A popular therapy among chiropractors who treat pets is low level laser or “cold laser” treatment. It is an impressive bit of showmanship to pull out a complex-looking device and with a serious expression wave a beam of light over a patient, but the evidence to suggest it is anything more than showmanship is weak at best.
An example of the enthusiasm, and irrationality, of some proponents of this treatment can be found at the joint web site of the International Association of Veterinary Chiropractors and American Animal Adjusting Association.
The article on cold laser begins by anticipating and defying criticism:
Invariably a new technique or process is often fraught with counter-intentions that are usually seen throughout the field of study and across the board. The relative benefit of such a process or new technology is directly proportional to the amount of consternation, doubt, and criticism that, it in fact receives….This author has seldom seen a technology as valuable and inspiring, as this particular technology appears to be. Suffice to say you are witnessing the emergence of a completely new age in healing and certainly a total paradigm shift in veterinary health care.
So the existence and strength of opposition to the technique should be seen as evidence of its benefits? Interesting logic. And if I haven’t mentioned it before, the use of the term “paradigm shift,” not to mention “completely new age,” are not only examples of ludicrous hyperbole, they are highly correlated with quackery, if not pathognomonic for it.
The underlying theory presented to explain the benefits of cold laser treatment is a bit of pseudoscience known as the Biophoton or Ultraweak Photon Emission idea. It is possible to detect very low energy photons emitted from living cells as the result of biochemical reactions. The significance, if any, of this for health and disease has never been demonstrated, which makes it a gap in real scientific knowledge into which all kinds of mystical nonsense can be stuffed, much like the pseudoscientific misuse of quantum physics. The veterinary chiropractic site advertising this treatment explains it this way:
It has been proven that cells communicate through coherent light. When a sperm and ovum fertilize, they immediately give off coherent light at precisely 632.8 nanometers.
Cells in the living matrix also communicate throughout the total body living things via a coherent light, and that communication is done instantaneously through the living matrix to direct all aspects of healing, growth, regulation of metabolism, and general cell survival.
To be able to dial into this communication process via an artificial methodology such as a cold laser is the ability to emulate the exact methodology is that the cells themselves use to heal themselves and also to grow, to change, and to survive. It has been said, “it is the way God talks to all cells, tissues, organisms and creatures.”
None of this is based on any sound science. It is merely vitalist, mystical speculation, which does not, of course, limit in any way the certainty and authority with which the fantasy is presented as scientific fact. This is yet another example of how chiropractic is fundamentally a pseudoscience based on imaginary “energy” and fake abnormalities like the “subluxation.” As such, it is open to any similar sounding nonsense, and any benefits it might have in practice are accidental and unrelated to the irrational and bogus underlying principles.
Like most pseudoscientific therapies, cold laser not only addresses the one true underlying cause of disease, it can also be applied in almost any way. Directly over diseased organs, in the general area of a symptom, even on acupuncture points associated with the meridians connected to the problem area. And since the proponents here are chiropractors, we should not be surprised to find that the use of lasers “is particularly effective in rehabilitating the effects of vertebral subluxation complex and their effects on the myofascial tissues affected by these subluxations.”
What else do these folks claim cold laser can do?
These protocols are designed to enhance a particular disease therapy or can be used in a general sense as the sole treatment of choice.
If a practitioner were to master only these protocols and use only these, he would be still far more effective than any of his colleagues to date using methods other than cold laser.
They list a number of general protocols first:
Arthritis/Spondylitis/Myelopathy Protocol
Neuropathy Protocol
Immune Protocol
Lymphatic Drainage Protocol
Pre and Post Surgical Protocol
Liver Detox Protocol
Hormone Balance Protocol
Acute Pain-Injury Protocol
Sympathetic-Parasympathetic (S-PS) Balance Protocol
Acupuncture Meridian Balance Protocol
Infection Protocol
Allergy Protocol (Specific or General)
If one prefers a slightly more specific indication for the treatment, they can also provide protocols for laser treatment of:
Feline-
Abscesses
Chronic Inflammatory Bowel Disease (CIBD)
Feline Hyperthyroidism,
Feline Skin-Spinal Reflex, Feline Neurodermatitis, Endocrine Alopecia, Milliary Eczema
Kidney Disease, FUS, FLUTD
Megacolon
Pyorrhea
Canine-
Canine Hip Dysplasia Syndrome
Canine Idiopathic Epilepsy
Chronic Inflammatory Bowel Disease
Cushing’s Disease
Canine Wobbler’s Disease
Hypothyroid
Progressive Degenerative Myelopathy
Urinary Incontinence
Equine-
Arthritis, (General or Focal) Sore Back etc.
Bleeder (exercise induced naso-pharyngeal hemorrhage) Elevated Blood Pressure
Bronchitis, Bronchopneumonia, Pneumonitis
Bruising, Subcutaneous Hemorrhage, Wound Reorganization
Bursitis
Colic (all kinds), Bloat
Bone Injury, (splint bone and acute boney injuries)
Dermatosis, Urticaria, Hives, Rain Scald
Ear and Guttoral Pouch Disease
Edema, (general, hypostatic, ventral, extremities)
Equine Protozoal Myelitis (EPM)(see also Neurotropic Herpes)
Facial Nerve Paralysis, Lip Paralysis
Fear, Terrors, Miss-emotion, Training Problems
Hepatitis, Hepatosis
Hock Distension
Heart and Heart Related Conditions
Focal or General Inflammation
Lacerations
Lack of Focus in Training
Laryngeal Hemiplegia
Kidney Disease
Malignant Hyperthermia
Navicular Disease and Laminitis
Neurotropic Herpes (West Nile Virus?)
Proud Flesh, Excessive Granulation Tissue
Sepsis, (General or Focal)
So what is the truth behind all of these claims? Despite the nonsense of the underlying theory, is there any evidence cold laser therapy might have real benefits?
The answer for the vast majority of conditions is “No!” For a few conditions, the answer is more appropriately a “Maybe, but probably not much.”
Extensive reviews of the human literature have been done by the Cochrane Collaboration and the insurance companies Aetna and Cigna. These have found mixed but generally poor evidence for benefit as follows. A review of the veterinary literature on the subject can be found in Ramey 2004.
1. Cochrane Review for rheumatoid arthritis: 6 studies with a total of 660 people were examined. There was limited evidence for a small benefit, with an improvement in self-reported pain of 1.1 points on a 10 point scale. The studies were short term and methodologically weak and inconsistent, and the conclusion was, as usual for Cochrane reviews, that no firm conclusion can be drawn and more research is needed.
2. Cochrane Review for osteoarthritis: This examined 6 studies, three of which found no effect and three of which found a benefit. The studies were methodologically weak and inconsistent and more research was recommended. The review has since been withdrawn pending analysis of additional evidence and correction of some statistical errors.
3. Cochrane Review for nonspecific low back pain: 7 studies of 384 people. Three studies (168 people) showed very small improvement in pain compared with fake laser. Three studies (102 people) found no difference. All the studies used different treatment protocols and short-term evaluation, so no firm conclusions could be made.
4. Cochrane Review for tuberculosis: One poor quality study from India was available and did not meet even basic methodological standards, so no conclusion could be drawn.
5. CIGNA Review: References 1-36
A. Musculoskeletal Conditions: A number of studies and reviews in addition to the Cochran Reviews were examined. Generally, they showed no effect from most treatments for most measures but small benefits for a few measures in some trials. Overall, the evidence was weak and of poor quality, and it suggested some small benefit for discomfort and range of motion might be possible.
B. Wound Healing: Several systematic reviews were discussed, none of which showed convincing evidence of benefits for wound healing.
C. Oral Mucositis: Two small studies were reviewed, one of which showed a benefit to laser therapy and the other of which did not.
D. Other Medical Conditions: Reviews of laser use for temperomandibular joint disease and acute and chronic Achilles tendinitis found no clear evidence of benefit.
Summary: Low-level laser therapy (LLLT) has been proposed for a wide variety of uses, including wound healing, tuberculosis, and musculoskeletal conditions such as osteoarthritis, rheumatoid arthritis, fibromyalgia and carpal tunnel syndrome. There is insufficient evidence in the published, peer-reviewed scientific literature to demonstrate that LLLT is effective for these conditions or other medical conditions.
6. Aetna Review: References 37-81 (duplicates with CIGNA deleted)
” Although the results from large, uncontrolled, open trials of low-energy lasers in inducing wound healing have shown benefit, controlled trials have shown little or no benefit. The analgesic effects of low-energy lasers have been most intensely studied in rheumatoid arthritis. Recent well-designed, controlled studies have found no benefit from low energy lasers in relieving pain in rheumatoid arthritis or other musculoskeletal conditions. Furthermore, although positive effects were found in some earlier studies, it was not clear that the pain relief achieved was large enough to have either clinical significance or to replace conventional therapies.”
Published reviews indicate a lack of evidence for effectiveness for the following conditions:
chronic wounds, arthritis, tuberculosis, tinnitus, pain, smoking cessation, epicondylitis, Achilles tendinitis, plantar heel pain, back pain, and carpal tunnel syndrome.
Some evidence of benefit was found for the following conditions:
Raynaud’s phenomenon, pain following endodontic procedures, palpation sensitivity and passive extension in patients with shoulder pain (but not other measures), swelling following dental extraction when used in combination with steroids, tennis elbow pain in combination with plyometric exercise
Most of these studies were small and had methodological weaknesses, an most of their authors conclded that the treatment was promising but more research was needed to conclusively demonstrate a benefit.
7. Ramey 2004: References 82-100
Some studies have found evidence of improved wound healing in diabetic mice, dairy cattle, and laboratory rats. Other studies in rats and rabbits find small but clinically insignificant effects, and several studies have found no evidence of any effect on wounds in rats, guinea pigs, pigs, beagle dogs, and horses. A couple of poor quality studies of tendon and ligament injuries in horses have had conflicting results, one showing benefit and the other not. Other unblinded or uncontrolled studies in horses have suggested benefit for a variety of conditions. “Laser acupuncture” has been examined in uncontrolled and unblinded studies in horses, with the expected claims of benefit. Overall, there is weak evidence to suggest possible benefit in wound healing (though this conflicts with the results of higher quality studies in humans), and many claims made based on studies so poorly designed as to be no different from mere anecdotes. There is no good quality clinical research on which to base firm conclusions, or to support the dramatic claims of laser therapy proponents.
Overall, then, the theoretical foundations for low power laser therapy range from questionable to completely nonsensical pseudoscience. The in vitro research does suggest some real effects on living cells, but it does not indicate that such effects would be achievable or beneficial in actual patients. The human clinical research is extensive but of generally poor quality with no consistency to the laser treatment methods investigated, and it provides only very weak evidence of any clinically meaningful effects. The veterinary research is even more limited and of poor quality, ad it to is mixed with little convincing demonstration of real clinical benefits. All of this suggests an appropriate stance towards this therapy would be neutral to somewhat pessimistic, though certainly better quality research could identify some meaningful clinical benefits. The evidence does not support, and in some cases directly contradicts the claims made by the chiropratic organization website and much of the marketing materials on cold laser therapy veterinarians receive.
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99. Martin BB Jr, Klide AM. Treatment of chronic back pain in horses. Stimulation of acupuncture points with a low powered infrared laser. Vet Surg. 1987 Jan-Feb;16(1):106-10.
100. Klide AM, Martin BB Jr. Methods of stimulating acupuncture points for treatment of chronic back pain in horses. J Am Vet Med Assoc. 1989 Nov 15;195(10):1375-9.
I was highly amused to see in the ‘equine’ list that such things as fear, emotional problems and training problems are considered suitable for treatment with these lasers. Where would they shine the beams for that, then? Especially as in these cases it is generally the owner rather than the horse that needs the treatment.
My boyfriend’s mother (a massage therapist at his father’s chiropractic office) uses one of these. She refers to it as “the healing light of Jesus” when she offers it to her patients.
Thankfully we don’t visit them often, it’s very hard to keep from losing it when they start spouting off about stuff like this.
Wow, can’t get a much clearer example of faith-based medicine than that!
You wouldn’t happen to have any fun stuff on crystal healing in vet medicine would you?
As woo-ful as his family is, they did actually stumble across a vet who was too far gone into woo even for them. They brought in a cat with a urinary condition and the vet pulled out some kind of crystal (or multiple crystals, been a bit since they told me this story) and waved it over the cat and picked medicines based off of whether the crystal “pulled toward certain areas of the body” or something like that.
They payed for these medicines (why?!?!) but never administered them, choosing to go to a real vet shortly thereafter. For which I’m sure the cat was quite grateful.
I was quite disturbed by the whole thing, since urinary problems can so quickly become life threatening (my family lost a cat to a urinary blockage that went unnoticed for too long) and the woo-vet failed to prescribe any real medicine at all.
Sadly, it’s pretty easy to find “veterinary crystal healing” with a quick web search. I sort of though of it like pet pyschics, as something so patently ridiculous I wouldn’t need to bother with it, but it looks like I may have to come up with something on the subject.
Cold Laser or Low Level Laser Therapy / LLLT (a MeSH term on pubmed) has been hijacked by the esoteric new age quacks and it is right that you point that out.
You reference many positive clinical papers but do not refer to them in your conclusion and somehow you missed out the biggest and most recent review published in The Lancet.
The fact that 30% of clinical research papers are inconclusive or negative does not mean LLLT does not work.
LLLT has a power density and a dose specific effect which when applied to the correct anatomical location has a good anti-inflammatory effect equal to NSAID’s but without side effects, some tissue repair and analgesic action also.
See the the Harvard Medical School review available here
http://thorlaser.com/downloads/research/Biphasic-Dose-Response-in-Low-Level-Light-Therapy-Harvard.pdf
The Lancet review
http://www.ncbi.nlm.nih.gov/pubmed?term=19913903&cmd=DetailsSearch
Mr. Carroll,
Thank you for your comment and the references. I am waiting to comment on the Lancet article until I can get a copy of the complete paper.
The other review you linked to is not especially convincing. It acknowledges that “LLLT remains controversial in mainstream
medicine,” yet it reviews only positive research findings and ignores the negative findings. It attributes studies which fail to show efficacy,
“to several factors including dosimetry (inadequate or too much energy delivered, inadequate or too much irradiance, inappropriate pulse structure, irradiation of insufficient area of the pathology), inappropriate anatomical treatment location and concurrent patient medication (such as steroidal and non-steroidal anti-inflammatories which can inhibit healing).”
I cannot help but notice the omission of the possibility that lack of efficacy could be due to lack of efficacy. The article is certainly biased, and it is published in a journal for the International Dose Response Society, a group devoted entirely to the promoting the concept of hormesis as an important phenomenon of great potential therapeutic value. This is even more controversial than the concept of LLLT, so I do not consider this an entirely reliable source. The plethora of alternative medicine journals devoted to publishing material not acceptable for mainstrea medical journals is ample evidence that there mere existence of a positive literature review is not conclusive evidence for the claim being made.
As for the conclusions of my post, I did acknowledge that there is evidence for efficacy of LLLT in humans. I merely pointed out that it is “generally poor quality with no consistency to the laser treatment methods investigated, and it provides only very weak evidence of any clinically meaningful effects.” I stand by this conclusion based on reviewing the literature.
This is not meant to categorically deny that LLLT might have clinical utility, only to point out that we are nowhere near the point where we are justified in making comments like, “‘cold laser therapy’ is on track to become one of the most important developments in life sciences since the discovery of penicillin” as your company does on its web site. If people such as yourself selling this therapy were more circumspect in the marketing of it and limited yourselves to claims that were at all reasonable in light of the existing evidence, I shouldn’t be writing posts such as this one in the first place.
Your cold laser link is to a website of a veterinarian whose license to practice was suspended for significant negligence and fraud (falsified lab tests) in Washington State (VT00002687) in 1996 and he does not hold a valid license to practice ANYWHERE.
Rich,
Thanks, that is an important detail.
So, I had a look at the Lancet review. It does provide some support for the claim that cold laser may have some benefit for pain, but it is also riddled with biases and weakness. The authors, of course, practice laser therapy and clearly deisgned the review to prove the benefit. The appropriate goal of a scientific study is to disprove the hypothesis being examined, since it is all too easy to confirm our beliefs but much harder, and more meaningful, to disconfirm them.
The authors included non-English language journals and journals devoted to alternative medicine, both of which are often excluded from Cochrane reviews due to concerns about publication bias.
They included only studies in which no “specific pathological changes could be identified,” which tends to select a population with less precisely defined disease, the very population that seeks out and believes in CAM and for whom it is most likley to appear to work.
They also included in their search terms nomenclature such as “trigger points,” a somewhat controversial term that suggests an alternative bias.
There was inconsistent reporting of concurrent therapies, and it was impossible to know in 6 of the 16 studies included what concurrent therapy was used in each of the groups.
And, of course, all the results were ultimately self-reported pain scores or comfort surveys, which are notoriously unreliable and likely to suggest a benefit to almost any therapy one applies.
There are quite a few of such weakness, and while they do not invalidate the results, they suggest pretty strongly that the authors set out with an agenda to prove an a priori position and did so. Ultimately, that is likely to lead to false positive results, which is why consistency and replication is required and the best conclusions come from considering the preponderence of the evidence. The preoponderence of the evidence at this point is still weak, with reasonable suggestions that LLLT might lead to subjective improvements in pain scores but no consistent, strong evidence that it has tangible benefit and no justification for extreme claims concerning it. Further research is certainly warranted, but widespread clinical application with florid promises are inappropriate.
I’ve been treating patients with cold laser for more than ten years and when you treat a paraplegic patient with a chronic wound of more than 2 years which heals with laser in 15 sessions, i don’t care what research has been done the evidence is in the results. I have had amazing results with acute tendinitis, sometimes only 1 session required. I’ve treated canine and equine wounds with success, actually, my woundcare patients have had the best results. I used my laser following a c section and i was even impressed at how quickly i healed and how faint my scar is.
There has been extensive research carried out over the past 40 years and NASA have some very interesting results. sometimes things just work, backed up by good research or not, its like BOBATH approach to treating stroke patients and CP, it works but the research is not good. It is the best treatment to prevent abnormal tone and movement. It’s so easy to knock something that doesn’t make full sense. But when you use it on a daily basis and see results you will never be able to tell me it doesn’t work because frankly it’s just not true.
Tracey,
I understand why personal experiences are so compelling. I also understand wy they are often not reliable. George Washington’s doctors had seen many respiratory infections cured by bloodletting, and they truly believed they were helping him when they bled him to death. Every homeopath believes they are curing diseases with their magic water. The reason medical care, and the length and quality of our lives have improved more in the last 200 years than all the rest of human history is because we have better methods of deciding what is true and what isn’t than what looks like it works. The hardest thing about practicing science-based medicine is accepting that things may not be what they seem, and that takes a level of humilty and open-mindedness that is sometimes painful and hard to achieve.
Light or photon energy with the unique property of being able to penetrate up to two inches below the skin surface causing an increase in cellular metabolism with no tissue damage whatsoever
So chiropractors often claim. Unfortunately, there is no solid evidence that this theory is true, as the numerous references cited above illustrate. Such claims are, for the moment, only unsubstantiated opinion.
We are seeing more positive studies and I believe this will continue. In the future, I believe the research will focus on the specific parameters of low level laser therapy for specific conditions.
Would you care to share any of these studies so I and my readers can evaluate their significance for ourselves?
I used cold laser as an adjunct to hypnotherapy for chronic insomnia and pain. This cost me approximately $1500. Three words: MASSIVE RIP OFF.
After my 3rd treatment I honestly felt like a bit of a lunatic for allowing this assistant to “laser” my wrists while we all wore sunglasses. I so wanted it to work but to say the results were ZERO would be overstating the efficacy of the cold laser. I know that the placebo effect should have had some positive effects on the pain and sleeplessness. And the doctor who was administering the hypnotherapy kept going on and on about what a great patient I was. I guess I was a great patient for parting w/ 1500 bucks!
Thanks for sharing your experience. All too often, people who believe they are helped trumpet it to the world, and those who don’t experience a benefit quietly move on to something else, which contibutes to the false impressio of real efficacy.
I have been looking for studies to support laser usage for arthritis in dogs. A lot of believers out there. No real evidence, so far. I will continue following your blog and hold off on purchasing a “miracle laser” for now. Thanks.
There are numerous studies showing efficacy of low level laser for inflammatory conditions. Arthritis in dogs is an inflammatory condition. Look for yourself at http://www.pubmed.gov
Lasers Med Sci. 2011 Apr 12. [Epub ahead of print]
Infrared (810-nm) low-level laser therapy on rat experimental knee inflammation.
Pallotta RC, Bjordal JM, Frigo L, Leal Junior EC, Teixeira S, Marcos RL, Ramos L, de Moura Messias F, Lopes-Martins RA.
Source
Laboratory of Pharmacology and Experimental Therapeutics, Department of Pharmacology, Institute of Biomedical Sciences, University of São Paulo, São Paulo, SP, Brazil, 05508-900.
Abstract
Arthritis of the knee is the most common type of joint inflammatory disorder and it is associated with pain and inflammation of the joint capsule. Few studies address the effects of the 810-nm laser in such conditions. Here we investigated the effects of low-level laser therapy (LLLT; infrared, 810-nm) in experimentally induced rat knee inflammation. Thirty male Wistar rats (230-250 g) were anesthetized and injected with carrageenan by an intra-articular route. After 6 and 12 h, all animals were killed by CO(2) inhalation and the articular cavity was washed for cellular and biochemical analysis. Articular tissue was carefully removed for real-time PCR analysis in order to evaluate COX-1 and COX-2 expression. LLLT was able to significantly inhibit the total number of leukocytes, as well as the myeloperoxidase activity with 1, 3, and 6 J (Joules) of energy. This result was corroborated by cell counting showing the reduction of polymorphonuclear cells at the inflammatory site. Vascular extravasation was significantly inhibited at the higher dose of energy of 10 J. Both COX-1 and 2 gene expression were significantly enhanced by laser irradiation while PGE(2) production was inhibited. Low-level laser therapy operating at 810 nm markedly reduced inflammatory signs of inflammation but increased COX-1 and 2 gene expression. Further studies are necessary to investigate the possible production of antiinflammatory mediators by COX enzymes induced by laser irradiation in knee inflammation. PMID: 21484455 [PubMed - as supplied by publisher]
Photomed Laser Surg. 2009 Aug;27(4):577-84.
The effect of low-level laser in knee osteoarthritis: a double-blind, randomized, placebo-controlled trial.
Hegedus B, Viharos L, Gervain M, Gálfi M.
Source
Physio- and Balneotherapy Center, Orosháza-Gyopáros, Hungary. arthrodent@freemail.hu
Abstract
INTRODUCTION:
Low-level laser therapy (LLLT) is thought to have an analgesic effect as well as a biomodulatory effect on microcirculation. This study was designed to examine the pain-relieving effect of LLLT and possible microcirculatory changes measured by thermography in patients with knee osteoarthritis (KOA).
MATERIALS AND METHODS:
Patients with mild or moderate KOA were randomized to receive either LLLT or placebo LLLT. Treatments were delivered twice a week over a period of 4 wk with a diode laser (wavelength 830 nm, continuous wave, power 50 mW) in skin contact at a dose of 6 J/point. The placebo control group was treated with an ineffective probe (power 0.5 mW) of the same appearance. Before examinations and immediately, 2 wk, and 2 mo after completing the therapy, thermography was performed (bilateral comparative thermograph by AGA infrared camera); joint flexion, circumference, and pressure sensitivity were measured; and the visual analogue scale was recorded.
RESULTS:
In the group treated with active LLLT, a significant improvement was found in pain (before treatment [BT]: 5.75; 2 mo after treatment : 1.18); circumference (BT: 40.45; AT: 39.86); pressure sensitivity (BT: 2.33; AT: 0.77); and flexion (BT: 105.83; AT: 122.94). In the placebo group, changes in joint flexion and pain were not significant. Thermographic measurements showed at least a 0.5 degrees C increase in temperature–and thus an improvement in circulation compared to the initial values. In the placebo group, these changes did not occur.
CONCLUSION:
Our results show that LLLT reduces pain in KOA and improves microcirculation in the irradiated area. PMID: 19530911 [PubMed - indexed for MEDLINE]
We’ve been through this, ut you don’t seem to be hearing me. There are lab animal studies that show some effects on artificially induced inflammation. That means it is plausible that there might be clinical benefit in naturally occurring disease in dogs, but it is NOT definitive proof that this is true. Many things which show promise during in vitro or lab animal studies don’t really work once put into clinical practice, and without controlled clinical trials we can’t justify definitive statements either way. So it is still the case that laser might have benefits but the question remains open. If you sell it to patients by telling them it might have benefits or it might not, fair enough. But if you are selling this as a scientifically proven treatment, that isn’t accurate.