Why isn't laser therapy part of the standard of care?
Updated: Dec 18, 2020
Here's a question I get frequently- if laser therapy is so great, and there's so much evidence behind it, then why isn't it being used everywhere? Why isn't it in every primary care office? Why don't we have it in every orthopedic surgeon's office? Why isn't it at the oncology department at the hospital? Well, we have standards of care and standards of care are very important guidelines for doctors to be able to work within. They help to protect doctors from malpractice claims. Standards of care and the guidelines for care can identify what works, what doesn't work, what's safe, what's unsafe, and even what's cost-efficient versus what is far too expensive to be realistic. And that's good. Right? We want to have evidence-based recommendations to lean on when we're recommending care for patients.
So, where's the disconnect? Where's the disconnect between this well-supported laser therapy modality and this lack of support in the recommendations and the guidelines? Well, maybe the problem is with the guidelines, not the laser therapy evidence. That's a bold statement, I know, but just wait until I get into this review with you, because this is wild.
I've never read a review quite like this. These researchers that put this together, absolutely destroy the recommendations that were made for using laser to treat knee arthritis. Here's the title really quick before I go any further- "Guidelines versus evidence: What we can learn from the Australian guideline for low level laser therapy in knee osteoarthritis? A narrative review." It was published in July of 2020 in Lasers in Medical Science. And these researchers held nothing back. They absolutely tore this guideline up.
Before I get into their issues that they found with the guideline itself, I'm going to pull a quote from the article talking about knee osteoarthritis. "Knee osteoarthritis is common and costly, both to the individual, due to multiple associated comorbidities, including stroke and cardiovascular disease, and to health systems due to the economic burden it generates. Many of the therapies outlined in these guidelines, have low or very low levels of evidence, are compromised by short term benefit only, serious side effects when used long-term, and are invasive or addictive. The recommended treatments require a long-term commitment to weight loss, psychological support, and regular exercise, all desirable goals, but often unachievable in the real world."
Have you seen that in practice? I'm sure you have. Somebody comes in and they're a hundred pounds overweight and they hurt everywhere. Their back hurts or knees hurt, hips are problematic, and you know they need to lose weight and maybe they're trying, maybe they've already lost 40, 50 pounds and they've got another 40 or 50 to go. But for every one of those patients that comes in that is willing and able to get in there to start losing weight, to help themselves out, there's 10 patients who just won't do it, or for whatever reason can't. Many times, because their pain levels are so high every time they try to exercise, they're in much more pain for days it's discouraging, it means that they can't lose the weight they need to. And especially when they're just being hounded by their doctor to get off of the ibuprofen, to get moving and exercise, it is depressing. These researchers said, look, we need treatment options for knee osteoarthritis other than just weight management and behavioral coaching.
How Laser Therapy is Different
They go on to say that "laser therapy offers patients a non-drug non-invasive treatment with minimal side effects." They say the first randomized controlled trial of laser therapy in knee osteoarthritis was performed in 1987. So, we have a long period of time where lots of studies have been done that we can look at. And when we're looking at those studies, they say you should not group laser therapy with other electrotherapy modalities like shockwave and ultrasound and interferential. They say, "this is a meaningless legacy grouping that simply classes the machine as having a switch that can be turned on and off. What comes out of the switched device is critical and differs vastly across the grouping listed in the Guideline. The fundamental physics of [laser therapy] as electromagnetic energy bears nothing in common with shockwave therapy or ultrasound" or interferential. That is strong wording right there to say, get it out of your head that laser therapy is just like interferential or diathermy or ultrasound therapy. It is not, it is totally different.
Bias Against Laser Therapy?
Now, this is where they start getting into problems with the Guideline and they are strongly worded complaints about the way this guideline is put together. Number one, for this particular guideline, they say the literature search method was not comprehensive.
The latest of the cited papers was published in 2012, even though the guideline was published in 2018. "The difference is stark between the latest systematic review with 22 studies, which show both clinically and statistically significant pain relief as well as improvement in disability scores. This factor demonstrates the lengthy time frames associated with guideline development by committee and the folly of publishing guidelines that are not reviewed and updated regularly." That's an incredibly strong statement because I've seen this before with standards and guidelines being slow and incomplete. I've just not seen researchers really take a guideline to task for being developed to slowly and not looking at all the evidence that's out there because of a poor search.
The last several episodes of the podcast and this blog have been looking at research that was published this year, over 380 studies published this year on laser therapy. A guideline from 2018 that only looked at studies from as recently as 2012 is far out of date before it was ever even published.
They go on to say another "aspect to be reconciled was why the quality of evidence did not appear to be used in a consistent manner when making recommendations." So, in this guideline, they had certain treatments that were recommended based on a level of evidence. And then laser was one that was not recommended even though it had the same level of evidence. And what they're saying here is that "the subjectivity of the [judgment] process raises the question as to what values and judgements were the basis of the recommendations." They restate that the recommendation against laser therapy was because of the "considerable cost and time burden to be placed on individuals and that clinicians were required to deliver the intervention two to three times per week."
That was the Guideline's opposition to laser. Well, these researchers say, look, laser therapy generally only takes 20 to 30 minutes as a maximum amount of time. So that is not long at all.
As far as cost goes, when you are using laser for knee osteoarthritis, they say there there is a reduction in the need for knee arthroplasty in patients with knee osteoarthritis treated over six years with obvious economic benefits. As far as clinicians being required to deliver the intervention, this paper says many health professionals, including medical practitioners, physiotherapists, nurses, osteopaths, podiatrists, and chiropractors can administer laser therapy, either alone or in conjunction with other therapies like exercise. And then they really kill the statement of, *it has to be done two to three times a week.* They say "importantly, the therapeutic benefits of [laser therapy] are based on modulating the underlying pathology and are multifaceted, encompassing tissue repair, modulation of inflammation, and neural blockade, which are cumulative over several treatments."
So yes, it's going to take several treatments, but many therapies take several treatments. And this is not just pain relief. We're talking about actually changing the underlying pathology by using laser therapy. They go on to say, "in contrast, many of the recommended treatments in the guideline are for symptom management only lasting hours, (such as Paracetamol or NSAIDS), or a few weeks at best (such as corticosteroid injections).
The next attack that these researchers’ level against the guidelines is the lack of expert input during the development of the recommendations. Now, obviously if you're going to be deciding for, or against a particular treatment, you should know a little bit about the treatment. But these researchers say that "no experts in the field were consulted and none of the members of the working group had expert knowledge and understanding of the biological mechanisms and dosing factors" of laser therapy. And that's crazy. You wouldn't ask a group of massage therapists to make recommendations on a surgical procedure, and you shouldn't be asking unqualified individuals to make a judgment about a therapy that they don't know anything about.
And finally, the researchers say that improperly managed guidelines are worse than useless. They say, "given the rapidity of technological developments and an exponentially increasing number of publications, our review demonstrates that guidelines can become outdated as soon as they're published." They say "the inflexibility of a guideline which is not updated when new information becomes available is a failure of evidence-based practice." And that is the whole reason we have guidelines, right. Is to provide evidence-based practices that are in a patient's best interest. But if you have a guideline that's built in 2018 and hasn't looked at any new studies from the past six years and has no way to amend it, then as more publications become available and more evidence is published, then that guideline will do patients harm.
So why isn't laser therapy part of the standard of care? Well, at least in this case, the problem is not the laser therapy evidence. The problem is the formation of these guidelines and how often they are reviewed and updated. Do they even consider all the evidence that's at hand and are there even knowledgeable individuals passing judgment on laser therapy? In this case, and not in every case, but in this case none of that is true, we have outdated information that's not comprehensively reviewed, that is not even understanding the mechanisms of how laser works, that isn't really looking at all the evidence they should be, and then passing judgment on this critically important modality.
So next time you hear somebody criticize laser therapy as being unproven or experimental realize we have some serious, serious problems with how we handle evidence and how we evaluate these therapies. I encourage you to not simply look at the guidelines, but to look into the nitty gritty research of what's been done,
Laser Therapy Training
We'll help you do that. These blog articles are a great way to get into some of the research without drowning in the technical jargon. If you have specific questions, I would love to hear from you. You can email me email@example.com. You can also hit us up on the website and find out more about what we do and the training we provide to medical professionals who deliver laser therapy to their patients. This is what we do and we will be back next week with more in depth looks at the research around laser therapy, and how you can use laser to help your patients out.