Make Low-Level Laser Therapy Part of Your Evidence-Based Practice

Low-level laser therapy (LLLT), also referred to as photobiomodulation, has been increasingly utilized in the clinical setting over the past decade. Although laser technology has been around for some time, improved clinical outcomes have led providers to discover and implement laser therapy into their practices. In addition to the chiropractic practice setting, laser therapy is used in hospitals, sports facilities, veterinary offices and rehabilitation centers. Let's review the clinical applications of LLLT and why increasing research suggests it is an essential tool for the evidence-based practice.

Support Chiropractic Techniques

I have used various laser therapies in my practice for more than 15 years. However, laser technology has changed greatly and the research supporting it has grown with this technology. I have always believed in the "evidence-based practice" and I base my clinical practice on this model. In my own practice, I have found the use of laser therapy supports my chiropractic techniques, helping patients with both acute and chronic problems.^1-2

Low-level laser therapy is extremely safe, with more than 50 years of use without incident or side effects. There is strong evidence for the use of this modality, with over 15 systematic reviews for a variety of common conditions seen in a chiropractic practice; conditions including tendinitis,³ spasms⁴ and neck pain.⁵ Various studies have shown that LLLT has superior clinical results compared with ultrasound therapy, yet many chiropractors and physical therapists are still using ultrasound therapy on a daily basis.⁶

Low-level laser therapy and light-emitting diode therapy (LEDT) use various wavelengths of light designed to work at the cellular level in the healing process.^7-9 These therapies are typically used to help relieve pain, improve inflammation and reduce muscular spasms.^10-11

Clinical Significance: Promising New Research

Although there has been a significant amount of positive clinical findings when using phototherapy, there has been a lack of clinical trials, especially those that translate the statistical significance into clinically relevant and significant outcomes. But that void is beginning to be filled. For example, recently a study was performed to assess how nonspecific knee pain responded to the combined use of various wavelengths of light.¹² In this study, 86 subjects with various forms of knee pain were treated with a super-pulsed laser in a randomized, double-blind, placebo-controlled environment. The control group received chiropractic or PT standard of care and sham laser; the experimental group received chiropractic or PT standard of care and active laser.

While the control group showed clinical improvements (VAS 6/10 to 4/10), improvements plateaued after four treatments. On the other hand, the laser group improved similarly after four treatments, improved further over the course of all 12 treatments, and then maintained it at a 3/10. Overall, the study demonstrated the following:

• "Photobiomodulation significantly decreased pain and significantly improved SF-36 physical component summary at post-treatments and follow-up assessments compared to the placebo."
• "Outcomes were maintained at a 30-day follow-up."
• "A combination of super-pulsed laser, red, and infra-red LEDs is effective for decreasing pain and improving the quality of life in patients with knee pain."

The study, conducted by Ernesto Leal Junior, PhD, and colleagues, demonstrates promising results, as it focused on patient-based outcomes for the treatment of knee pain. In addition to appearing in Lasers in Medical Science, these findings were also presented at the joint meeting of the World Association of Laser Therapy and the North American Association of Laser and Light Therapy in Washington, D.C., in September 2014.

Studies such as this are ground-breaking in the sense that they move the research in photobiomodulation from statistically significant to clinically significant. It provides us with more evidence that certain drug-free, nonsurgical therapies can be used within the chiropractic office with direct benefit to our patients.

Modern Applications

We know the baby boomers are embracing a more active lifestyle. In the past 10 years, I have seen a greater number of these patients requesting alternative treatment for their knees and other musculoskeletal conditions. In fact, this part of my practice has grown significantly. Laser gives me a variety of therapeutic options when treating these patients. Studies like the Leal Junior, et al., investigation suggest a wide variety of laser and LED wavelengths can provide pain relief and enhance healing.

Relative to knee pain, as was researched by Leal Junior and colleagues, I often treat the anterior and posterior compartment of the knee. Anteriorly, I will treat the specific injured area and treat the posterior aspect with the knee in a flex position, which includes the vascular aspect behind the knee. By limiting the thermal effect, there is no hazardous heat production and zero probability of tissue damage. This allows me to focus on an area without having to move the emitter head to prevent heat buildup.

Research suggests there may be a significant loss of penetration due to refraction, reflection and hemoglobin absorption if there is no skin contact.¹³ Deeper tissue penetration is also enhanced with the higher wavelengths of the therapeutic window.¹⁴ This increases the ability to treat those hard-to-reach areas deep within the tissues and joints of patients without heat buildup. This is done by using a high-photon, dense pulse at optimal wavelength. By treating these deeper tissue layers, I have seen some significant positive clinical outcomes in patients who ordinarily would have been very difficult to treat.

Maximizing Your Care in the Changing Health Care World

As chiropractors, we are in a very unique position because we use conservative care to relieve patients of their worst pains and improve function and lifestyle. The combination of chiropractic care and low-level laser therapy allows you to offer non-invasive treatment to help resolve acute and chronic musculoskeletal conditions. As a chiropractor, I encourage you to view laser as a modality that can be used in tandem with chiropractic care to provide better patient care and broaden the scope of neuromusculoskeletal conditions you can treat.¹⁵

It is important that we continue moving forward with research that finds the most effective ways to better treat our patients. Chiropractic patient management is moving to the front lines in our national health care system. We need to embrace evidence-based treatment options like laser therapy to best serve our communities.

References

1. Konstantinovic LM, Kanjuh ZM, Milovanovic AN, et al. Acute low back pain with radiculopathy: a double-blind randomized, placebo-controlled study. Photomed Laser Surg, 2010;28:553-560.
2. Gur A, Surac Aj, Cevik R, et al. Efficacy of 904 nm gallium arsenide low level laser therapy in the management of chronic myofascial pain in the neck: a double-blind and randomized-controlled trial. Lasers Surg Med, 2004;35:229-235.
3. Tumilty S, Munn J, McDonough S, et al. Low level laser treatment of tendinopathy: a systematic review with meta-analysis. Photomed Laser Surg, 2010;28(1):3-16.
4. Vernon H, Schneider M. Chiropractic management of myofascial trigger points and myofascial pain syndrome: a systematic review of the literature. J Manip Physio Ther, 2009;32:14-24
5. Chow RT, Johnson MI, Lopes-Martins RA, Bjordal JM. Efficacy of low-level laser therapy in the management of neck pain: a systematic review and meta-analysis of randomised placebo or active-treatment controlled trials. The Lancet, 2009;374(9705):1897-1908.
6. Renno AC, Toma RL, Feitosa SM, et al. Comparative effects of low intensity pulsed ultrasound and low level laser therapy on injured skeletal muscle. Photo Laser Surg, 2011 Jan;29(10:5-10.
7. Hashmi JT, Huang YY, Osmani B. Role of low level laser therapy in neurorehabilitation. Phy Med Rehab, 2010;2(12 Suppl 2):5292-5305.
8. Filippin LI, et al. Nitric oxide and repair of skeletal muscle injury. Nitric Oxide, 2009 Nov-Dec;21(3-4):157-63.
9. Friedmann H, Lipovsky A, Nitzan Y, Lubart R. Combined magnetic and pulsed laser field produce synergistic acceleration of cellular electron transfer. Laser Ther, 2009;18:137-14.
10. Bjordal JM, Johnson MI, Iversen V, et al. Low level laser therapy in acute pain: a systematic review of possible mechanisms of action and clinical effects in randomized placebo controlled trials. Photomed Laser Surg, 2006;24:158-168.
11. Almeida P, Tomazoni SS, Frigo L, et al. What is the best treatment to decrease pro inflammatory cytokine release in acute skeletal muscle injury induced by trauma in rats: low level laser therapy, diclofenac, or cryotherapy? Lasers Med Sci, 2014;29:653-658.
12. Leal-Junior ECP, Johnson DS, Saltmarche A, Demchak T. Adjunctive use of combination of super-pulsed laser and light-emitting diodes phototherapy on nonspecific knee pain: double-blinded randomized placebo-controlled trial. Lasers Med Sci, 2014:1-9.
13. Toshio O. The proximal priority technique: how to maximize the efficacy of laser therapy. Laser Ther, 2005;14;3:121-128.
14. Joensen J. Skin penetration time profiles for continuous 810 nm and super pulse 904 nm laser in rat model. Photomed Laser Surg, 2012;30(12):668-694.
15. Fitz-Ritson D. Laser: their therapeutic application in chiropractic. J Can Chiro Assoc, 2001;45(1).