Knee Surgeons. This is an open access article under the CC BY-
NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
2 H. Bahrami et al. / Arthroplasty Today 19 (2023) 1e9

between 600 and 1000 nm [8]. Several systematic reviews have therapy, and controls on postoperative pain and functional out-
established that LLLT as an adjunct to rehabilitation exercise can be comes after a primary TKA. The institutional review board of our
beneficial for treating knee OA [9,10] and other musculoskeletal university of medical sciences reviewed the study's protocol and
conditions [11]. According to evidence, LLLT provides anti- approved the study design, and there is no ethical concern. All
inflammatory properties that work at the cellular level by influ- patients signed informed consent statements and participated
encing the mitochondrial membrane, increasing ATP production voluntarily. The study was registered in the Iranian registry of
and oxygenation of tissues, as well as regulating reactive oxygen clinical trials (IRCT, registry code: IRCT20160809029286N4). This
species, cytokine levels, and inflammatory mediators [12e14]. RCT followed the guidance in the Consolidated Standards of
Experimental studies have indicated that LLLT and NSAIDs have Reporting Trials (CONSORT) 2010 [34].
similar effects on reducing inflammatory cells, while LLLT has even
greater efficacy in reducing proinflammatory cytokines (IL-1b, IL-6, Study sample size and participants
and TNF-a), Prostaglandin E2, and myeloperoxidase [15,16]. How-
ever, controversy exists among studies, and some other compre- The sample size was calculated based on the study by Eid and
hensive reviews found that LLLT is not beneficial for patients with Aly (2015) [35] that used LLLT to treat hemarthrosis in hemophilic
OA [17,18]. patients. We considered a b value of 20% and a of 5% for sample size
Regarding using LLLT to improve postoperative outcomes, many calculation. We used the knee range of motion (ROM) at 6 weeks
studies in the field of endodontics and oral maxillofacial surgery after the treatment (group 1: 106 ± 5.7 vs group 2: 100.1 ± 5.0) as a
revealed beneficial effects in terms of implant stability, bone loss, reference value for sample size calculation. Therefore, the calcula-
swelling, and postoperative pain [19e21]. Furthermore, some tion resulted in 15 patients in each group for a total of 45 patients.
studies have investigated the impact of laser therapy on outcomes In the present study, 45 consecutive patients (45 knees) were
of TKA [22e26] and total hip arthroplasty (THA) [27], and others are enrolled between February 2017 and February 2018 in Imam
in progress [28]. According to the study by Huang et al. on older Khomeini hospital, Tehran, Iran. The summarized enrollment flow
patients with TKA, LLLT reduced postoperative pain severity and diagram and procedures are shown in the CONSORT flowchart
morphine usage within 72 hours after the surgery [22]. The study (Fig. 1).
by Langella et al. on THA patients also showed that pain levels and
inflammatory factors (TNF-a and IL-8, but not IL-6) decreased Inclusion and exclusion criteria
significantly in the laser group compared to those in the control
group [27]. All in all, LLLT, compared to pharmacological agents, Inclusion criteria
may have better risk benefits and appears to be effective in pain,
swelling, and inflammation control and safe in patients with  All patients who underwent a primary unilateral TKA for pri-
metallic implants with or without cement [23]. mary knee OA at our institution during the period (February
Polarized polychromatic noncoherent light (Bioptron light; 2017 to February 2018).
Bioptron AG, Wollerau, Switzerland) is another new modality that  American Society of Anesthesiologists score of I-III.
physiotherapists use to ameliorate musculoskeletal conditions such
as carpal tunnel syndrome [29] and lateral epicondylitis [30]. As
with LLLT, Bioptron light is also a low-power beam, but it is a Exclusion criteria
polychromatic and incoherent 1. It contains visible light at a
wavelength of 480-700 nm and infrared at 700-3400 nm, but LLLT  TKA in patients with rheumatoid arthritis or secondary OA such
includes both types of light at 1 wavelength [31]. As far as no ul- as posttraumatic arthritis.
traviolet light exists in both LLLT and Bioptron light, there is no  Light sensitivity
concern of tanning or skin burn, and they are safe for pregnant  Hemophilia
women [31]. However, the use of lasers is rarely associated with  Opium- or narcotic-dependent patients
complications, including burns, infections, eye injuries, pigmenta-  Unicompartmental or bilateral knee replacement
tion abnormalities, and erythema [32]. Researchers claim that  Revision TKA patients or previous knee surgery (eg, arthroscopy,
Bioptron light has bio-stimulating effects that help cellular pro- ligament reconstruction, fracture fixation, and osteotomy)
cesses accelerate and improve blood supply, but additional research  Patients who developed deep vein thrombosis or infections in
is needed to determine exactly how it works [33]. To our knowl- the postoperative period.
edge, Bioptron light has not been studied as a supplement to an  Patients who were unwilling to participate in the study or had
exercise program during recovery after a TKA surgery. difficulty in communication due to cognitive dysfunction or
There is limited evidence that LLLT and light therapy can effec- mental retardation.
tively manage musculoskeletal conditions such as knee OA [9,10],
particularly after a joint replacement surgery [22e26]. Therefore, Interventions and study protocol
the present study compares the efficacy of LLLT and light therapy as
physical modalities in the rehabilitation protocol of patients un- This study had 2 interventions (Bioptron light or LLLT) and 1
dergoing TKA with a control group. The study hypothesis is that control group. Light (Bioptron light; Bioptron AG, Wollerau,
LLLT reduces postoperative pain and opiate painkiller consumption, Switzerland) was applied in 1 intervention group and LLLT
improves function, and does not cause complications in early (LASERPEN; RJ-LASER, Reimers & Janssen, Berlin, Germany) to
rehabilitation protocols for knee OA patients who underwent TKA. another group with standardized pharmacological and surgical
protocols (Fig. 2). Both groups received light therapy or LLLT on the
Material and methods posterior region of the knee (points H and D). Acupuncture points
were chosen due to surgical wound hygiene and possible wound
Study design and ethics statement complications caused by acupuncture in the anterior region and
also due to the difficulty of exposing the patients immediately
A single-center, single-surgeon, 3 parallel-armed, nonblinded following the surgery. The LLLT had the following properties: 804
prospective randomized clinical trial (RCT) compared LLLT, light nm, Ga-Al-As semiconductor diodes, a power density of 500 mW, a
 H. Bahrami et al. / Arthroplasty Today 19 (2023) 1e9 3

Figure 1. Consolidated Standards of Reporting Trials (CONSORT) flow diagram of patients’ enrollment and assessments.

Figure 2. (a) Bioptron light instrument. (b) Low-level laser (LASERPEN; RJ-LASER) instrument. (c and d) Applying laser on the posterior region of the knee.
4 H. Bahrami et al. / Arthroplasty Today 19 (2023) 1e9

Table 1
Comparison of demographic data between 3 groups.

Groups Age (y) Sex (female, %) Side (right) Weight (Kg) Height (cm) BMI (Kg.cm-2)

Control 64.9 ± 6.5 12 (80.0) 9 (60.0%) 76.0 ± 11.1 163.5 ± 10.5 27.9 ± 2.8
Laser 62.4 ± 8.0 9 (60.0) 10 (66.7%) 78.1 ± 11.0 163.4 ± 8.4 28.7 ± 3.8
Light 65.7 ± 6.8 8 (53.3) 9 (60.0%) 73.4 ± 7.7 161.7 ± 9.0 27.8 ± 4.1
P value .4 .3 .9 .4 .8 .7

BMI, body mass index.

dosage of 10J per session in 2 points (5J/Point), for 10 seconds. The ketorolac (60 mg), Bupivacaine (AstraZeneca, London, UK) (4 mL
intervention was applied during the first 3 days after the operation, 0.5%), lidocaine (5 mL 2.0%), and 1.5 mg of tranexamic acid. A
1 session of laser therapy each day. Patients were lying supine standard protocol at our center is to prescribe the following med-
during the laser and light therapy and used protective goggles. ications daily for a month after the surgery: celecoxib (400 mg),
Patients received LLLT during their first 2 days of hospitalization omeprazole (20 mg), pregabalin (75 mg), acetaminophen (2 g), and
after the surgery, were discharged on day 2, and returned to the oxycodone 5 mg as needed (maximum 15 mg per day).
hospital on their third postoperative day (POD) for the final session.
These procedures are combined with an exercise program [36] and Randomization and blinding
5 minutes of ice gel on the operated knee for all postoperative TKA
patients. The second group received 10-minute treatment with Based on the type of conservative treatment after a TKA, 45
Bioptron light (480-3400 nm; 95% polarization; 40 mW/cm2; and patients were randomized into 3 groups: LLLT, light, and control (15
2.4 J/cm2) for the same 3 days at 10-cm distance from the device patients per group). Block randomization was performed with a
and the same quadriceps isometric exercise program with ice. The block size of 3. We used opaque and sealed envelopes and random
third group only received an exercise program with ice as in all numbers generated by the excel RAND function and divided all the
groups. The cost of 3 sessions of LLLT or light therapy is approxi- patients into 3 interventions, each consisting of 5 blocks with a size
mately 60$ in our country and is performed by experienced of 3. Patients selected their envelope after the surgery randomly.
physiotherapists. Despite the difficulties in blinding patients and the surgery team,
All patients were diagnosed with severe knee OA and underwent the researcher performing the assessments and analyzing the data
a standard conventional primary TKA by the anterior midline inci- was blind to the interventions in each group. Therefore, the present
sion approach, using a tourniquet (250 mmHg) and without suction study was not blinded.
drainage. All patients underwent a TKA by the senior author, who is
an adult joint reconstruction fellowship trained surgeon (SMJM). Outcome measures
The NexGen LPS-Flex cemented (Zimmer Biomet Inc., Warsaw, IN)
posterior stabilizer TKA. Standardized spinal anesthesia was applied The study's primary outcome measure was knee flexion ROM
for all patients using Bupivacaine (AstraZeneca, London, UK). Pa- (degree) and knee pain level at a 3-month follow-up. The knee ROM
tients were mobilized by a walker within 6-8 hours of the surgery was measured by a 360
digital goniometer (Ghamatpooyan Co.,
and began ROM and isometric rehabilitation exercises. Patients Iran) using the method described by Norkin and White [37]. In
remained in the hospital for 3 days after the surgery. We did not use orthopedic surgery, goniometry is widely used to measure ROM
any joint immobilizer for the patients postoperatively. and has an intraclass correlation coefficient of 0.99 [38]. Another
Following the surgery, we administered aspirin (325 mg/two primary outcome measure was the articular pain at 3 months
times a day) to all the patients as a venous thromboembolism assessed using the visual analog scale (VAS). Patients' consumption
chemoprophylaxis. The pain management protocol consists of of opioid painkillers was also measured as a representative of
celecoxib (400 mg), pregabalin (75 mg), acetaminophen (1 g), and articular pain. Opiate painkiller use (oxycodone) was documented
omeprazole (40 mg) before the surgery. In the end, a cocktail was on POD 9 (first postoperative visit) and at the end of the first month
administered intraarticular containing normal saline (90 mL), after the surgery. Swelling in the knee was measured using a tape

Table 2
Comparison of outcomes of ROM, swelling, and VAS pain score between the 3 groups.

Variables Before surgery After surgery P value (repeated measure

ANOVA)
Second day postop. Third day postop. 3 mo Postop. 1 y Postop.

ROM
Control 98.3 ± 5.2 41.7 ± 4.5 70.1 ± 10.6 92.3 ± 5.0 113.7 ± 7.9 Group effect: <.001a
Laser 97.5 ± 4.1 60.3 ± 12.9 90.9 ± 3.3 116.8 ± 6.3 119.7 ± 5.8 Time effect: <.001a
Light 100.9 ± 4.4 49.8 ± 5.5 87.8 ± 3.6 104.0 ± 6.6 116.0 ± 6.6 Interaction: <.001a
P value (ANOVA) .12 <.001a <.001a <.001a .064
VAS pain
Control 9.5 ± 0.9 7.5 ± 0.9 5.9 ± 0.9 3.5 ± 0.9 0.5 ± 0.6 Group effect: <.001a
Laser 9.1 ± 0.8 6.0 ± 1.3 3.9 ± 1.2 0.7 ± 0.4 0.6 ± 0.9 Time effect: <.001a
Light 9.4 ± 0.9 6.5 ± 0.9 4.7 ± 1.2 2.1 ± 0.5 0.9 ± 0.7 Interaction: <.001a
P value (ANOVA) .56 .002a .04a .04a .31
Swelling
Control 49.6 ± 1.2 53.9 ± 1.2 53.3 ± 1.7 52.4 ± 1.4 - Group effect: <.001a
Laser 48.8 ± 2.5 52.5 ± 2.4 51.7 ± 2.5 50.9 ± 2.3 - Time effect: <.001a
Light 48.8 ± 1.4 52.5 ± 1.6 51.7 ± 1.7 50.9 ± 1.9 - Interaction: .008a
P value (ANOVA) .35 .04a .04a .04a -

ANOVA, analysis of variance.

a
Indicates significant P value.
 H. Bahrami et al. / Arthroplasty Today 19 (2023) 1e9 5

All patients were followed up for 12 months, and outcomes

were measured before the surgery and after the intervention on the
POD 2, POD 3, month 3, and month 12. Then, we compared the
between-group differences of these measures to the minimally
clinically important differences (MCIDs) previously reported for
patient-reported outcome measures, 2 points for VAS [41], 5.3 for
KSS knee score, and 6.1 for KSS function score [40]. Considering
there is no prior literature reporting the MCID of the ROM following
TKAs, we only make statistical conclusions regarding the ROM.

Statistical analysis

All data were collected in IBM SPSS v.22.0 software (Armonk,

NY). To assess normality, the Shapiro-Wilk test was used. The
continuous variables were compared using the students’ t-test and
analysis of variance based on their normality. The nominal variables
were also compared using the chi-square test. Repeated-measures
analysis of variance was used to compare the group's scores before
and after the surgery. A P value <.05 was considered significant
(two-sided).
Figure 3. The comparison of the ROM between the 3 groups, which was significantly
higher in the laser group after 3 months (laser > light > control).
Results
measure (cm) while the patient was lying supine and in full
extension. Approximately 1 cm proximal to the patella was The distribution of patients in age, sex, surgery side, weight,
measured as knee circumference [39]. In this case, 2 measurements height, and body mass index was similar in the 3 groups (Table 1). A
were made, and the mean value was analyzed. Knee function was wound complication occurred in 1 patient in the light group who
measured by the Knee Society Score (KSS), consisting of knee score was treated conservatively. Thromboembolic events were not
and function score [40]. Assessments and examinations were per- found in either of our study groups. No major side effects were
formed by an experienced orthopedic resident who was blinded to reported during or after the treatment period.
the groups (A.M., postgraduate year 3). Laser and light in- Knee ROM was significantly better on all follow-ups, except 12-
terventions were performed by an experienced physical therapist month follow-up, in the LLLT group than that in the light group and
(H.B., Doctor of Physical Therapy). control group (P < .001) (Table 2) (Fig. 3). The binary comparison

Table 3
Comparison of outcomes of ROM, swelling, and VAS pain score between binary groups.

Variables Before surgery After surgery

Second day postop. Third day postop. 3 mo Postop. 1 y Postop.

ROM
Laser 97.5 ± 4.1 60.3 ± 12.9 90.9 ± 3.3 116.8 ± 6.3 119.7 ± 5.8
Light 100.9 ± 4.4 49.8 ± 5.5 87.8 ± 3.6 104.0 ± 6.6 116.0 ± 6.6
P value .12 .005a .42 <.001a .32
Control 98.3 ± 5.2 41.7 ± 4.5 70.1 ± 10.6 92.3 ± 5.0 113.7 ± 7.9
Laser 97.5 ± 4.1 60.3 ± 12.9 90.9 ± 3.3 116.8 ± 6.3 119.7 ± 5.8
P value .86 <.001a <.001a <.001a .053
Control 98.3 ± 5.2 41.7 ± 4.5 70.1 ± 10.6 92.3 ± 5.0 113.7 ± 7.9
Light 100.9 ± 4.4 49.8 ± 5.5 87.8 ± 3.6 104.0 ± 6.6 116.0 ± 6.6
P value .30 .03a <.001a <.001a .62
Pain
Laser 9.1 ± 0.8 6.0 ± 1.3 3.9 ± 1.2 0.7 ± 0.4 0.6 ± 0.9
Light 9.4 ± 0.9 6.5 ± 1.0 4.7 ± 1.2 2.1 ± 0.5 0.5 ± 0.6
P value .69 .36 .14 <.001a .97
Control 9.5 ± 0.9 7.5 ± 1.0 5.9 ± 1.0 3.5 ± 1.0 0.9 ± 0.7
Laser 9.1 ± 0.8 6.0 ± 1.3 3.9 ± 1.2 0.7 ± 0.4 0.6 ± 0.9
P value .56 .001a <.001a <.001a .46
Control 9.5 ± 0.9 7.5 ± 0.90 5.9 ± 0.90 3.5 ± 0.90 0.9 ± 0.7
Light 9.4 ± 0.9 6.5 ± 0.90 4.7 ± 1.2 2.1 ± 0.5 0.5 ± 0.6
P value .98 .04a .02a <.001a .33
Swelling
Laser 48.8 ± 2.5 52.5 ± 2.44 51.7 ± 2.5 50.9 ± 2.3 -
Light 48.8 ± 1.4 52.5 ± 1.55 51.7 ± 1.7 50.9 ± 1.9 -
P value .99 1.00 .99 1.0 -
Control 49.6 ± 1.2 53.9 ± 1.18 53.3 ± 1.7 52.4 ± 1.4 -
Laser 48.8 ± 2.5 52.5 ± 2.44 51.7 ± 2.5 50.9 ± 2.3 -
P value .39 .10 .08 .08 -
Control 49.6 ± 1.2 53.9 ± 1.2 53.3 ± 1.7 52.4 ± 1.4 -
Light 48.8 ± 1.4 52.5 ± 1.6 51.7 ± 1.7 50.9 ± 1.9 -
P value .45 .10 .07 .08 -
a
Significant P value.
6 H. Bahrami et al. / Arthroplasty Today 19 (2023) 1e9

53.3, and 60.3 mg on POD 30 (P ¼.02). Bonferroni's post-hoc analysis

revealed that only patients in the LLLT group used fewer opioids in
both time points than controls (P < .05). Also, the post-hoc analysis
did not detect a difference between the light and other groups.
KSS knee scores were increased by 54 scores in the LLLT group,
37.9 in the light group, and 30.2 in the control group at the 3-month
follow-up, and it showed significantly greater improvement in the
LLLT group (laser > light > control) (P < .001) (Fig. 6a) (Table 4,
Table 5). For the laser, light, and control groups, the KSS knee score
difference between the groups met the MCID (5.3 units). At the last
follow-up at 12 months, the laser group was still superior to other
groups (Table 5).
The KSS function score increased by 40.3 in the LLLT group, 34.3
in the light group, and 20.3 in the control group at 3 months after
the surgery visit, which was statistically higher in the LLLT group (P
< .001) (Table 4) than that in each group (laser > light > control) as
seen in the Figure 6b and Table 5. For the laser and control groups
and light and control groups, the KSS function score difference
Figure 4. The comparison of the VAS pain score between the 3 groups, which was
significantly lower in the laser group after 3 months (laser < light < control). between the 2 groups met the MCID (6.1 units). At the most recent
follow-up, no difference was detected regarding the KSS function
score, and the 3 groups showed comparable scores (P ¼ .07).
revealed a significant difference between groups in terms of ROM at
3 months: laser > light > control (P < .001) (Table 3). Discussion
Pain decreased by 8.5 points (using the VAS score) in the LLLT
group, 7.2 points in the light group, and 6.0 points in the control The main finding of this study was that the LLLTdas an adjunct
group at 3 months of follow-up, statistically significant (Table 2). As modality in the rehabilitation of patients undergoing a primary
seen in Table 2 and Figure 4, the laser group had the lowest pain TKAdcould effectively improve ROM and function and reduce pain
score compared to each group, which was significant on POD 3 and in the short-term follow-up (3 months) compared to light therapy
month 3 after the surgery (laser > light > control). The binary or controls. These improvements were clinically significant as they
comparison revealed a significant difference between the groups in met MCID for patient-reported outcome measures. No adverse ef-
terms of VAS pain score at 3 months: laser < light < control (P < fects related to LLLT or light were observed in intervention groups,
.001) (Table 3). The VAS pain score difference between the 2 groups indicating these modalities' safety. In the case of swelling, both
for the laser and control groups met the VAS MCID (2 units) but not light and LLLT groups were significantly more effective than con-
with that of the light group. trols but comparable with themselves. Another important finding is
Knee circumference increase (swelling) was 2.1 cm in the LLLT that LLLT patients used a significantly lower amount of opiate
and light groups and 2.8 cm in the control group at 3 months after painkillers (oxycodone) than controls during the first 30 days after
the intervention. The control group significantly has higher knee the surgery. At the end of the 12-month follow-up, most pain and
swelling than other groups (P < .001) (Table 2), but as seen in the functional scores are similar, indicating these modalities are effi-
Table 3, there are no significant differences in the swelling between cient in the short-term and early recovery.
the laser and light groups at the 3 months of follow-up (P > .05) Reviewing the literature revealed some articles investigating the
(control > laser z light). impact of laser therapy on total joint arthroplasty (TJA) outcomes
Opiate painkiller consumption, measured by the milligram of [22e28]. According to a recent RCT by Huang et al. on old-aged par-
oxycodone consumed on POD 9 and POD 30, significantly differed ticipants with TKA, the low-level laser acupuncture group had
between groups (Fig. 5a and b). LLLT, light, and control groups significantly less pain 10 to 72 hours after the surgery. Also, they
consumed 25.0, 26.0, and 34.0 mg of oxycodone on POD 9 and 48.3, showed that the intervention group used a lower amount of

Figure 5. Mean consumption of opiate painkiller (oxycodone 5-mg tablets) on (a) postoperative day 9 and (b) postoperative day 30, which were significantly lower in the laser
group.
 H. Bahrami et al. / Arthroplasty Today 19 (2023) 1e9 7

Figure 6. The comparison of the KSS (a) knee score and (b) function score between the 3 groups, which were significantly higher in the laser group after 3 months (laser > light >
control).

morphine and had a significantly lower rate of related complications LLLT and light-emitting diode therapy in their study, had a signifi-
than the controls [22]. However, they did not evaluate patients' cant impact on decreasing inflammation [27]. In the PBMT group,
function and only followed them up for 72 hours. Their results are in the VAS pain score and serum levels of inflammatory markers (TNF-
line with our study regarding pain and opioid consumption. The same a and IL-8) decreased more than those in the placebo group (P <
author in an earlier study [24] reported ROM and Western Ontario .05) [27]. Perhaps, the role of LLLT in reducing inflammation and
and McMaster Universities Arthritis Index stiffness scores as the muscle damage was the mechanism that improves recovery and
representative measures of function. They claimed that LLLT could reduces postoperative pain. There is animal evidence that PBMT is a
facilitate recovery and improve ROM during the first 3 days after the safe, noninvasive, effective modality for modulating inflammation
surgery but not significantly influence the knee stiffness score. and regulating inflammatory markers, including IL-1b, IL-6, and
Moreover, in a scientific abstract by Fusakul et al., they reported TNF-a [16,42]. Moreover, an animal model of OA treated with PBMT
significantly superior outcomes in TKA patients regarding ROM at exhibited improved cartilage recovery (greater optical densitom-
POD 2, pain at POD 4 and 2 weeks after the operation, and KSS at 6- etry) and reduced spinal cord sensitization [43]. Thus, PBMT has a
week follow-up [23]. Their study concludes that postoperative LLLT possible promising role in cartilage recovery and relieving pain in
reduced pain early and improved knee flexion and extension ROM OA. PBMT may also modulate inflammation induced by surgical
without causing side effects [23]. Also, this survey confirms the injuries during TJA [44]; therefore, PBMT can have a therapeutic
present study’s results that pain, ROM, and function (KSS) were role after a TJA surgery.
superior in the LLLT group at the very early stages and after 3 Our study is not without limitations. First, there are few patients
months of follow-up. Most of the previous studies investigated in each group, as explained in the method section on how sample
patients only for a few days; however, our study revealed that the sizes are calculated. The small sample size hindered the statistical
beneficial effects of LLLT remain until 3 months after the surgery. analysis' ability to have high power. Second, we did not compare
Moreover, comparing LLLT to Bioptron light was a novel finding of the clinical and radiological severity/grading of knee OA in patients
this study, which showed LLLT to be superior to light in terms of before the surgery. However, the demographics between groups
pain and function (KSS) but similar regarding knee swelling. As a were similar, as shown in Table 1. Third, because this study was not
distinct modality, light therapy has also shown superior pain, blinded, it was not controlled for the placebo effect or the effect of
function, and swelling outcomes than controls. acupuncture without a laser beam. Last but not the least, this study
Another study on patients with THA patients uncovered that could not achieve a sex balance, and a majority of the groups were
photobiomodulation therapy (PBMT), which was a combination of female patients.

Table 4
Comparison of outcomes of KSS between the 3 groups.

Variables Before surgery After surgery Repeated measure ANOVA (P value)

3 mo Postop. 1 y Postop.

Knee score
Control 43.4 ± 8.2 73.6 ± 9.1 87.5 ± 7.6 Group effect: .001a
Laser 41.7 ± 11.6 95.7 ± 4.4 97.4 ± 3.0 Time effect: <.001a
Light 42.8 ± 12.5 80.7 ± 8.6 90.6 ± 6.1 Interaction: .01a
P value .9 <.001a .01a
Function score
Control 48.7 ± 18.8 69.0 ± 5.1 84.9 ± 5.0 Group effect: .44
Laser 42.0 ± 16.1 82.3 ± 6.8 89.9 ± 4.6 Time effect: <.001a
Light 42.0 ± 18.3 76.3 ± 8.4 87.0 ± 7.5 Interaction: <.001a
P value .5 <.001a .07

ANOVA, analysis of variance.

a
Significant P value.
8 H. Bahrami et al. / Arthroplasty Today 19 (2023) 1e9

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