Low-level laser therapy

Low-level laser therapy (LLLT) is a form of medicine that applies low-level (low-power) lasers or light-emitting diodes (LEDs) to the surface of the body. Whereas high-power lasers are used in laser medicine to cut or destroy tissue, it is claimed that application of low-power lasers relieves pain or stimulates and enhances cell function.

Not to be confused with Light therapy.
Low-level laser therapy
LLLT being applied for rheumatism in Sweden
MeSHD028022

The effects of LLLT appear to be limited to a specified set of wavelengths,[1] and administering LLLT below the dose range does not appear to be effective.[2]

Despite a lack of consensus over its validity, some studies suggest that LLLT may be modestly effective, in relieving short-term pain for rheumatoid arthritis,[3] osteoarthritis[4], chronic low back pain[5], acute and chronic neck pain,[6] tendinopathy,[1][7] and possibly, chronic joint disorders.[2] The evidence for LLLT being useful in dentistry,[8][9] and in the treatment of wound healing[10] is unclear.

Names

Variations of LLLT have gone by a variety of alternate names including low-power laser therapy (LPLT), soft laser therapy, low-intensity laser therapy, low-energy laser therapy, cold laser therapy, bio-stimulation laser therapy, photobiomodulation,[11] photo-biotherapy, therapeutic laser, and monochromatic infrared light energy (MIRE) therapy.[12] When LLLT is administered to acupuncture points, the procedure is called laser acupuncture. When applied to the head, LLLT may be known as transcranial photobiomodulation, transcranial near-infrared laser therapy (NILT) ,[13] or transcranial low level light therapy.

Medical uses

Various LLLT devices have been promoted for use in treatment of several musculoskeletal conditions including carpal tunnel syndrome (CTS), fibromyalgia, osteoarthritis, and rheumatoid arthritis. They have also been promoted for temporomandibular joint (TMJ) disorders, wound healing, smoking cessation, and tuberculosis. While these treatments may briefly help some people with pain management, evidence does not support claims that they change long term outcomes, or that they work better than other, low tech ways of applying heat.[14]

LLLT appears to be effective for preventing oral mucositis in recipients of a stem cell transplant with chemotherapy.[15][16][17]

Mechanism

Research is ongoing about the mechanism of LLLT. The effects of LLLT appear to be limited to a specified set of wavelengths of laser,[1] and administering LLLT below the dose range does not appear to be effective.[2] Photochemical reactions are well known in biological research, and LLLT make use of the first law in photochemistry (Grotthuss-Draper law): light must be absorbed by a chemical substance in order for a photochemical reaction to take place. In LLLT that chemical substance is representated by the respiratory enzyme cytochrome c oxidase which is involved in the electron transport chain in mitochondria,[11][18] which is the generally accepted theory.

History

Hungarian physician and surgeon Endre Mester (1903-1984) is credited with the discovery of the biological effects of low power lasers,[19] which occurred a few years after the 1960 invention of the ruby laser and the 1961 invention of the helium–neon (HeNe) laser.[11] Mester accidentally discovered that low-level ruby laser light could regrow hair during an attempt to replicate an experiment that showed that such lasers could reduce tumors in mice. The laser he was using was faulty and wasn't so powerful as he thought. It failed to affect the tumors, but he noticed that in the places where he had shaved the mice in order to do the experiments, the hair grew back more quickly on the treated mice than on those among the control group.[20] He published those results in 1967.[11] He went on to show that low level HeNe light could accelerate wound healing in mice.[11] By the 1970s he was applying low level laser light to treat people with skin ulcers.[11] In 1974 he founded the Laser Research Center at the Semmelweis Medical University in Budapest, and continued working there for the remainder of his life.[21] His sons carried on his work and brought it to the United States.[19]

By 1987 companies selling lasers were claiming that they could treat pain, accelerate healing of sports injuries, and treat arthritis, but there was little evidence for this at that time.[19] By 2016 they had been marketed for wound healing, smoking cessation, tuberculosis, and musculoskeletal conditions such as temporomandibular joint disorders, carpal tunnel syndrome, fibromyalgia, osteoarthritis, and rheumatoid arthritis, and there was still little evidence for these uses, other than a possible use in temporarily treating muscle or joint pain.[14] Mester originally called this approach "laser biostimulation'", but it soon became known as “low level laser therapy" and with the adaptation of light emitting diodes by those studying this approach, it became known as "low level light therapy", and to resolve confusion around the exact meaning of "low level", the term "photobiomodulation" arose.[20][22]

Society and culture

Reimbursement

In the US as of 2006 the Centers for Medicare and Medicaid Services did not provide coverage for LLLT,[23] as of 2014 Aetna did not provide coverage,[24] and as of 2016 Cigna did not provide coverage.[25]

Blue Cross and Blue Shield Association as of 2017 provide coverage if for the prevention of oral mucositis, but not any other reason.[26]

In Norway the use of LLLT is reimbursed through physical therapy [27] - look at paragraph 4, item number 3 in the list. The Norwegian Health Economics Administration [28] is responsible for direct payments to various health service providers (physical therapists).

Research
Demonstration of LLLT with intranasal irradiation

Musculoskeletal

A 2008 Cochrane Library review concluded that LLLT has insufficient evidence for treatment of nonspecific low back pain,[29] a finding echoed in a 2010 review of chronic low back pain.[30] A 2015 review found benefit in nonspecific chronic low-back pain.[31]

LLLT may be useful in the treatment of both acute and chronic neck pain.[6] In 2013, however, a systematic review and meta-analysis of LLLT for neck pain indicated that the benefit was not of significant importance and that the evidence had a high risk of bias.[32]

There are tentative data that LLLT is useful in the short-term treatment of pain caused by rheumatoid arthritis,[3] and possibly chronic joint disorders.[2] While it does not appear to improve pain in temporomandibular disorders, it may improve function.[33] A 2019 systematic review and meta-analysis found evidence for pain reduction in osteoarthritis.[34]

There is tentative evidence of benefit in tendinopathy.[1][7] A 2014 review found benefit in shoulder tendinopathy.[35] A 2014 Cochrane review found tentative evidence that it may help in frozen shoulders.[36]

Evidence does not support a benefit in delayed-onset muscle soreness.[37] It may be useful for muscle pain and injuries.[38]

Mouth

Similarly, the use of lasers to treat chronic periodontitis[8] and to speed healing of infections around dental implants[9] is suggested, but there is insufficient evidence to indicate a use superior to traditional practices.[39] There is tentative evidence for dentin hypersensitivity.[40] It does not appear to be useful for orthodontic pain[41][42] LLLT might be useful for wisdom tooth extraction (complications)[43] and oral mucositis.[44]

Hair loss

LLLT has been studied as a treatment for hair loss; a review in 2012 found little evidence to support the use of lasers to treat hair loss.[45] A 2014 review found tentative evidence for benefit for lasers,[46] while another 2014 review concluded that the results were mixed, had a high risk of bias, and that its effectiveness was unclear.[47] A 2015 review found tentative evidence of benefit.[48]

Brain injuries

LLLT has been studied for traumatic brain injury (TBI) and stroke among other conditions.[11] When applied to the head it is known as transcranial photobiomodulation or transcranial low level light therapy.

Cancer

LLLT has been studied as a way to reduce pain and swelling in breast-cancer related lymphedema.[49][10] Stephen Barrett, writing for Quackwatch, concluded in 2009 there was evidence to support LLLT use for temporary pain relief, but "there's no reason to believe that they will influence the course of any ailment or are more effective than other forms of heat delivery."[50] Barrett's position was unchanged as of 2017.[14]

Stem cells

An ongoing area of research is the application of LLLT for increasing cell proliferation, including stem cells.[51]

Veterinary use

Veterinary clinics use cold laser devices to treat a wide variety of ailments, from arthritis to wounds, on dogs and cats.[52][53] Very little research has been done on the effects of this treatment on animals. Currently, laser therapy equipment is aggressively marketed to veterinarians as a supposedly powerful therapeutic tool and revenue generator. Brennen McKenzie, president of the Evidence-Based Veterinary Medicine Association, has stated that "research into cold laser in dogs and cats is sparse and generally low quality. Most studies are small and have minimal or uncertain controls for bias and error".[54][55] While allowing that some studies show promising results, he reports that others do not. While believing that there is enough evidence to warrant further study, he concludes that there is not enough evidence to support routine clinical use of cold laser in animals.

If vets want to try this therapy, they have an obligation to be clear with client that the risks and benefits have not been established and that the treatment is essentially experimental. There is nothing wrong with using such a treatment given appropriate informed consent, but the aggressive marketing of laser equipment to vets as a profitable treatment is ethically questionable given the lack of good evidence that it is a truly safe and effective treatment for any condition.[56]

See also

References
  1. Bjordal, J. M.; Lopes-Martins, R. A.; Joensen, J. .; Couppe, C. .; Ljunggren, A. E.; Stergioulas, A. .; Johnson, M. I. (2008). "A systematic review with procedural assessments and meta-analysis of Low Level Laser Therapy in lateral elbow tendinopathy (tennis elbow)". BMC Musculoskeletal Disorders. 9: 75. doi:10.1186/1471-2474-9-75. PMC 2442599. PMID 18510742.
  2. Bjordal, JM; Couppé, C; Chow, RT; Tunér, J; Ljunggren, EA (2003). "A systematic review of low level laser therapy with location-specific doses for pain from chronic joint disorders". The Australian Journal of Physiotherapy. 49 (2): 107–16. doi:10.1016/s0004-9514(14)60127-6. PMID 12775206.
  3. Brosseau, L.; Welch, V.; Wells, G. A.; de Bie, R.; Gam, A.; Harman, K.; Morin, M.; Shea, B.; Tugwell, P. (2005). "Low level laser therapy (Classes I, II and III) for treating rheumatoid arthritis". Cochrane Database of Systematic Reviews (4): CD002049. doi:10.1002/14651858.CD002049.pub2. PMID 16235295.
  4. Stausholm, Martin Bjørn; Naterstad, Ingvill Fjell; Joensen, Jon; Lopes-Martins, Rodrigo Álvaro Brandão; Sæbø, Humaira; Lund, Hans; Fersum, Kjartan Vibe; Bjordal, Jan Magnus (2019-10-28). "Efficacy of low-level laser therapy on pain and disability in knee osteoarthritis: systematic review and meta-analysis of randomised placebo-controlled trials". BMJ Open. 9 (10): e031142. doi:10.1136/bmjopen-2019-031142. ISSN 2044-6055. PMC 6830679. PMID 31662383.
  5. Huang, ZeYu; Ma, Jun; Chen, Jing; Shen, Bin; Pei, FuXing; Kraus, Virginia Byers (2015-12-15). "The effectiveness of low-level laser therapy for nonspecific chronic low back pain: a systematic review and meta-analysis". Arthritis Research & Therapy. 17: 360. doi:10.1186/s13075-015-0882-0. ISSN 1478-6362. PMC 4704537. PMID 26667480.
  6. Chow, R.; Johnson, M.; Lopes-Martins, R.; Bjordal, J. (Nov 2009). "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". Lancet. 374 (9705): 1897–1908. doi:10.1016/S0140-6736(09)61522-1. PMID 19913903.
  7. Tumilty, S. .; Munn, J. .; McDonough, S. .; Hurley, D. A.; Basford, J. R.; Baxter, G. D. (2010). "Low Level Laser Treatment of Tendinopathy: A Systematic Review with Meta-analysis". Photomedicine and Laser Surgery. 28 (1): 3–16. doi:10.1089/pho.2008.2470. PMID 19708800.
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  9. Sculean, A.; Schwarz, F.; Becker, J. (2005). "Anti-infective therapy with an Er:YAG laser: influence on peri-implant healing". Expert Review of Medical Devices. 2 (3): 267–76. doi:10.1586/17434440.2.3.267. PMID 16288590.
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  12. American Cancer Society. Cold Laser Therapy Page archived April 24, 2015
  13. Lapchak, PA (December 2010). "Taking a light approach to treating acute ischemic stroke patients: transcranial near-infrared laser therapy translational science". Annals of Medicine. 42 (8): 576–86. doi:10.3109/07853890.2010.532811. PMC 3059546. PMID 21039081.
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  16. On behalf of The Mucositis Study Group of the Multinational Association of Supportive Care in Cancer/International Society of Oral Oncology (MASCC/ISOO); Zadik, Yehuda; Arany, Praveen R.; Fregnani, Eduardo Rodrigues; Bossi, Paolo; Antunes, Héliton Spindola; Bensadoun, René-Jean; Gueiros, Luiz Alcino; Majorana, Alessandra (October 2019). "Systematic review of photobiomodulation for the management of oral mucositis in cancer patients and clinical practice guidelines". Supportive Care in Cancer. 27 (10): 3969–3983. doi:10.1007/s00520-019-04890-2. ISSN 0941-4355. PMID 31286228.
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  25. "CIGNA medical coverage policy: Low-level laser therapy". Revised, July 15, 2016.
  26. Blue Cross and Blue Shield of Kansas City (Blue KC). "Low-Level Laser Therapy" (PDF). Policy No. 2.01.56. Retrieved 2 February 2019. (Policy reviewed each June; if link is dead try replacing "06-18" with a more recent year.)
  27. https://lovdata.no/dokument/SF/forskrift/2018-09-25-1465#KAPITTEL_3
  28. "About Helfo - Helfo".
  29. Yousefi-Nooraie, R.; Schonstein, E.; Heidari, K.; Rashidian, A.; Pennick, V.; Akbari-Kamrani, M.; Irani, S.; Shakiba, B.; Mortaz Hejri, S.; Mortaz Hejri, S. O.; Jonaidi, A. (2008). Yousefi-Nooraie, Reza (ed.). "Low level laser therapy for nonspecific low-back pain" (PDF). Cochrane Database of Systematic Reviews (2): CD005107. doi:10.1002/14651858.CD005107.pub4. PMID 18425909.
  30. Middelkoop, M.; Rubinstein, S. M.; Kuijpers, T.; Verhagen, A. P.; Ostelo, R.; Koes, B. W.; Van Tulder, M. W. (2010). "A systematic review on the effectiveness of physical and rehabilitation interventions for chronic non-specific low back pain". European Spine Journal. 20 (1): 19–39. doi:10.1007/s00586-010-1518-3. PMC 3036018. PMID 20640863.
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  32. Kadhim-Saleh, Amjed; Maganti, Harinad; Ghert, Michelle; Singh, Sheila; Farrokhyar, Forough (2013-10-01). "Is low-level laser therapy in relieving neck pain effective? Systematic review and meta-analysis". Rheumatology International. 33 (10): 2493–2501. doi:10.1007/s00296-013-2742-z. ISSN 1437-160X. PMID 23579335. his systematic review provides inconclusive evidence because of significant between-study heterogeneity and potential risk of bias.
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  34. Stausholm, Martin Bjørn; Naterstad, Ingvill Fjell; Joensen, Jon; Lopes-Martins, Rodrigo Álvaro Brandão; Sæbø, Humaira; Lund, Hans; Fersum, Kjartan Vibe; Bjordal, Jan Magnus (2019-10-28). "Efficacy of low-level laser therapy on pain and disability in knee osteoarthritis: systematic review and meta-analysis of randomised placebo-controlled trials". BMJ Open. 9 (10): e031142. doi:10.1136/bmjopen-2019-031142. ISSN 2044-6055. PMC 6830679. PMID 31662383.
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