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Gaining Traction: Lasers and the Evidence-Based DC

By Curtis Turchin, MA, DC, DACBN, DCBCN

These are days of intense challenges in the field of chiropractic. Health care reform, competition from other professions performing adjusting, and decreasing insurance coverage plant fear in the hearts of many chiropractors.

However, the future is actually very bright if DCs focus on what they do best: getting sick people well. Because we have such a wide scope of practice in most states and the need for treatment is so great, it is surprising that so many chiropractors feel their practices are not thriving. I want to make sure we all understand that our ability to adjust, provide nutritional support, exercise and rehabilitation, and use electrotherapy modalities, if done properly, is all a doctor needs to gain traction and build the practice of their dreams. However, to do this you must look to the research community to validate what you do; don't listen to the snake oil salesmen and gurus. In this article, let's consider the value of electrotherapy modalities, especially laser therapy.

Research Support

One powerful endorsement of laser therapy is the overwhelming number of studies attesting to its value. There are more than 2,000 positive studies and more than 250 randomized double-blind clinical trials that document the value of laser therapy in terms of pain management, reduction of inflammation, and improved rate of healing.¹ With this in mind, it is vital to understand the latest scientific research regarding cold and hot lasers, and how they fit into a modern practice. When I teach classes around the country, one of the first questions I get from chiropractors, once they are convinced that the use of laser is based on science, is, "Why should I spend thousands of dollars on a laser when I already have ultrasound and electrical stimulation?" First, recognize that lasers vary considerably in price, and higher price does not necessarily mean greater effectiveness. Second, laser therapy is different than ultrasound and electrical stimulation, pure and simple. Let's take a look at how laser compares to other modalities.

Laser Compared to Ultrasound

When comparing laser to ultrasound, research indicates that ultrasound has value, but less potent stimulation of healing than laser therapy. Laser has been shown to produce stronger wound closing than ultrasound.² Also, ultrasound tends to cause a slight retraction of hard and soft tissues, whereas laser causes a proliferation of these tissues.³ Thus, when the goal is to accelerate the healing of injuries, laser therapy has unique strengths above ultrasound. Doctors must accept that ultrasound has tremendous strengths as a destructive modality, in that it is brilliant at breaking up old, fibrous scar tissue, but it is not a potent stimulator of healing and tissue regeneration, like laser therapy. I recommend that doctors still use ultrasound as the first phase of treatment with chronic scar tissue adhesions, with laser coming later to stimulate healing and blood vessel development.

Laser Compared to Electrical Stimulation

At one time, many doctors used electrical stimulation regularly in their practice. When I asked them why, they often responded that by billing it along with ultrasound and an adjustment, they could increase their income significantly. However, for a doctor to be evidence based and successful in the 21st century, they must look at the science behind electrical stimulation. When comparing laser therapy to electrical stimulation, research indicates that laser therapy provides more healing stimulation.⁴ In addition, laser therapy appears to be equal to or more effective than acupuncture with electrical stimulation.⁵ However, electrical stimulation can provide quick pain relief, even if it is temporary, so it can be quite effective to use electrical stimulation while painting the area with laser. This appears to accomplish a synergistic effect.⁶

Lasers and Time Management

In these days of decreasing insurance reimbursement, chiropractors must be extremely efficient in terms of time management. The faster a chiropractor can deliver effective treatment, the more likely the event will be profitable. With a powerful cold laser, treatments for most conditions, in my opinion, are faster and easier than using ultrasound, electrical stimulation, a very low power laser, or even a hot laser. Total treatment time using a powerful cold laser is commonly two to four minutes per session, with no preparation time and no clean-up.7 Thus, when compared with ultrasound, which takes quite a bit of time, laser is a very time-efficient modality. This is because ultrasound requires the application of gel, which often requires that the patient change their clothing and put on a medical gown. The process of changing clothing, especially with the elderly, postsurgical, or seriously injured patients, is very time-consuming. In addition, more impaired patients have the added necessity of supervision to prevent falling or assistance with dressing activities.

Unlike with ultrasound, lasers can be applied under clothes because there is no contact gel or need for any type of connecting medium. This also eliminates the need for time to wipe off messy gels and clean off equipment. Light and laser therapy, therefore, does not require the time-consuming preparation or clean-up associated with ultrasound.

When applying electrical stimulation, there also may also be a need for gowns because of the need for some type of electrode or pad. In addition, because these pads are applied directly to the skin, there is worry about contamination and skin irritation with reusable pads or the additional cost of disposable electrodes.⁸ However, with a laser, a quick wipe with an alcohol or disinfectant swab is all that is necessary to maintain proper hygiene with the glass lens of a laser device.

Cold Lasers vs. Hot Lasers

Although hot lasers can, like all heating modalities, provide analgesia, they can potentially create a superheating of the skin and resulting increase in blood and hemoglobin, which reduces penetration of the photons. In a recent study, the cell damage thresholds varied in the range of 0.5-5 J/cm² for red blood cells, 4.4-42 J/cm² for lymphocytes, and 36-90 J/cm² for blast cells.9 Since blood and hemoglobin absorb a lot of laser radiation, any increase in blood flow over the site of treatment will lessen the effectiveness and depth of penetration. That is why very powerful hot lasers, in the 5,000 - 10,000 mW power range, often have much longer treatment times than powerful cold lasers. Research supports the contention that hotter lasers may produce less stimulation and more cell damage.¹⁰

Also, as lasers get hotter, they provide excellent pain-relieving effects, but may retard healing.¹¹ One other worry, from a very recent study, is that under certain circumstances, hotter lasers are more likely to stimulate cancer growth than colder lasers. This study looked at melanomas and found that colder laser application did not increase cancer growth, but application of a hotter laser did.¹²

Laser Affects Many Types of Tissues and Conditions

As chiropractors and chiropractic continue to grow, undoubtedly we will see an increasingly wider range of patients. Expertise will drive even more difficult patients into your clinic. Because of this, there will be need for modalities that can address a wide variety of pressing issues. For example, it has been documented that laser therapy is strongly anti-viral. This is especially important with chronic and acute pain syndromes such as herpes zoster and other acute and chronic viral infections. Because it has been documented that laser can actually address these problems, this gives laser a distinct advantage as a therapeutic modality.¹³

Another example: Chiropractors who are focused on sports and athletic rehabilitation are now seeing a wave of athletes, both professional and amateur, seeking out clinics that provide high-quality laser therapy. The need among athletes for laser therapy springs out of laser's rapid success with pain relief, stimulation of healing, and improved muscle function. In fact, recent research documents that laser therapy applied even to healthy muscles improves muscular performance.¹⁴

In summary, chiropractors who desire to grow their business in this competitive and challenging environment need to be aware of the latest research on the value and effects of all physiologic modalities. There is no question that ultrasound and electrical stimulation can be helpful, but laser therapy, with its wide and varied uses, is beginning to take a prominent position in the area of neuromusculoskeletal rehabilitation. Laser therapy may be one of the better ways for a chiropractor to gain traction and grow their business in the 21^st century.

References

1. Tuner J, Hode L. The Laser Therapy Handbook. Grangesberg, Sweden: Prima Books, 2004.
2. Demir H, et al. Comparison of the effects of laser and ultrasound treatments on experimental wound healing in rats. J Rehabil Res & Dev, Sep/Oct 2005;41(5).
3. Lirani-Galvao AP, et al. Comparative study of how low-level laser therapy and low-intensity pulsed ultrasound affect bone repair in rats. Photomed Laser Surg, Dec 2006;24(6):735-40.
4. Medlicott MS, et al. A systematic review of the effectiveness of exercise, manual therapy, electrotherapy, relaxation training, and biofeedback in the management of temporomandibular disorder. Phys Ther, Jul 2006;86(7):955-73.
5. Bjordal JM, et al. Short-term efficacy of physical interventions in osteoarthritic knee pain. A systematic review and meta-analysis of randomised placebo-controlled trials. BMC Musculoskel Disord, Jun 2007;22(8):51.
6. Kato MT, et al. TENS and low-level laser therapy in the management of temporomandibular disorders. J Appl Oral Sci, Apr 2006;14(2):130-5.
7. Turchin C. Science of Laser Therapy. In: Light and Laser Therapy: Clinical Procedures, 2007:5-42.
8. Weber-Muller F, et al. [Contact dermatitis from polyacrylate in TENS electrode.]Ann Dermatol Venereol, May 2004;131(5):478-80.
9. Lapotko DO, et al. Spectral evaluation of laser-induced cell damage with photothermal microscopy. Lasers in Surgery and Medicine, Jan 2005;36(1):22-30.
10. Houreld N, et al. In vitro exposure of wounded diabetic fibroblast cells to a helium-neon laser at 5 and 16 J/cm2. Photomed Laser Surg, Apr 2007;25(2):78-84.
11. Hawkins DH. The role of laser fluence in cell viability, proliferation, and membrane integrity of wounded human skin fibroblasts following helium-neon laser irradiation. Lasers Surg Med, Jan 2006;38(1):74-83.
12. Frigo L, et al. The effect of low-level laser irradiation (In-Ga-Al-AsP-660 nm) on melanoma in vitro and in vivo. BMC Cancer, Nov 2009;20(9):404.
13. Navarro R, et al. Low-level laser therapy as an alternative treatment for primary herpes simplex infection: a case report. J Clin Pediatr Dent, Summer 2007;31(4):225.
14. Nakano J, et al. Low-level laser irradiation promotes the recovery of atrophied gastrocnemius skeletal muscle in rats. Exp Physio, Sep 2009;94(9):1005-15.

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Dr. Curtis Turchin received his undergraduate degree in biomedical sciences from the University of Southern California, a master's in education from San Francisco State University and a doctorate in chiropractic from Palmer College. He was director of clinical sciences for the company that developed the first FDA-cleared light device, and is now president of Apollo PT Products. Dr. Turchin is the author of Light and Laser Therapy and Treating Addictions With Laser Therapy, and has authored numerous articles in research and other publications.