362 | What is Cold Laser Treatment and When is it beneficial?

[00:00:05] Welcome to The Optimal Body Podcast. I'm Dr. Jen. And I'm Dr. Dom and we are doctors of physical therapy, bringing you the body tips and physical therapy pearls of wisdom to help you begin to understand your body, relieve your pains

[00:00:17] and restrictions, and answer your questions. Along with expert guests, our goal of The Optimal Body Podcast is really to help you discover what optimal means within your own body. Let's dive in. For any of you listening, do you have foot problems? Do you have foot pains? Maybe

[00:00:32] you have plantar fasciitis. Maybe you think your high arches or your flat feet are contributing to those foot aches and pains. Do you have those pesky bunion pains that you just can't seem to

[00:00:41] get rid of? That's why Jen and I have partnered with and absolutely love Neboso Technology. They are a company that has created all sorts of foot tools to help with your foundational foot health. The founder, Dr. Emily Spickle, has been on our podcast multiple times and talked

[00:00:57] about foundationally how we address the four pillars of foot health. She has tools like the Neboso SPLAY that helps you with that foot mobility. There are all sorts of sensory tools like their stimulation socks, mats, and the NeuroBall that help wake up our feet so we can

[00:01:14] better feel the ground underneath us. Jen and I are such huge believers in that if we address our foot health, the rest of our movement health, whole body health, and movement quality will come

[00:01:24] along with it. We have a special 15% discount code for our podcast listeners. If you go down to the link in the show notes and use code OPTIMAL at checkout, you'll get 15% off your

[00:01:35] entire order. Go down to the link in the show notes and start using Neboso Technology tools to help address those foundational foot issues. Let's get into it. We are talking about laser therapy today. Now this was a question that we were asked,

[00:01:49] so we want to help and dive into the research so that you better understand your treatment. And if you have questions or you want a different treatment plan, you have the authority to

[00:01:59] ask because you have some knowledge behind it now. And I think that's like the majority of what we want to cover today is really understanding some of the research behind different laser

[00:02:11] techniques and what they could be using within your therapy office. I know when I worked in my therapy clinic, a few of mine, but one in particular, it was like every patient kind of got

[00:02:24] the same kind of treatment and there was always either laser or ultrasound prior to manual work and then maybe some home exercises, you know, but it was always kind of like the same routine

[00:02:37] kind of practice. And I think understanding it a little bit better now, you know, was that necessary to use with every single patient and what are we telling people, I think is really

[00:02:50] helpful to understand. And there's a whole lot to unpack there as to, in my mind, why clinics do that. Again, do they actually believe it's something that's benefiting the patient or on the billing side, does it allow them to bill a unit of something else because that's what

[00:03:06] outpatient clinics need to do to survive based on how they make revenue? That's a whole other topic. That's a whole other soapbox of mine that clinics out there literally will do these treatments not because they believe it's going to be life-changing for the patient's care,

[00:03:19] but because they can bill an ultrasound unit or a laser therapy unit and those get reimbursed by insurance companies. That's a whole other issue as to whether the therapist actually thinks it's effective and necessary. Again, there's a lot of ethical dilemmas in there. There's a lot of

[00:03:36] dilemmas and issues about the system in general, but that's not what we're talking about. I just wanted to comment on that quick because I understand how outpatient physical therapy clinics need to stay alive and the system that they're operating in, I get the dilemma.

[00:03:52] But laser therapy, we found this fun fact that the first form of laser therapy was used in 1967 when Andre Mester wanted to investigate if laser radiation could possibly cause cancer in mice. To his surprise, the laser did something very different. The hair grew back in the area of

[00:04:12] the mouse that he had shaved and where he applied the laser demonstrating that there was biological change happening. So, didn't find that the lasers gave the mice cancer, but he found, hey, there's something biological going on here because the mice's, the meese's, mouse's, the hair is growing

[00:04:29] back on the mice. Yes. I know. It's so interesting and it's also interesting for me to see that it wasn't honestly that long ago that we introduced laser therapy as a type of therapy to be used in

[00:04:43] practice and how common it is to see it nowadays, you know, where it wasn't that long ago. So, just something interesting to note. But what you're mostly going to see in physical therapy

[00:04:57] is what's called a class four laser, okay? Because we need enough of a wavelength, and this is a wavelength between 600 and 1100 nanometers, which is a near infrared light within the visible spectrum in order to create effective physiological change into the tissue of what we're trying to

[00:05:19] create, right? So, it has to be a high enough class laser, but yet not too high where now we shouldn't be doing it in the clinic. It's not going to be burning you, but it's similar to like

[00:05:29] infrared saunas, how they say like, oh, the infrared light from the sauna helps to stimulate physiologic processes in your body because it's a certain wavelength light and it excites your mitochondria and your cells in different ways. Interrupting real quick because I've gotten this

[00:05:45] question. Now, we've talked about element a ton, right? This is something we use in our everyday life and now that I'm pregnant, people want to know, am I still using element? And I am, 100%, I am. Hydration is so incredibly important in pregnancy. If you're not hydrating enough,

[00:06:01] you can find yourself cramping or just feeling really uncomfortable, swelling, just not feeling good within your body. Hydration is so important and your body's doing so much. So, adding electrolytes to help support your body is key. Now, I will say in first trimester, like I didn't

[00:06:20] want a lot of flavor to my water. So, I slowed down in how much I was taking. I wasn't taking it now every single day, especially I wasn't moving hardly as much because I was so exhausted,

[00:06:31] but I was still making sure I was getting it in throughout the week. And then as I start to feel better, I've added it in, especially as I've continued my workouts and I'm sweating and I'm

[00:06:40] you know, needing electrolytes within my body. And you have to understand if you are really in the stage of eating super clean, not eating processed food, you need to be replenishing your body with electrolytes. It's so important to help with fatigue throughout the day rather

[00:06:54] than reaching for that extra cup of coffee. Don't reach for that extra cup of coffee. Go for element. If you have not tried it yet, I highly recommend you get a free sample pack with your order. And please, please to help support our podcast, go to drinkelement.com

[00:07:11] backslash optimal. That's drinkelement.com backslash optimal. And that's with any order, you'll get a free sample pack so that you can try all the flavors they have available, which are so delicious. And again, this isn't just for pregnancy, but I use it for postpartum and

[00:07:28] all throughout your life. This is something that Dom and I both use every day, and it's just going to help to support your body. So I highly recommend if you haven't yet, try element

[00:07:38] and get that in your life. And so that's what we're going to dive into. And so there's a couple different types of class four laser because there's high intensity laser therapy, and then

[00:07:50] there's low level laser therapy. A lot more of the studies that we looked more in depth at were on the low level laser therapy. It's typically what's seen in physical therapy offices. That is more typical versus the high intensity laser therapy. And there's still both this class

[00:08:06] four laser, but of course the high intensity one, they just use a higher intensity light and energy, and it allows them to penetrate a little bit deeper, quicker. So you have to use

[00:08:19] the laser therapy for a lower amount of time versus the low level laser therapy. But in one of the studies that we looked at using the high intensity laser therapy specifically, it was a review of eight different randomized controlled trials. And they just found that in

[00:08:40] general, they found benefit of the use of the HILT, the high intensity laser therapy, and found that it could have been because of a few different reasons, but the analgesic effect, or meaning like the pain reducing effect introduced by the laser therapy, could have

[00:09:01] explained the improved range of motion that people were seeing. But also the thermal effect, or essentially the heat that the light was imparting into the tissues may also have improved deep tissue relaxation and flexibility resulting in the increased range of motion.

[00:09:15] What I think is important to note as well, that this was typically combined with exercise, so we're seeing improvement with the laser treatment plus exercise over just using exercise alone. So it is good to note that it was beneficial and it did have a reduction in

[00:09:36] pain intensity and increase, particularly they were looking at the neck or cervical range of motion. However, we also have to see when they're looking at all of those eight studies, there was limitation

[00:09:49] in the research and the quality of the research. So we can't just say, okay, now we know that high level laser therapy is for sure going to help and I should use it with every treatment.

[00:10:01] Well, we're limited on the amount of people that we're really assessing, we're limited because we're looking at, well, does this help combined with exercise or what if we're just looking at compared to placebo, there wasn't really a change.

[00:10:17] So yeah, there's a lot of, like Jen said, limitations and there was a large variability in the methods of the studies, which is always an interesting thing to look at. Because when you say high intensity laser therapy, there's still a lot of different settings,

[00:10:33] there's a lot of different ways, the intensity, there's so many different settings on these machines that might be slightly different. So the homogeneity or how close the studies were together in their methods was very different. And the level of evidence is just relatively

[00:10:49] low, like Jen said, because of sample size, number of studies and when you look at specific things like did it improve quality of life? There was one study that even mentioned anything about quality of life. So just relatively low level evidence. And then when we go and review

[00:11:06] the remaining evidence from a lot of which looked at low level laser therapy, there's a lot of discrepancies in what you see. And so, I mean, just this first study up here

[00:11:19] found that even in using half of people received real laser therapy and the other half got a sham treatment, which essentially was just like a thing they put on people that had a red light on it. So they... But it's not a class for laser.

[00:11:32] Yeah. So they couldn't tell that it wasn't the actual laser therapy. And there was no clinically important difference in pain intensity between these 148 subjects that were in the test in pain intensity, general disability or any secondary outcome after one, three, six or 12

[00:11:48] months. So no different than placebo, right? And that's kind of where we look at some of these treatments and say, where did they get the benefit from? Did they get the benefit from thinking that something was happening to their tissues? Jen loves to point out that when you're

[00:12:02] getting these treatments, you're talking to the therapist. They're talking to you in a positive way about how... Well, you're just like, you're going through either your story, your journey, your pain, like you just talk therapy we know is beneficial. You're getting to offload a bunch of

[00:12:16] the baggage about the pain that you're going through and that can feel very beneficial and healing to people and can contribute to what we call this placebo effect where whether they turn the machine on or not, you feel like something beneficial is happening. Exactly. And especially

[00:12:33] we know that if someone tells you that something is going to be beneficial and you believe it, the belief that we know that you go forward with in treatment is usually going to have a positive

[00:12:43] outcome. So that alone could be why the placebo also showed an effect. And you know, when we're really looking at the mechanisms of these laser treatments, so when we're looking at like the high intensity laser treatment, some of the things that were the mechanisms proposed. So this is

[00:13:02] proposed like we don't still know exactly what is happening down to a cellular level. We're looking at like it's possibly increasing your blood circulation. It's improving vascular permeability, you know, promoting the absorption of inflammatory substances and the clearance of inflammatory

[00:13:20] cells. The phototherm effect may make patients feel warmer and more comfortable and therefore reduce pain. The high intensity has a stronger and broader photo-bio modulation effect on local tissues than low laser therapy. So more ATP, proteins, and other metabolic substances are

[00:13:43] produced by stimulated cells, thus boosting tissue metabolism. So could there be more that's happening to help with the healing process, you know, healing tissue, healing tendons. But overall, I think what was most important too is that the laser may inhibit peripheral nociceptive

[00:14:03] receptors, slow nociceptive transmission and increased secretion of pain relieving substances in the body, thereby increasing your pain threshold. So all of that to really kind of say we're now changing the threshold of what your body is detecting pain. So now you're going to

[00:14:23] have a higher threshold for that pain so you're not going to detect it quite as much, therefore reducing the pain sensitivity that you're feeling, right? Which is really powerful, but we can,

[00:14:35] we know and we've done podcasts on this that you can also have those effects based on touch in general, based on other manual techniques, based on breath, based on movement. You know,

[00:14:47] there's other ways that we can start to play with this pain threshold, but could this be something beneficial? Potentially. And it's funny, I had a few things that came up that I want to say about

[00:14:59] this and when you look at the mechanisms for the low-level laser therapy, they basically list the exact same things in slightly different words. Increased endogenous opioid neurotransmitter production, that was like the last thing you said where it helps you create the chemicals,

[00:15:15] your internal pain relief system essentially, raised threshold to thermal pain by enhancing local blood circulation, increased oxygen consumption, increased ATP production, increased production of anti-inflammatory cytokines. And essentially what this is all saying

[00:15:34] is like it's increasing your physiology in that local area and some things that are more global, like this opioid production that might have more of a global effect on the body. And exactly what Jen said, like what this makes me think of, you know, what also does this

[00:15:52] movement? You go on a 30-minute walk, you're going to raise the body temperature and raise the physiologic activity in your body, you know, to some degree. I don't know how it would compare

[00:16:03] exactly to this, but it's essentially doing locally what you can do globally in your whole body by doing some exercise, by doing some activity, by getting your internal body temperature up just a little bit, increasing your circulation, your lymph flow. So, there's more than one way to

[00:16:20] cut this cat and I do understand that people might be seeking out treatments like this because it's painful to move to some degree, but again there's more than one way to move in order to

[00:16:32] increase that body temperature that might not be as painful to you or that might not, you know, be as irritating to whatever your injury or area that you're rehabbing is. So, essentially the proposed effects are like, oh it'll increase the physiologic activity in that area

[00:16:49] and then be more beneficial to healing or more beneficial to the healing process. That's my take on that. Yeah, well you know this is where the research kind of gets muddied because we can also, we looked at a systematic review that reviewed five different studies and

[00:17:03] within those studies you see one that's like, you know, oh combined with exercise it was more effective than exercise alone in relieving pain and improving shoulder range of motion. However, then we look at the next study and it's like this study results didn't, did not manage to

[00:17:19] demonstrate superiority of the low laser therapy with respect to placebo group. Both groups seem to slow improvements in pain, show improvements in pain severity and range of motion and functional status based on using a thera, like a low laser light therapy and a placebo therapy. So, you know,

[00:17:38] it's, it's, which can kind of contradict the first study by saying, well what if they would have done placebo and exercise, would that have improved more than exercise alone versus just comparing laser therapy and exercise with exercise alone? Right. The very next study says

[00:17:56] placebo and laser therapy showed no difference. So, is it just the placebo effect that helped show the difference in that first study kind of like you talked about earlier, those people have a little more time, they think something's happening, maybe they talked with the therapist

[00:18:10] that was doing the laser therapy a little bit. So, it's just when you start seeing these discrepancies in specific studies, it makes you question how effective actually is this as a part of the overall broader treatment. Exactly. And in another study in that, you know,

[00:18:30] one of the authors also concluded that low laser light therapy and passive therapies in general are no more effective than placebo. The author investigated different passive therapies and concluded that the results after a passive treatment showed that ultrasound was

[00:18:45] not more effective than a sham application, which we haven't necessarily done an ultrasound podcast. Have we not yet? Have we? I can't remember. But, you know, it's, it's all kind of going into

[00:18:56] the same kind of thing now. Can it be effective? Can it be a form of light therapy that acts on mitochondria, you know, to help with cell proliferation and fibroblastic changes and regeneration? That's what we're hoping is happening, right? When we're using it,

[00:19:14] especially on like a tendon dysregulated teninopathy. And here's where I say, I feel like I've said this in multiple other podcasts, if you're ever going to go in for laser or light therapy, believe that it's working. Believe that it's doing something amazing for your body.

[00:19:30] Buy into it because as we've seen, placebo effect is strong. The placebo is strong with this one. So, if you go in with belief and it is part of a broader program that includes exercise, that might include some other hands-on therapy from a professional, whether it's a PT,

[00:19:51] chiropractor, athletic trainer. Yeah, if you go in with belief, it could show more benefit than just the exercise alone. That's what we're seeing. Is it something that we would recommend, hey, go in and get your laser therapy, leave, do nothing else? No.

[00:20:08] No. And that is what we would say about just about any passive treatment. Right. As far as showing benefit long-term or helping you become more independent long-term. Like, that's just a route to becoming dependent on a treatment.

[00:20:23] And one last study that we kind of looked at, you know, documented where is this low laser light therapy most beneficial. And what they found was that with bone disorders, so bone regeneration is accelerated with laser treatments, tendon repair. So, it's reported that low-level

[00:20:44] laser in combination with stem cell treatment improved the initial phase of tendon repair. Now, again, that's in combination with stem cells, right? So, can we say that low laser therapy alone helps with tendon repair? Unlikely. It even says unsure if it's the laser treatment or the stem cell.

[00:21:05] Right. Like, so... Right. It's very difficult to say. And then lastly, with carpal tunnel syndrome, when they looked at, you know, using it on 34 patients with carpal tunnel syndrome, the low laser light therapy strain ratio and cross-sectional area of the median nerve,

[00:21:23] which is the nerve that's going through that hand right there that's affected, in patients decreased after low laser light therapy. They concluded that nerve regeneration and deployment of vascular supply affects the laser therapy led to the improvements of patient's condition.

[00:21:40] So, but here's where I want to also preference that... Okay. So, if they're using it with carpal tunnel syndrome, if they're using it, you know, to try to help with regeneration of the tendon, we also have done podcasts on tendinopathy and the most

[00:21:55] effective thing for, you know, tendinopathy is progressive overload of that tendon, is movement. So, we always have to address that with the most effective treatment that we know to date.

[00:22:13] This can be if you have the time, if you have, you know, the resources, if you want to do it, sure. Make sure that they're doing other therapy, movement therapy with you as well. And make sure

[00:22:24] you're addressing the root cause of why this happened in the first place for only trying to, and this goes back to like kind of using surgery. If I'm using surgery to fix the alignment of

[00:22:34] something, well, why did it fall out of alignment in the first place? Right? Why did I get carpal tunnel syndrome in the first place? Am I going back and getting to the root cause of how I can

[00:22:45] structure my desk a little differently or do exercises throughout the day so that I manage those symptoms before they're coming on? Always getting back to the root cause and not just relying on passive therapies to fix you is my overall message. Thanks so much for tuning in

[00:23:03] for another PT Pearl. Hopefully, that cleared up some of the confusion about what laser treatment is doing and gave you more information and empowerment going into your treatment protocols. If you haven't, please consider leaving a rating and review on your favorite podcasting platform

[00:23:16] that helps us out so much get this out to more and more people. And of course, we will see you next time on the Optimal Body Podcast.