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Metropolitan Grill - Mount Royal Village
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Calgary, AB T2R 1J9
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Lectures will include clinical case studies and hands-on customization of protocols. A training manual and Certificate will be presented upon completion.

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CONTINUING EDUCATION CREDITS

Advanced  Certification Training - Musculoskeletal Conditions

Advanced Certification Training - Low Back Pain

Advanced Certification Training - Neuropathies

Advanced Certification Training - Wound Healing

Dynamic Chiropractic July 15, 2009, Vol. 27, Issue 15
By Fred Kahn, MD, FRCS(c) and Michael Patterson, MSc

Low back pain has obvious lifestyle and financial burdens; when it is accompanied by radiation of pain and numbness in the lower extremities, it can be truly debilitating. Lumbar disc herniations account for only 4 percent of low back pain patients but account for a high percentage of low back pain costs.

A painful disc herniation results when a tear of the annulus fibrosus allows migration of the nucleus pulposus (protrusion), resulting in nerve root irritation. Lumbar disc herniations typically occur in individuals between the ages of 30-40 years, ^1-2 when the nucleus pulposus is still fluid and the annulus is weakened by strenuous activity and age. Due to this relatively young demographic, poor treatment outcomes can result in decades of suffering for these patients.

Prior to the existence of imaging studies, little was known about the healing mechanism of disc herniations. Imaging studies have confirmed what has been long suspected: Disc herniations can decrease in size and even disappear spontaneously, leading to the absence of pressure on the nerve root.³

In adult discs, blood vessels are normally restricted to supplying only the outer layers of the annulus. Low oxygen tension at the center of the disc leads to an anaerobic metabolism, resulting in high concentrations of lactic acid and low pH. These deficiencies in metabolite transport limit both the density and metabolic activity of disc cells.⁴ Collagen turnover time in articular cartilage is approximately 100 years⁵ and is theorized to be even longer in the disc.⁶ The result is that intervertebral discs have a limited ability to recover from metabolic or mechanical injuries such as herniations.

There have been a number of mechanisms investigated in attempts to determine how disc herniations heal. It is generally accepted that the herniated disc fragments are reabsorbed.^7-8 Histological investigations have shown the presence of granulation tissue with abundant vascularization surrounding the fibrocartilaginous fragments.⁷ Within the granulation tissue, the prevailing cell types are macrophages with fibroblasts and endothelial cells.8 These cell types have been demonstrated to be positively affected by laser therapy. The stimulation of macrophages and fibroblasts could be the primary mechanism by which laser therapy heals disc herniations.⁹

Inflammatory markers such as IL-1, IL-6 and TNF-a are also present at the site of disc herniations, leading to higher prostaglandin E2 concentrations. Two studies have demonstrated that laser therapy is effective in reducing prostaglandin E2 concentrations.^10-11 Bjordal has demonstrated that inflammation is greatly reduced 75, 90, and 105 minutes after active laser therapy compared to levels prior to treatment.11 The reduction in inflammation appears to be another method by which laser therapy promotes healing in disc herniations.

There is substantial published research on the effectiveness of laser therapy in treating LBP and lumbar disc herniations. The majority of these research articles discuss chronic (nonspecific) low back pain either alone^12-14 or with exercise.^15-16 These positively inclined studies seem to be absent in reviews from either the American Pain Society / American College of Physicians17 or the Cochrane Collaboration18 indicating that all publications are suspect in varying degrees.

In the review of laser therapy for low back pain performed by the American Pain Society / American College of Physicians, four trials (566 patients) demonstrated that laser therapy was effective and one trial (140 patients) found laser therapy to be no more beneficial than a sham laser device. The conclusion from this review was: "Non-invasive therapies (low-level laser therapy) have not been shown to be effective for chronic, sub-acute or acute low back pain."¹⁷ A letter to the authors regarding their bias against laser therapy and in support of pharmaceuticals19 only prompted the authors to downgrade the evidence supporting acetaminophen and cite the Cochrane study to support their stance on laser therapy.

The Cochrane study they refer to found that "three high quality studies (168 people) separately showed statistically significant pain relief with laser therapy in the short-term (less than three months) and intermediate term (less than 6 months) when compared with sham laser therapy."¹⁸ Two small trials (151 people), also included in the Cochrane review, independently found that the relapse rate in the laser therapy group was significantly lower than in the control group at six-month follow-up. The conclusion was that "based on these trials, with a varying population base, laser therapy dosages and comparison groups, there is insufficient data to either support or refute the effectiveness of laser therapy for low back pain."

The resounding statements from both of these meta-analyses were that "more studies are required" and "larger trials on specific indications are warranted." Lacking in the conclusions were any suggestion of "how many patients and studies" are required to provide sufficient evidence. A recent study examining the effectiveness of laser therapy in treating lumbar disc herniations measured by clinical evaluation and magnetic resonance imaging (MRI) found that "low power laser therapy is effective in the treatment of patients with acute lumbar disc herniations."²⁰

Invariably, studies provoke questions. Some of the more common parameters for consideration are the duration and extent of laser therapy, joules per centimeter square of irradiation, power settings, etc. One must conclude these studies and meta-analyses, although well-intentioned, may in many instances be misguided. In our experience, almost 40 percent of all patients presenting for treatment at our clinic suffer from back problems characterized by severe pain, and over 85 percent can be treated successfully with laser therapy.²¹

The financial justification for the use of laser therapy as the first line of defence in disc herniations is overwhelming. Data collected from the SPORT trial found that the average surgical procedure cost $15,139, which rises to $27,341 when other costs such as diagnostic tests and missed work are factored in.21 The cost of conservative treatment in that same study averaged $13,108. In our experience, even the most extreme example of a herniated disc patient (receiving 40 treatments), resulted in a total treatment cost of just $3,200. When diagnostic tests and health care visits are factored into this equation, the total cost of laser therapy is closer to $5,700. This is a savings of more than $20,000 versus surgery and $7,500 over standard conservative treatment. Moreover, laser therapy is noninvasive and no adverse events have been reported in more than 3,000 publications.

In summary, this review of the current literature clearly reveals some of the shortcomings of meta-analyses and the performance of studies without standardized methodologies. We conclude that medical convention has demonstrated that the relief of symptomatic disc herniations continues to be problematic and that both conservative and surgical solutions in the majority of cases appear to be equally ineffective. While the application of appropriate therapy requires a comprehensive understanding of the anatomy, pathology and biomechanics of the spinal column, we feel that laser therapy presents the most logical and effective therapeutic approach in managing these pervasive medical conditions.

References

1. Adams MA, Hutton WC. Prolapsed intervertebral disc. A hyperflexion injury. 1981 Volvo Award in Basic Science. Spine, 1982;7:184-191. 2. Gallagher S. Letter to the editor. Spine, 2002;27:1378-1379.
3. Teplick JG, Haskin ME. Spontaneous regression of herniated nucleus pulposus. Am J Roentgenol, 1985;145(2):371-5.
4. Urban JP, Smith S, Fairbank JC. Nutrition of the intervertebral disc.Spine, 2004;29(23):2700-9.
5. Verzijl N, DeGroot J, Thorpe SR, Bank RA, Shaw JN, Lyons TJ, Bijlsma JW, Lafeber FP, Baynes JW, TeKoppele JM. Effect of collagen turnover on the accumulation of advanced glycation end products. J Biol Chem, 2000;275(50):39027-31.
6. Adams MA, Roughley PJ. What is intervertebral disc degeneration, and what causes it? Spine, 2006;31(18):2151-61.
7. Doita M, Kanatani T, Harada T, Mizuno K. Immunohistologic study of the ruptured intervertebral disc of the lumbar spine. Spine, 1996;21(2):235-41.
8. Groenblad M, Virri J, Tolonen J, Seitsalo S, Kaeaepae E, Kankare J, Myllynen P, Karaharju EO. A controlled immunohistochemical study of inflammatory cells in disc herniation tissue. Spine, 1994;19(24):2744-51.
9. Young S, Bolton P, Dyson M, Harvey W, Diamantopoulos C.Macrophage responsiveness to light therapy. Lasers Surg Med, 1989;9(5):497-505.
10. Lim W, Lee S, Kim I, Chung M, Kim M, Lim H, Park J, Kim O, Choi H. The anti-inflammatory mechanism of 635 nm light-emitting-diode irradiation compared with existing COX inhibitors. Lasers Surg Med, 2007;39(7):614-21.
11. Bjordal JM, Lopes-Martins RA, Iversen VV. A randomised, placebo controlled trial of low level laser therapy for activated Achilles tendinitis with microdialysis measurement of peritendinous prostaglandin E2 concentrations. Br J Sports Med, 2006;40(1):76-80.
12. Toya S, Motegi M, Inomata K, Ohshiro T, Maeda T. Report on a computer randomized double blind trial to determine the effectiveness of the effectiveness of the GaAlAs (830nm) diode laser for attenuation in selected pain groups. Laser Therapy, 1994;6:143-148.
13. Soriano F, Rios R, Gallium Arsenide laser treatment of chronic low back pain: a prospective, randomized and double blind study. Laser Therapy, 1998;10:175-180.
14. Basford JR, Sheffield CG, Harmsen WS. Laser therapy: a randomized, controlled trial of the effects of low-intensity Nd:YAG laser irradiation on musculoskeletal back pain. Arch Phys Med Rehabil, 1999;80(6):647-52.
15. Gur A, Karakoc M, Cevik R, Nas K, Sarac AJ, Karakoc M. Efficacy of low power laser therapy and exercise on pain and functions in chronic low back pain. Lasers Surg Med, 2003;32(3):233-8.
16. Djavid GE, Mehrdad R, Ghasemi M, Hasan-Zadeh H, Sotoodeh-Manesh A, Pouryaghoub G. In chronic low back pain, low level laser therapy combined with exercise is more beneficial than exercise alone in the long term: a randomised trial. Aust J Physiother, 2007;53(3):155-60.
17. Chou R, Huffman LH. Nonpharmacologic therapies for acute and chronic low back pain: a review of the evidence for an American Pain Society/American College of Physicians clinical practice guideline.Ann Intern Med, 2007;147(7):492-504.
18. Yousefi-Nooraie R, Schonstein E, Heidari K, Rashidian A, Pennick V, Akbari-Kamrani M, Irani S, Shakiba B, Mortaz Hejri SA, Mortaz Hejri SO, Jonaidi A. Low level laser therapy for nonspecific low-back pain.Cochrane Database Syst Rev, 2008: CD005107.
19. Bjordal JM, Klovning A, Lopes-Martins RA, Roland PD, Joensen J, Slordal L. Overviews and systematic reviews on low back pain. Ann Intern Med, 2008;148(10):789-90.
20. Unlu Z, Tasci S, Tarhan S, Pabuscu Y, Islak S. Comparison of 3 physical therapy modalities for acute pain in lumbar disc herniationmeasured by clinical evaluation and magnetic resonance imaging. J Manipulative Physiol Ther, 2008;31(3):191-8.
21. Tosteson AN, Skinner JS, Tosteson TD, Lurie JD, Andersson GB, Berven S, Grove MR, Hanscom B, Blood EA, Weinstein JN. The cost effectiveness of surgical versus nonoperative treatment for lumbar disc herniation over two years: evidence from the Spine Patient Outcomes Research Trial (SPORT). Spine, 2008;33(19):2108-15.
22. Kahn F. Low intensity laser therapy: The clinical approach. Proc of SPIE, 2006:6140, 61400F-1-61400F-11.

Power 100mW

Wavelength 660nm

The red laser probe is now available, having undergone rigorous ergonomic and clinical testing over the past three years. This addition will complement the already existing 75mW and 200mW infrared laser probes.

During the early 90s, we developed a 25mW red laser probe which we utilized extensively in our clinics, but did not promote in the marketplace as the demand was limited, except by acupuncturists and dentists.

Several were acquired by users who understood the importance of this probe. Most consumers felt that the cost could not be validated and we always choose to allow individuals to make their own informed decisions.

At the same time, we continued to use the 25mW red laser probe in our clinics, with substantial benefit in many situations. In view of this, in 2004 we decided to explore the impact of a 100mW red laser probe which we have now tested extensively under controlled circumstances.

Application:

The probe can be operated from low levels, i.e. 1mW to its 100mW maximum output. Developed primarily for utilization in treating dermatological conditions and wound healing, it may also be used for the treatment of epicondylitis, rotator cuff injuries and other pathologies.

From a clinical perspective, the red laser probe may replace the use of the infrared probes in the treatment of superficial lesions. It may also be combined with the infrared probes in cases that have plateaued or are slow to respond. As always, clinical judgment must prevail in its utilization.

The length of application will be in the 1-10 minute range, depending on the extent of the underlying pathology. As with all BioFlex treatment arrays, the probe can be used in both continuous and pulsed mode.

Synopsis:

Summary of Applications:

Dermatological Utilization

The most common condition that we treat in dermatology is eczema. It is therefore incumbent for the therapist to understand the various aspects of this pathological entity.

Eczema is frequently referred to as atopic dermatitis or non-specific dermatitis. This condition has a genetic basis. It often has no specific etiology, but results from the interaction of multiple genes and is triggered by external environmental factors. The greater the number of atopic genes that are present, the less environmental initiators are required to activate the disease.

The cells at the centre of the inflammation are called T lymphocytes. Their presence represents the immune system's reaction to the trigger factors.

Increased T-cell activity occurs in response to various antigens. Excessive stimulation of T-cells is secondary to the activity of genetically altered atopic Langerhans cells (Langerhans cells are resident in the epidermis and are responsible for presenting antigens to lymphocytes).

Genetic defects in the epidermal barrier make the skin susceptible to breakdown, permitting entry of numerous irritants including detergents, mites and other foreign materials. All of these permit increased penetration of antigens.

Acute flare-ups occur when the immune system in the dermis over-reacts to environmental or emotional triggers, resulting in clinical symptoms characterized as dermatitis or in lay terms, a "rash".

Different individuals have unique etiologies or triggers that result in a breakout of the rash. Some of the more common triggers include:

A significant aspect of therapy is to determine the trigger factors and delete them from the environment.

If this is not effective, LILT presents a new therapeutic approach.

As we continue to treat more eczemas, psoriasis and other dermatological conditions, we are experiencing significant variations in response to laser therapy. As previously indicated, these are based on genetic, environmental, allergic and unknown factors.

The ability to customize protocols is essential in treating these lesions, in addition to other conditions. Whereas it is somewhat less important in treating musculoskeletal problems, in the dermatological sector it is of paramount importance.

For instance, when a patient presents with a generalized dermatological problem i.e. profuse lesions scattered over various body surfaces, we can initially treat four or more lesions utilizing different protocols for each.

We might begin treating one area with red continuous for 5-10 minutes depending on the extent of the lesion, another area with infrared pulsed at 50/50 for a similar length of time, a third area with infrared and red superluminous arrays combined and some areas utilizing only the laser probes, particularly if they are relatively small.

The application of four or more different protocols initially and observation of the reaction of the lesion on each visit will quickly point to the most effective approach. This permits each therapist to develop protocols appropriate for that particular patient and these may be incorporated in the treatment of similar conditions in other patients. The net result is that each therapist will learn how to develop protocols most suitable for each problem, regardless of the type of pathology that exists.

Case Profiles:

Recently, a patient presented with severe chronic psoriasis in two areas. One area was treated with the large surface array at red continuous for 7 minutes. It disappeared completely after two treatment sessions. At the other site, we utilized infrared 100/80. It improved about 60% after two treatments.

Conclusion - Both protocols were applicable but red continuous was superior. After five sessions, both areas had cleared completely using the protocols that were most effective.

Another recently assessed patient had severe eczema of all the extremities. Again, we used the red large surface array at continuous wave setting with a rapid response. In another area we used infrared continuous, also demonstrating a rapid response. In the other sites we used a combined approach. In this instance, the combined approach was superior to the other two. Again, this clearly indicates the need for an individualized approach to provide the foundation for therapy.

At this point, based on our experience, we have reached some firm conclusions and provide the following guidelines:

Additional information will be provided as we proceed. Finally, it should be noted that the flexibility of the BioFlex System permits the unlimited development of protocols and therefore the device can also be described as a "clinical laboratory". The importance of this particular feature should be apparent.

AVAILABLE NOW

Click here to read the official Press Release.

Volume I of this series of texts entitled, "Laser Therapy in Clinical Practice," was primarily devoted to a review of the basics of the technology and the results of early clinical research conducted at the Meditech Rehabilitation Centres. Some conclusions were established, however, many unanswered questions remain.

Volume II, "Low Intensity Laser Therapy - The New Therapeutic Dimension", focuses on the treatment of an increasing number of medical conditions where in the past, conventional approaches have been inadequate with regard to clinical outcomes. Most important it provides insight into the healing potential of Laser Therapy and how this can be effectively integrated into the healthcare system. In addition, it reflects on some important aspects of the interaction between light and cells and matters germane to developing best practice strategies.

In the commentary section, we review the role of governments, insurance companies, HMOs and other gate keepers, who increasingly dictate standards of practice, without really understanding patient needs and the necessity for the institution of therapy - promptly. This must lead one to conclude that greater effort must be directed to bring enlightenment to these areas of endeavour and at the same time, further the education of those engaged in this enterprise.

Volume III, the Clinical User's Manual, represents the updated International Version of this document. There are a number of variations of this material, in order to conform to the regulatory requirements of each sovereign state, where the system may be utilized. We recommend that users adhere to these directives, obtain an IRB approval in the U.S. or permission from regulatory bodies in other countries, to apply the system for conditions not yet approved in that particular region.

The manual is essential to both the understanding and application of Low Intensity Laser Therapy. It describes many of the technical aspects of the technology necessary to achieve optimal clinical outcomes. Moreover it provides guidelines for therapeutic application and describes the many combinations and permutations permissible in applying treatment. Careful study of this compilation of strategies is mandatory in order to achieve maximum effectiveness.

To produce these texts required the efforts of many individuals and I take this opportunity to acknowledge their contributions and extend my gratitude to them. The list includes: Alex Chan, B.A.(Hons), Jeffrey Matthews, B.Sc.(Hons), Michael Patterson, M.Sc., Leslie Perrin, B.A., M.Sc. and many others.

On a final note, I dedicate these volumes to those healthcare practitioners whose objective is to improve patient care.

Fred Kahn, M.D., F.R.C.S.(C).

Go to online order form or printable order form.

Click here to read reviews (3).

At the same time, we bring to your attention the many synonyms commonly used, particularly in the literature:
• Photo bio-stimulation
• Light therapy
• Phototherapy 
• Laser therapy
• Soft laser therapy     
• Cold laser therapy
• Laser light therapy
• Low level laser
• Low power laser
• Low energy laser
• Low energy photon therapy
• Soft tissue laser therapy
• Low reactive laser therapy
• Therapeutic laser

As utilization of the technology increases, more synonyms will undoubtedly surface, often to describe variations, which may be based on the engineering perspective. Until the scientific community arrives at a consensus, Meditech will continue to use the term, Low Intensity Laser Therapy.   

It should be noted that differentiations are frequently related to the power or intensity of the device output, operating from one milliwatt to twenty watts. At Meditech, based on our experience, it is clear that laser therapy above 250 milliwatts, even if used for milliseconds, can result in tissue damage. Below 250 milliwatts, using proper frequencies, duty cycles and controlling a number of other parameters, tissue stimulation can be advanced in a cumulative pattern, rather than produce inhibition of healing, which may occur at higher power settings.

Fred Kahn, M.D., F.R.C.S.(C).