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Editor's note: This is part one of a two-part series on the use of low-level laser therapy for musculoskeletal pain. The second installment is also available online and will appear in the October issue of AAOS Now.
In July, the Food and Drug Administration (FDA) cleared the Erchonia FX 635, a low-level laser therapy (LLLT) device, for 'whole body' pain. As a spine surgeon, I was aware that this technique was used in some patients with chronic low back pain but was always skeptical about claims involving lasers and diffuse pain. The truth: I did not know much about it. Given the likelihood of more widespread use, I investigated LLLT.
Laser primer
There are several good, basic primers on LLLT, including a review by Cotler et al., and a number of websites. Industry site and laser vendor ColdLasers.org offers some excellent practical and taxonomic information about LLLT. It notes that lasers cost $2,000 to $15,000, with a number of manufacturers selling disparate devices. A nice summary of the technology behind the recent FDA approval can be found on the National Institutes of Health's ClinicalTrials.gov website.
Cotler and colleagues provide a history of LLLT extending to the Nobel Prize in Medicine, which was awarded to Dr. Niels Finsen for his work using concentrated light radiation in lupus vulgaris. Lasers were first described by Gordon Gould and built by Theodore Maiman around . (Editor's note: The invention remained controversial for decades; my parents were friends of Mr. Gould's.) By the late s, the first medical uses of lasers were described by the term 'laser bio stimulation.' Today, the term photobiomodulation (PBM) is used. Some authors include LED therapies; others insist that only lasers, by offering a narrow wavelength, produce the effects needed.
LaserSafetyFacts.com reports that the devices are classified by their power output and, thus, the risks they pose. The site offers excellent tables discussing handling and dangers, as well as examples of the devices in each class. Class I lasers, such as those found in CD players, do not confer significant risk. Class II devices, such as many laser pointers, emit less than 1 milliwatt (mW) of energy and are generally considered safe unless directly pointed into the eye. Most LLLT devices are class III and emit as much as 500 mW. The broad power range confers a similarly broad range of potential risks as well. Class IV devices, sometimes referred to as 'hot lasers,' emit more than 500 mW and are used in surgeries to cauterize tissue. Such devices pose risks to the eyes and skin from both their direct and reflected beams.
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The relative safety of LLLT also includes the absence of collimation or beam focusing. In fact, lasers in the higher power ranges of class III purposefully defocus beams to about 30 degrees to allow wider treatment areas and to decrease the risks of focused laser energy. ColdLasers.org states that the 250 W (not mW) heat lamps employed by most practitioners have a greater tendency to burn patients' skin. With all this, experts on such treatments note that power output, wavelength of laser light, and the presence or absence of pulsations can influence device efficacy'with huge ranges in devices, from small handheld systems available for home use to larger, more powerful units purchased by healthcare providers. ColdLasers.org notes that devices emitting wavelengths from 1,350 nanometers (nm) to 400 nm (in the blue spectrum) are available. For musculoskeletal uses, 800 nm to 860 nm devices are typically recommended.
After wavelength, dose is another concern. In a study, Tunér and Hode argued that in their review of 1,200 papers on LLLT, they found 85 positive and 35 negative double-blind studies. Among the negative studies, however, each utilized a suboptimal dose of laser energy, and therefore would not have expected positive results. In principle, dose should increase with the depth and size of the treatment area in question.
Both online and in the literature, two main applications of LLLT are described. Papers describing its use in small targets, 2 mm2 to 20 mm2, are said to affect distant sites along the body's meridians, trigger points, acupoints, or lymph system that 'control the problem area.' More typical in musculoskeletal practice are 60 mm2 to 250 mm2 target areas directly reflecting the affected tissue itself.
Given the depth of many perispinal tissues, a reasonable question is how deep will a laser penetrate? At 2 cm, 84 percent of a laser's energy has been absorbed. At a given spectrum, more powerful lasers do not achieve great depths of penetration but, in transferring more energy to the patient, can achieve the desired doses, typically 4 joules/cm2 to 12 joules/cm2, more quickly.
Unfortunately, insurance does not cover the cost of these treatments. The initial exam and consultation is at a reduced price of $100. If you are a good candidate, the average cost and time of the treatment is $ to $ over the course of 2 to 3 months.
*This is an average and not a guarantee. We accept CareCredit and all major credit cards.
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