Research
- “Low Intensity Laser Therapy in Clinical Practice”
Fred Kahn, M.D., FRCS(C),
Michael Graham, B.PHE., Clinical Report.
Introduction
This is a definitive study
based on the results of 151 consecutively discharged patients following
clinical treatment with low intensity laser therapy.
Low Intensity Laser Therapy
was the basic platform in the therapeutic program, augmented in 50%
of the cases by massage, thermal therapy and exercise. The latter were
utilized to speed up the process initially, particularly in acute injuries
but were not felt to be essential to the treatment program.
Historically, laser therapy
has failed to gain wide acceptance in the therapeutic community for
many reasons (4, 5, 6, 7), usually justifiable. Previous devices were
generally poorly engineered, protocols were inappropriate and therapists
were not provided with the proper education to operate the equipment.
Whereas academics over the past 10 years have continued to promote additional
double blind clinical trials (3, 4) and this is certainly commendable,
in actual fact over the past decade minimal practical progress has been
achieved.
At Meditech we began to recognize
this problem twelve years ago at the inception of our research and in
this publication share some observations, the results of our clinical
approach.
As we often like to quote
“no patient's health status was ever improved by a test” and
on occasion some have been made considerably worse. Unquestionably there
is the need for continuing science and controlled studies. Ideally all
tissue treated should be biopsied prior to initiating therapy and subsequently
in order to accurately determine the degree of physical resolution of
scar tissue, osteophytes, regeneration of cartilage and other phenomena
that are discussed in the literature. Unfortunately in a normal clinical
setting this is usually not possible. Notably in our studies we have
evaluated patients utilizing clinical criteria that have been standard
for a long period of time and are still applicable, especially if treatment
and observations can be uniformly applied. It can be stated unequivocally
that in these 151 patients on completion of therapy the results are
sufficiently conclusive to establish laser therapy in its proper position
as the ideal therapy in treating musculo-skeletal conditions, particularly
when compared to symptom modulators such as ultrasound, interferential
current and the use of pharmaceuticals. It should be noted that over
50% of patients in this series suffered from more than one medical problem
and the majority of patients had undergone therapy varying from a matter
of weeks to years under the direction of the family physician, physiotherapist,
chiropractor, neurologist, rheumatologist, orthopedic surgeon or psychologist.
Analgesics, anti-inflammatory medications and cortisone had been utilized
extensively in a large number of cases and many surgical procedures
had been carried out, often with results that were less than desirable.
A recent review of the world
literature comprising over 300 cited articles and abstracts including
double blind clinical trials published between January 1998 and November
2001 (8) reveals an overwhelming amount of evidence supporting the positive
effects achieved utilizing low intensity laser therapy.
The articles that are negative
have generally failed in their approach owing to inappropriate therapy.
A lack of standardization, inadequate power and duration of therapy
(energy density) are most frequently noted (1, 6), however there exist
numerous additional shortcomings. This calls to mind the work of the
late Dr. Alvan Feinstein, Sterling Professor of Medicine and Epidemiology
at the Yale School of Medicine whose work I recently reviewed. Dr. Feinstein’s
greatest contribution was his advocacy for the information that patients
can offer and the role that clinicians can play in collecting this data.
In brief, Dr. Feinstein threw his weight into the issue of evidence-based-medicine
versus judgmental reasoning and patho-physiological observations. He
endorsed medicine-based-evidence as opposed to evidence-based-medicine
(2). To wit the evidence will be revealed by paying close attention
to the clinical status of the patient. In essence physicians must rely
to greater a degree on independent clinical judgment, rather than only
the observations of academic and professional journals.
At our clinic we have followed
that course, customizing therapy in accordance with clinical observations
based on the following criteria:
Reduction in pain
Increase in mobility and range of motion
Cessation of the use of multiple medications including analgesics, NSAIDS
and cortisone
The patient’s general state of well-being (sleep patterns, activity
level, headache relief, etc.).
This requires intense effort and close team collaboration but pays immense
dividends with regard to results achieved.
Results
Review Table 1 . ‘Compilation
of Raw Data Based on the Results of 151 Consecutive Discharge Summaries’-
summarizing diagnosis, gender, age, area of
treatment, number of treatments and results. Findings – average
age of patient treated 49, average number of treatments for maximum
improvement 11, overall improvement rate 89.7%.
Discussion
Analysis of the 151 subjects
indicates that -
- 35%
of the patients fall into the category of degenerative osteoarthritis.
The majority of these involved the lumbo-sacral spine and over 60% of
these were accompanied by degenerative disc disease., bulging discs,
nerve root compression and/or stenosis of the spinal canal. Numerically
in descending order came knees, the cervical spine, hips and ankles.
- In excess of 35% of cases were in the sports injury sector. Individuals
in this group were generally younger and the injuries healed with surprising
rapidity. For example a 28-year-old NFL safety with a non-resolving
tear of the biceps femoris muscle, distally involving the tendon junction
had been treated for over two weeks with multiple other therapies without
any improvement. This patient was restored to 100% functional capacity
in asymptomatic condition after six days of consecutive treatment involving
40 minutes per session, utilizing the BioFlex system. Younger gymnasts,
hockey and basketball players often with severe and long-term injuries
responded in similar fashion, a feature gratifying to both patient and
therapist.
- 20% of cases were ascribed to the repetitive motion injury component.
A significant percentage of these individuals work with computers and
sit for long periods of time. In some instances these included rotator
cuff injuries, carpal tunnel syndrome, epicondylitis and what we sometimes
refer to as “the shoulder-neck-arm syndrome”.
- The remaining 10% were composed of a variety of diagnoses such as
rheumatoid arthritis, acromio- clavicular joint pathology, plantar fascitis
and trauma.
- In almost every situation the biomechanical factor was active. A patient
might present with severe symptoms relating to the back, hips and both
knees. Through careful assessment our approach was to treat the area
most severely affected. This method resolved the symptoms in most of
the other areas, obviating the need for additional treatment. This can
be ascribed to the compensatory biomechanical factors involved.
Conclusions
- Low intensity laser therapy
utilized as the primary therapy in the treatment of musculoskeletal
problems including soft tissue and sports related injuries, arthritis
and repetitive motion injuries was found to be highly effective.
- The therapeutic process can be accelerated utilizing massage, thermal
modalities, gentle stretching in the early phases and strengthening
programs as the acute symptoms are alleviated.
- Whereas we have made immense progress in both the engineering and
application of this new technological approach, we expect continuing
advances as our experience and knowledge increase.
- Low intensity laser therapy appropriately customized for each individual
as required can best be described as the most dramatic advance in
the rehabilitation process.
Note: This study has excluded patients who for a variety of reasons
failed to complete the prescribed course of treatment and those who
are continuing maintenance therapy.
References
1. Low level laser
therapy for osteoarthritis and rheumatoid arthritis: a meta analysis.
Brosseau L, Welch V, Wells G, Tugwell P, de Bie R, Gam A, Harman K,
Shea B, Morin M.
J Rheumatol 2000 Aug;27(8):1961-9
PMID: 10955339 [PubMed - indexed for MEDLINE]
2. Problems in the “Evidence” of Evidence-based Medicine.
Feinstein A., M.S., M.D., Sterling Professor of Medicine and Epidemiology,
Yale University School of Medicine.
Translating Evidence into Practice 1998, Conference Summary. Agency
for Health Care policy and Research, Rockville, MD.
3. Low-intensity
laser therapy: A review. Schindl A., Schindl M., Pernerstorfer-Schon
H., Schindl L., J Investig Med. 2000 Sept; 48(5):312-26. Review.
PMID: 10979236[PubMed – indexed for Medline]
4. Frustrations
with clinical trials; Sherry S.
Eur J Clin Pharmacol. 1980 Feb;17(2):79-80. No abstract available.
PMID: 7371708 [PubMed - indexed for MEDLINE]
5. Determining
optimal therapy--randomized trials in individual patients; Smyth J.A.
N Engl J Med. 1986 Sep 18;315(12):767-8. No abstract available.
PMID: 3748088 [PubMed - indexed for MEDLINE]
6. It's all in
the parameters: a critical analysis of some well-known negative studies
on low-level laser therapy; Turner, J., Hode L.,
J Clin Laser Med Surg. 1998 Oct;16(5):245-8. Review.
PMID: 9893504 [PubMed - indexed for MEDLINE]
7. Low-dose laser
therapy: critical analysis of clinical effect.
Schweiz Med Wochenschr. 1993 May 8;123(18):949-54. Review. German.
PMID: 8497783 [PubMed - indexed for MEDLINE]
8. Literature Review
available on request from Meditech International at http://meditech-BioFlex.com.
Table 1 Frequency Distribution
with average success rate
