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PHYS THER
Vol. 87, No. 2, February 2007, pp. 224-225
DOI: 10.2522/ptj.2007.87.2.224
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Letters and Responses

On "Is Low-Level Laser Therapy Effective..." Maher S. Phys Ther. 2006;86:1161–1167.


The assessment of low-level laser therapy (LLLT) in lateral epicondylitis by Maher1 in the August issue of Physical Therapy's Evidence in Practice section needs some commentary. The negative conclusion is not surprising based on the few studies the author was able to retrieve; however, the conclusion may still be wrong for a number of reasons:
  1. The reviews the author retrieved do not address the question of proper dose and treatment procedure.
  2. More trials and reviews could have been found if the search had included the Cochrane Library and CINAHL databases. For instance, our review of location-specific LLLT doses in tendinopathy was not included.2 In this review, we found a distinct dose-response pattern, and the results of later trials3,4 do not alter the positive overall result in which adequate doses of LLLT were 32% more effective than placebo. For updated guidelines on location-specific LLLT doses, see the World Association of Laser Therapy Web site.5
  3. To my knowledge, the fact that studies are "old" has never been a valid criterion for exclusion.
  4. Maher bases her clinical decision on the studies by Papadopoulos et al6 (0.714 mW/cm2 and 30 J/cm2) and by Basford et al7 (204 mW/cm2 and 12.24 J/cm2), which use power densities that are too high. Both treatment regimens will inhibit fibroblast activity and impair collagen production in injured superficial tendons such as the extensor carpi radialis brevis tendon in the lateral elbow (which is usually partially ruptured in patients who are middle-aged). The depth of this tendon is only 1.9 mm from the skin surface, and thus the upper power density threshold (30 mW/cm2) for fibroblast stimulation is probably surpassed.8 In the study by Papadopoulos et al,6 the LLLT dose probably inhibits collagen production, resulting in less improvement than in the placebo control group.
  5. A number of studies with negative results in lateral elbow tendinopathy9,10 state that they included patients who received steroid injections shortly before randomization. A number of LLLT trials have not specified whether such treatment had been given, which may seriously confound the results. Our research group11,12 has shown that the anti-inflammatory effect of LLLT is erased by steroids and down-regulated cortisol receptors. In addition, it has been shown that a group that received steroid injections had significantly poorer outcomes than a control group on a waiting list after 6 months.13

Several laboratories are currently working to elucidate the mechanisms behind LLLT.14 Based on the results from 19 out of 22 controlled trials, we are fairly certain that certain doses of LLLT can modulate inflammation.3 Low-level laser therapy also can temporarily increase or decrease collagen production from fibroblast cells (31 out of 34 controlled studies).15 I trust that we will see another face of LLLT in the literature when this new knowledge about LLLT doses is implemented in clinical research.

It is a bit frustrating to see yet another commentary about how ineffective laser is, when in fact it may be very effective when used properly for this condition. The insufficient evidence to support the use of LLLT provided by the manufacturers that the author describes is another problem, and I urge physical therapists to seek LLLT information from the published literature, laser Web sites such as http://www.laser.nu, and their colleagues.

Jan M Bjordal

JM Bjordal, PT, PhD, is Associate Professor, University of Bergen, Bergen University College, Bergen, Norway; Scientific Secretary, World Association of Laser Therapy (jmb{at}hib.no)

References

  1. Maher S. Is low-level laser therapy effective in the management of lateral epicondylitis? [Evidence in Practice.] Phys Ther. 2006;86:1161–1167.[Free Full Text]
  2. Bjordal J, Couppé C, Ljunggren A. Low level laser therapy for tendinopathy: evidence of a dose-response pattern. Physical Therapy Reviews. 2001;6(2):91–99.
  3. 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;40:76–80; discussion 76–80.[Abstract/Free Full Text]
  4. Stergioulas A. Effects of a 904 nm GaAs laser versus placebo in the treatment of patellar tendonitis. Laser & Technology. 2003;13(1-2):21–23.
  5. World Association of Laser Therapy Web site. Recommended dosage. Available at: http://www.walt.nu/dose/index.html. Accessed November 13, 2006.
  6. Papadopoulos ES, Smith RW, Cawley MID, Mani R. Low level laser therapy does not aid in the management of tennis elbow. Clin Rehabil. 1996;10:9–11.[Medline]
  7. Basford JR, Sheffield CG, Cieslak KR. Laser therapy: a randomized, controlled trial of the effects of low intensity Nd:YAG laser irradiation on lateral epicondylitis. Arch Phys Med. 2000;81:1504–1510.[CrossRef][ISI][Medline]
  8. Bjordal J, Demmink J, Ljunggren A. Tendon thickness and depth: an ultra-sonography study on healthy subjects. Physiotherapy. 2003;89(6):375–383.[CrossRef]
  9. Lundeberg T, Haker E, Thomas M. Effect of laser versus placebo in tennis elbow. Scand J Rehabil Med. 1987;19:135–138.[ISI][Medline]
  10. Haker E, Lundeberg T. Laser treatment applied to acupuncture points in lateral humeral epicondylagia: a double-blind study. Pain. 1990;43:243–247.[CrossRef][ISI][Medline]
  11. Albertini R, Aimbire FS, Correa FI, et al. Effects of different protocol doses of low power gallium-aluminum-arsenate (Ga-Al-As) laser radiation (650 nm) on carrageenan induced rat paw ooedema. J Photochem Photobiol B. 2004;74:101–107.[CrossRef][Medline]
  12. Lopes-Martins RA, Albertini R, Lopes-Mar-tins PS, et al. Steroid receptor antagonist mifepristone inhibits the anti-inflammatory effects of photoradiation. Photomed Laser Surg. 2006;24(2):197–201.[CrossRef]
  13. Smidt N, van Der Windt DA, Assendelft WJ, et al. Physiotherapy or a wait-and-see policy were best long-term treatment options for lateral epicondylitis [Evidence-based orthopedics]. J Bone Joint Surg Am. 2002;84:1487.[Free Full Text]
  14. Bjordal JM, Johnson MI, Iversen V, et al. Photoradiation in acute pain: a systematic review of possible mechanisms of action and clinical effects in randomized placebo-controlled trials. Photomed Laser Surg. 2006;24:158–168.[CrossRef][ISI][Medline]
  15. Bjordal JM, Couppé C, Chow RT, et al. A systematic review of low level laser therapy with location-specific doses for pain from chronic joint disorders. Aust J Physiother. 2003;49:107–116.[ISI][Medline]




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