Low Level Laser Therapy – A Clinician’s View
Low level laser therapy (LLLT) has been used in clinical practice for decades — although much more in Asia and Europe than in the U.S. It has been in more widespread use in the U.S. since the 1990’s, and has begun to be used extensively in the past five years as more instruments have become available. Two excellent reviews of the subject can be found in this journal from 2003 and 2004.1,2 In the past three years, I have become very interested in the use of “energy medicine” for the treatment of chronic pain in my practice. As part of this approach, I have used LLLT, microcurrent electrotherapy (MET), cranial electrotherapeutic stimulation (CES, which is a subtype of MET), and auriculotherapy. All of these have proven very successful in treating the variety of cases that I have seen over these years, and continue to demonstrate their effectiveness.
I am a Board-certified Anesthesiologist, having practiced anesthesiology in both an academic setting and in private practice. Twenty years ago, I developed Meniere’s Disease and was forced to stop practicing anesthesiology, as the malpractice insurance carrier would not provide coverage for someone “with my condition.” With the help of Dr. Janet Travell, and other colleagues in the Bethesda and northern Virginia areas, I was able to establish a Chronic Pain Treatment Center in Rockville, Maryland.
I see patients with:
- primary myofascial pain syndrome (MFPS),
- fibromyalgia syndrome (FMS),
- pre- and post- operative neck and back pain,
- carpal tunnel syndrome,
- migraine and “tension” headaches,
- chronic sinus headaches,
- neuropathic pain syndromes—including diabetic neuropathies,
- entrapment neuropathies such as greater occipital neuritis, common peroneal neuritis, piriformis syndrome,
- pudendal neuropathies (pre- and post- operative),
- vulvodynia, coccydynia, CRPS I and II,
- “visceral afferent” syndrome,
- Ehlers-Danlos Syndrome,
- plantar fasciitis,
- movement disorders of the face and extremities,
- interstitial cystitis,
- systemic lupus,
- rheumatoid arthritis,
It should be noted that each of these conditions has some component of myofascial trigger points as a cause of their pain symptoms.
One of the primary principles of treating myofascial pain that I learned from Dr. Travell was that MFPS was a condition that affected “functional units” (e.g., a shoulder, a hip, etc.) and that in order for a treatment to be as complete as possible, the clinician had to find and inactivate each and every trigger point that could be found in that functional unit. Otherwise, a non-treated trigger point would create the condition(s) for a rapid reactivation of the treated trigger points and the associated pain symptoms. Thus the evaluation and treatment of a particular functional unit is approached as if “peeling an onion,” until all of the trigger points are eliminated and the pain is resolved and function restored — through reconditioning, if necessary. Needless to say, most chronic pain patints have more than one functional unit involved, and the number of trigger point injections could get quite extensive. So I searched for a technique that would allow me to treat these difficult cases with a minimum of pain (from the treatment). LLLT was one of those modalities, and the use of these non-invasive techniques has changed the nature of my practice in many ways. This article is intended to present the how’s and the why’s of this approach as it involves LLLT.
Since the mid-1990s, I have begun to see more patients with FMS in my practice. It has been my observation (confirmed by numerous discussions with colleagues) that these patients do not respond well to the use of trigger point injections (TPIs) compared to patients who have only MFPS. It has been my experience, as well, that every patient with FMS has MFPS as a significant component of their pain. This continual pain is part of the reason that they develop the central sensitization that is the hallmark of FMS. Some method of inactivating their widespread trigger points (TPs)—without causing significant pain—had to be found. LLLT turned out to be the ideal treatment.
In the Beginning
I first heard about LLLT in early 2003, when a patient sent me an article from the Washington Post about the use of LLLT by a trainer for the New England Patriots during and before the Super Bowl that had recently been played. I read the article, was very skeptical, but began to look into the use of LLLT. I initially searched the Internet and read many of the citations noted in the later articles in Practical Pain Management.1,2 In addition, I went to the web site of the company that made the unit that had been used by the Patriots and read, downloaded, and obtained some of the cited research. I was quite intrigued, and called the company to arrange a demonstration of the unit two weeks later. I “recruited” seven patients with all types of MFPS, from simple, to complex — I had more volunteers than I could handle — for the demonstration. The eighth subject was me, as I have extensive TPs in my neck and upper back. The company representative came on the appointed day and we spent about six hours together. I was shown how to use the equipment and then did the procedures on my patients. My assistant then treated my own TPs. Each and every TP was inactivated using the LLLT, including eight of my own. I was so impressed that I bought a unit on the spot. The representative came back two weeks later to deliver the unit and we treated seven more patients with similar results. Two of those patients had carpal tunnel syndrome (CTS), symptoms of a positive Tinel’s sign and numbness and tingling in the distribution of the median nerve, in addition to TPs that referred pain into the forearm and wrist (more about these patients later).
Clinical and Technical Considerations
The laser unit that I use has three 30mW beams (90mW total power), with a wavelength of 830nM. This wavelength provides an adequate (for most purposes) depth of penetration through the skin, with power that it low enough to avoid heating or otherwise damaging the tissues. The laser does not penetrate bone, and this is occasionally a problem with certain conditions. There is essentially no risk to this procedure, other than avoiding direct illumination of the eye, which is avoided by the use of appropriate shielding glasses. I do not use it over a pregnant uterus, or over a known cancer or infection. For a fuller explanation — beyond the scope of, and basis for, this paper — see the excellent papers from PPM.1,2