Use of low-level light therapy in chiropractic is growing

The use of low-level laser therapy (LLLT) in medicine goes back to the late 1960s.¹ But all light or laser therapy is not the same. Different forms of light have very different properties and have very different effects on living tissue.

The unique pain-reduction abilities of LLLT have been extensively researched and documented in numerous clinical studies and medical papers, however.² This roundtable discussion will give more detail on laser therapy’s effectiveness for pain management.

Use of LLLT in chiropractic is growing. The acceleration of the healing process provided by a laser system cannot be discounted when treating a patient in pain.

Five experts spoke to Chiropractic Products about how DCs can use laser therapy to manage patients’ pain. Barry Ungerleider is chief technical officer for Healing Lasers (USA) in Austin, Tex. Richard Martin is director of science for Innovative Medical Group in Carson City, Nev. Larry K. Beardall is executive vice president, sales and marketing, for Dynatronics Corp. Mike Christoi is president of Lifetec Inc in Wheeling, Ill. Gerry Graham, DC, is president of LED Healing Light in Aurora, Colo.

How effective is laser therapy for pain management? What conditions is it effective in treating?

Ungerleider: Laser is very effective in treating many musculoskeletal pain conditions. It has been shown to be of use in strains, sprains, and even healing of trauma to muscles and joints. It may reduce the swelling and pain of disc syndromes. While it cannot physically go in and “fix” a herniated disc, it is adjective to the healing process and can reduce the pain and motion limitations of such injury. Laser can reduce inflammation and swelling, as well as accelerate healing. It has also been used (635-nm red laser) in burn and wound healing.

Martin: Both acute and chronic conditions have been effectively treated with laser therapy. The effectiveness of laser therapy, as with other types of therapy, is somewhat dependent on the condition being treated. However, more positive clinical studies have been published about the effectiveness of laser therapy in pain management than any other conditions. Musculoskeletal conditions and connective-tissue disorders are known and reported to have a high degree of response to laser therapy, and chronic pain syndromes (such as fibromyalgia and myofascial pain) have also reported good response to laser therapy.

Beardall: It is estimated that approximately 3,500 studies covering a broad range of pain and soft-tissue inflammatory conditions have been published relative to light therapy over the past 30 years. This wealth of research has shown promising results in a number of different conditions. Infrared therapy has been cleared by the US Food and Drug Administration (FDA) for the temporary increase in local blood circulation; for temporary relief of minor muscle and joint aches, pain and stiffness and relaxation of muscles; for muscle spasm; and for minor pain and stiffness associated with arthritis.

Christoi: There are a wide variety of suggestions and studies as to how lasers affect pain. Numerous texts are available citing protocols and expectations of results. Extremely positive results with infrared (IR) cold lasers are seen rather quickly in acute, soft-tissue inflammatory indications. More chronic ailments, for a variety of reasons, usually require increased applications of the laser, sometimes with higher dosages of joules/cm² of tissue, to obtain acceptable results.

Graham: My responses to all of the questions will be specific to the LazrPulsr 4X or any other unit that uses four fully collimated 635-nm laser diodes operating at <5 mW and individually pulsed from 1 to 1 million Hz. The LazrPulsr is very effective at reducing almost all sources of pain through physiological responses only. It does not have the capacity to produce an allopathic or pharmacological dose of therapy that will override normal physiology to kill pain. Therefore, the symptomatic response is directly related to improved function and health so that the pain control is tied to the ability of the body to respond to therapy. What conditions is laser effective at treating? All tissue injury, whether a result of surgical intervention or trauma (physical, chemical, or infection), is mediated by inflammation. The four cardinal signs of inflammation—pain, swelling, redness, and heat—result from the vascular and cellular responses of the body to an insult designed to protect the body against excessive blood loss and infection, and dispose of dead and dying tissue in preparation for the repair process, which restores the body to homeostasis. All of these processes are managed by the body through chemicals that respond to light (chromophores). Research also indicates that many components of the inflammatory process are mitigated by frequency therapy.

How affordable is laser therapy?

Ungerleider: Healing Lasers has equipment starting at approximately $900, with most practitioners buying our 635-nm (red laser) and 808-nm (near infrared laser) set for approximately $1,600. For the patient, the cost may be from approximately $45 to $150 per laser treatment. One to 10 treatments may be required. Laser may be used acutely 3–4 times per day, then daily, then tapered off. Some do well with few treatments. Treatment time is approximately three to 10 minutes. Laser works best when combined with some active range of motion to expose more joint surfaces.

Martin: Laser therapy has a per-treatment cost from $20 to $80 per session. At this cost level, laser therapy is very affordable in terms of the cost-benefit ratio when compared to more invasive treatments or pharmacological interventions. Because laser therapy’s effect is cumulative over time, many of the prescribed laser-therapy treatment protocols provide greater relief with less need for repeat therapy as compared to other interventions.

Beardall: As with any new technology, the price falls as competition increases. Within the last year, prices have decreased dramatically as more manufacturers have introduced light-therapy devices. Light therapy is no more expensive than traditional electrotherapy and ultrasound equipment. Light therapy is simply one more tool in the clinician’s toolbox and is not intended to replace other modalities.

Christoi: When first approved by the FDA, IR biostimulation lasers were being sold with very low power outputs of 5–15 mw in the $10,000–$15,000 range. Since then, power outputs are now available up to 1,500 mw for around $4,000. Lower-output systems are even less. Laser systems are now available in the 100-mw range for about $2,000.

Graham: Peer review-published work demonstrates that laser therapy is more effective and economical than conventional methods. Laser treatment is easy to use and has good patient acceptance, considering it is noninvasive and possesses no side effects.

How safe is laser therapy, and what risks are involved?

Ungerleider: Laser has been shown to be safe when pain is properly diagnosed, and used in low level (approximately 10 mw for 635 nm, approximately 50 mw for 650 nm, and less than 1,000 mw for 808 nm in my experiences and reading). The risks are using it in undiagnosed or misdiagnosed pain, possible photo-activation of seizures in patients with seizure disorder, and risk of direct laser-beam exposure to eyes. One important note here is any modality done to a pregnant woman could be “blamed” for something, so informed consent and avoiding the pelvis and abdomen is critical in pregnancy. I would treat an extremity or neck problem without as much worry in this type of case. However, full informed consent is advised in pregnancy.

Martin: Laser therapy is an extremely safe medical intervention. At the low-dose levels of the suggested protocols now in use, this noninvasive therapy is virtually free from any significant danger or side effects. When compared to other commonly used interventions such as ultrasound and electrotherapy, laser therapy has fewer contraindications and a wider application.

Beardall: In the case of most laser devices, it is required that safety goggles be worn by both the patient and the clinician to avoid the possibility of retinal-tissue damage. With recent advancements in technology, most manufacturers are switching to devices utilizing powerful superluminous diodes that eliminate the risk of eye injury and, therefore, the need to wear safety goggles.

Christoi: Laser systems are extremely safe. However, there are a few precautions and contraindications. These precautions are specific to not treating over the following indications: cancerous areas and tumors; direct irradiation of the eyes; photophobia or abnormally high sensitivity to light; direct irradiation over the fetus or the uterus during pregnancy; and direct irradiation over the thyroid gland.

Graham: The LazrPulsr is a true therapeutic laser, and has no known side effects. The only restriction is direct viewing into the eyes. This is similar to directly viewing the sun. Since the light is in the visible wavelength, no protective eyewear is required. The LazrPulsr utilizes a wavelength that will not proliferate any known pathogens and is known to inhibit most known pathogens. Research demonstrates that 635-nm wavelength will not cause cancer cells to proliferate since they are already at a high mitotic index. This means that the LazrPulsr is considered safe to use on all conditions, and on almost all areas of the body, with no protective eyewear.

For pain management, what type of laser-therapy equipment do you recommend for most chiropractic offices?

Ungerleider: We supply both 635-nm (red visible) and 808-nm (near infrared) lasers. My favorite wand is the 635 nm/5 mw pulsed (at 12 pulses per second) red visible laser with a line-beam output.

I also use clinically a 808-nm/150-mw pulsed (almost invisible) laser wand for deep and chronic cases, but I also use 635 nm to “polish off” the superficial components of even deep pain. For the “worst of the worst” deep chronic/longstanding cases, we offer an 808-nm/600-mw continuous laser beam unit that can make a difference in the lives of this patient population. Our goal is to put this technology in the hands of the practitioners who can and will use it for the benefit of all who suffer pain and disability. There is also a focus on making a good athlete better with better muscle function, as well as laser for smoking and other addiction treatment and weight management.

Martin: MicrolightLaser’s ML-830 series and BTL (BTL-2000, BTL-4000, and BTL-5000) line of laser products are appropriate for pain management in a chiropractic setting. The BTL series offers a broader range of treatment options, wavelengths and applications, single and multiparameter platforms, on-board programmed protocols, power adjustability from 10–1,800 mw, both pulsed and continuous waveforms, and many computerized functions; the ML-830 series offers handheld simplicity, continuous waveforms, and 90 mw of power. Both systems utilize the 830-nm wavelength, which has been shown to have the deepest penetration of any wavelength and the greatest physiological response for pain-management applications.

Beardall: With six different base units and five different probes and pads to choose from, no one has more options to offer the clinician. In addition to offering light therapy as a stand-alone unit, we also have the ability to package light with electrical stimulation, ultrasound, or both. We also offer both attended and unattended options for delivery light therapy. After evaluating the needs, preferences, and budget of the clinic, a recommendation can be made relative to which package would best meet all their needs.

Christoi: Since we carry eight or nine models of IR Biostimulation Lasers, I always recommend they use one with higher power outputs and a large applicator head. The higher the output available on your laser, the less time is needed to deliver the proper dosage. The same is true for the size of the applicator head. It’s easy to calculate that a 1,000-mw laser with the same size applicator would require the doctor or clinician to hold the applicator over the site 1/10 of the time of a 100-mw laser to deliver the same dosage. Since time is their most valuable resource, the small differential in prices of stronger lasers with larger applicator heads is worth the small investment.

Graham: Chiropractors are taught to treat the body through a process of changing the natural biochemical response of a cell or tissue within the normal range of its function, stimulating the cell’s innate metabolic capacity to respond to a stimulus. A cell can heal itself by this basis. This definition was not written by a chiropractor, but by three medical researchers describing the effects of low-level laser therapy. They termed this process as Biomodulation. Biomodulation fits the true essence of the chiropractic practice, and it is my opinion that we should utilize therapies that follow that same direction of therapy. This is why I will only utilize true therapeutic low-level pulsed laser on myself or my patients.

What are the latest technological advances in this field?

Ungerleider: In my opinion, pulsing the laser and the availability of affordable diode lasers is what I consider important. We focus on modular design and interchangeable laser wands, so one power supply can power many and different laser wands, so if and when a “new and better” wavelength is discovered, the practitioner can simply just acquire the new wand and plug it in, without having to buy a whole new outfit.

This makes field service also easier as we can often just overnight a replacement plug-in part, so maximum uptime is achieved.

Martin: The tremendously increased use and application of laser therapy in all disciplines has brought about several technological advances. Laser diodes (versus light-emitting diodes) have proven more effective at reaching deeper tissues and are increasingly more popular. Modest increases in dose ranges, the use of large cluster probes with multiple diodes, and a larger surface area for treatment have led to greater clinical efficacy. The expanded use of multiple wavelengths in tandem along with enhanced frequency modulation has also been shown to improve medical outcomes. Multiparameter platforms that include laser have also entered the field.

Beardall: Technological advancements are taking place in three areas. First, many of the new light-therapy devices are much more powerful than the older laser products. Since light treatments are dose specific, this is significant to the clinician since higher power translates into much shorter treatment times. Second, tremendous advancements have been achieved in making “unattended” light-therapy treatments practical. With the recent introduction of the new Dynatron XP Light Pad, an entire low back, for example, can be treated in 6–9 minutes. Finally, exciting new applications of light at both traditional and nontraditional wavelengths are emerging. With the introduction of the new Dynatron 405 wound probe, blue and infrared light are combined to more effectively treat wounds.

Christoi: Power output of the lasers is increasing, and this will save time when treating patients. Applicators are also changing from single diodes up to five laser diodes in one head delivering higher dosages in shorter periods. The market has advanced from using light-emitting diode (LED) and superluminous diode (SLD) phototherapy, providing deeper penetration and better results with the laser products. On some machines, like the Chattanooga Genisys Laser, an electronic library is built into the system, providing dosage recommendations for different indications. It even sets up the time and dosage for the DC, so he only has to hit start and hold the applicator over the site.

Graham: There are thousands of papers written every year on laser therapy. Since the fall of the iron curtain, the advanced Russian scientists have been catching us up on the latest information, and further advances are on a daily basis. CP

References
1.    Microlight Laser, Available at: http://www.microlightlaser.com/history_of_low_level.html. Accessed January 18, 2006.
2.     Martin R. Laser-Accelerated Inflammation/Pain Reduction and Healing. Practical Pain Management. 2003;3(6):20–25.