Low Level Laser Placebo?

In the last few years it appears that the number of clinics offering “Laser Therapy” for pain relief, arthritis, hair loss (or to remove hair) and a bevy of other health benefits. Billboard ads, radio spots, even flyers in alternative medicine offices (Chiropractors, naturopaths etc.) seem subjectively to be increasing. It got me thinking about what laser therapy is and why it would be effective for any sort of health problem, so let’s have a closer look at the fundamentals.

To start with, the idea of using a laser for health-related reasons apparently came in 1967 when Endre Mester in Budapest, Hungary noticed that if he shaved hair off the backs of mice, the hair grew back more quickly in mice that were subsequently bombarded by laser light. That’s an interesting finding, but before I start digging into the Internet treasure trove of studies on lasers in health applications, it might behoove us to take a look at exactly what a laser is in the first place.

Lasers, it turns out (and according to Wikipedia) “is a device that emits light through a process of optical amplification based on the stimulated emission of photons.” It also turns out that the word ‘Laser’ is an acronym for Light Amplification by Stimulated Emission of Radiation. Without boring the dickens out of everyone, it’ll suffice to say that lasers are highly focused beams of light that resist diffraction; meaning that you can see a laser spot on a white wall even if it’s being beamed from a small hand-held laser from 100 feet away. This reminds me of The Amazing Meeting 7 where the JREF’s gift to attendees was a combination pen/light/laser pointer and a large portion of the 800-strong audience decided to focus the beam of their new laser pointers on Phil Plait’s shiny forehead (the famously bald Bad Astronomer). But I digress…

Because the light is so concentrated in lasers they can produce a great deal of heat and can in fact cause damage to human tissue, including burning the human retina (the sensitive nerve at the back of your eyes) and ultimately causing permanent vision loss. However, the last two decades have seen the growth of the Low Level Laser Therapy (LLLT) devices, sold by an ever-increasing group of companies. What probably prompted the proliferation of laser treatment in the alternative medical circles were a few studies that showed some minor improvement in wound healing when the wounds were exposed to LLLT. Unfortunately LLL therapy has fallen into the snake-oil sinkhole, having become a cure-all for everything from daily aches and pains to a cure for serious diseases.

Indeed, there’s good news if you suffer from nearly any complaint because according to the Ontario Laser Health and Rehabilitation center’s website some of the many treatments lasers can help include:
• Soft tissue and sports injuries
• Smoking cessation
• Repetitive stress problems
• Arthritic conditions
• Musculoskeletal problems
• Carpal Tunnel Syndrome
• Weight Loss
• Fibromyalgia
• And much more! (yes, they really say this).

Thank goodness that lasers can help improve so many parts of our lives, all by shining a little light somewhere, although one wonders where the laser would be aimed for weight control or fibromyalgia. If a person had pain in their rectum or colon cancer where exactly would the probe go?

The Laser Therapy Review website, which states on its front page that it’s “designed to be a comprehensive website for news and information in the field of Laser Therapy” states that LLLT has proven physiologic effects such as increasing the production and release of endorphins, cortisol, growth hormone, and ATP (Adenosine Triphosphate). It also “Increases protein synthesis, venous and lymphatic flow facilitation, increases angiogenesis, and enhances immune response.” This sort of language is typical of cure-all treatments like LLLT. Indeed, throwing big words at the general public sounds impressive and if you don’t know any better, one might think it could actually have an effect.

While not a medical expert I attended university and was a Registered Nurse working in ICU for about 10 years. Let’s take a look at one claim they make about LLLT: Angiogenesis. Now for those who don’t know angiogenesis is the creation of new blood vessels in the body, although the Laser Therapy Review defines it as “elevation of oxygen saturation”. This definition is so disingenuous one doesn’t even know where to begin, since oxygen saturation has nothing to do with the production of new blood vessels. Still, angiogenesis must be good, right? Considering that most tumor growth is make possible only by the body’s misguided ability to create new blood vessels to feed the tumor, a great deal of cancer research is aimed at stopping angiogenesis, not encouraging it as LLLT claims to do.

A quick Google of the phrase “Cancer research and angiogenesis” and got an entire page of news about how cancer researchers are fighting to stop angiogenesis in cancer patients. I am certainly not suggesting that LLLT causes cancer, I am merely pointing out that the advertisements for what LLLT does are full of what appears to me to be meaningless fluff and medical words sprinkled around without context or real meaning.

The Laser Therapy Review goes on to list the conditions LLLT can treat, and these include (and I’m not making this up):
• Gout
• Fibromyalgia
• Tendinosis
• Temporo-mandibular Joint Dysfunction,
• Venous Stasis
• Atherosclerosis
• Diabetes
• Lymphedema
• MS
• Neuropathies
• Nerve regeneration
• Rheumatoid Arthritis
• Fractures
• Knee dysfunction
• Psoriasis
• Herpes
• Burns
• Acne
• Myofasciitis
• And the list goes on…

So what is the exact mechanism of action of these lasers and why can they do so much to help people? Since the penetration of the laser (Dr. Mark Crislip M.D, the infectious disease doctor who creates the excellent podcast “QuackCast” mentioned on a recent podcast that these lasers only penetrate a few millimeters into the tissue in the first place), the wavelengths of the laser treatments, and indeed even the type of lasers are not standard (not to mention the duration, dose, and location of treatments) it’s difficult to say what, if anything is actually going on therapeutically.

Many of the studies that the Laser Therapy Review point to in its reference section are small studies done in laboratory conditions looking at minute changes in cellular activity after being bombarded by a laser. That doesn’t mean this science isn’t important, but it does mean that it is an unproven treatment that may have some use for temporary pain relief, but it certainly is not something people should be turning to in order to treat diseases like atherosclerosis or diabetes.

The bottom line is that any time one sees a product or treatment that is a panacea cure for large numbers of disparate conditions and it’s being marketed with lots of big words the average Joe wouldn’t understand, it should spark one’s skeptical intuition. The reality of lasers is that a few studies have shown that LLLT can have some small-localized effects on wound healing (by treating the wound edges) and some pain reduction in certain situations where tendons are close to the surface of the skin. But pain is highly subjective and several recent studies show that when it comes to pain control, sham laser treatments work just as well as ‘real’ laser treatments, and even then the benefits are small and highly subjective.

As for the websites that promote LLLT, be skeptical. For example the Laser Therapy Review cleverly has a link to Health Canada (along with the Health Canada Icon) on the bottom of their web page. One can only assume that they are implying approval from the Canadian government, however clicking the link to Health Canada and searching the words Laser Therapy brings up several articles about laser hair removal (a proven treatment) and nothing else except the August 2012 recall of a Fraxel Re-Store Dual Laser system console made by Solta Medical Inc. The laser apparently burned a patient and an operator.

The bottom line is that the claims that LLLT is a new treatment that is a miracle for pain sufferers and those hobbled by chronic disease are just there to take your money. If it sounds too good to be true, it probably is.

16 Responses to “Low Level Laser Placebo?”

  1. Mike says:

    Every day I drive past a place that advertises ‘Laser Quit Smoking’ and I could never figure out how that would even work. Where would you even shoot a laser to remove the nicotine cravings? Unless they are zapping your brain, I can’t see how it would possibly work

  2. Bart Farkas says:

    Mike,

    I believe their justification for this is that the laser is used on acupuncture points. As you may know, acupuncture has been used for stop smoking programs for years, and I think they’re just using the laser at those points. Since acupuncture is highly debatable and its effects (in quality studies) don’t rise above placebo effect, it puts the laser therapy (for this use) into the realm of highly-questionable science/medicine.

  3. Gerry Ross says:

    I am a dentist who has used this modality for the past 20 years. I use it routinely for treating pain after surgery and use post op pain killers in less than 1% of my cases.
    I also treat facial pain on a referral basis, once again without the use of drugs.
    I attend many meetins and listen to the Science.
    I have never heard of the web site you quote. If you really want scintific sites go to laser.nu or Thor lasers.
    Your claim about penetratin depths is wrong; red light(630 to 660nm penetrates about 8mm and infrared light penetrates about 2cm.
    You say rhere are not studies; do a search under Roberta Chow and you will find an article published in Lancet , Dec 2010 which is a meta analysis showing laser to be far superior to NSAIDS. She has also published in Pain. These are 2 of the most prestigeous medical journals and articles are very heavily peer reviewed. In fact if you really want to find Quackery try doing research on NSAIDs.
    As for angiogenesis, yes this happens. It makes my surgical procedures heal faster and it also has helded in healing wounds in diabetics to pevent amputations( look for articles under Enwemeka)
    In short this is a modality that ihas pure science behind it. Like anything else peole who are not qualified can make claims that can give ammunition to websites like yours but ithas the ability to help many medical problems but it is not a silver bullet. It is a tool in our armamentarium.

  4. Bart Farkas says:

    Dr. Ross,

    Thanks for your comments. Yes, I was aware that lasers are used for medical procedures and have effective results. As for Meta-analysis, this is a fairly blunt tool, but your point is taken. My concern for writing the article wasn’t for properly medically trained folks who use lasers for wound healing, hair removal etc. but rather for the quackery around using lasers for quitting smoking and the long list of problems lasers are touted as being effective for. I agree that it has uses and that it does have science behind it for certain treatments. Unfortunately the alt-med crowd will take the effectiveness of helping with wound healing in dental procedures and then twist it by saying that Lasers can do X, Y and Z and it’s scientifically proven.

    Thanks for your feedback. That’s what the purpose of this site is for, to prompt discussion and improve education.

  5. Dr. David Kunashko says:

    Low Level Laser Placebo?
    Your tirade about LLLT clearly illustrates your lack of education in this field. As Dr. Ross pointed out, there is plenty of meta analysis research papers and double blinded placebo controlled studies that clearly support the use of this modality. The mechanisms of LLLT are complex and still being researched at institutions like Harvard (reference M. Hamblin). Your lack of education in this field and an attempt to present an expert opinion is just as misleading as those websites that inaccurately present information on LLLT. It is not a “quack” science and if you research this field properly, you will have a better understanding of why LLLT can treat a large number of medical conditions. I hope you take the time to educate yourself before your broadcast your opinion.

  6. Bart Farkas says:

    Dr. Kunashko,

    I never said Lasers don’t work for certain things, what I said was it’s being used as a quack therapy and I stand by this. What do you use it for? Are you an alternative medical practitioner who uses LLLT to make money? I don’t know the answer to this, perhaps you’re not, but anyone with a lick of science background knows that meta-analysis is a blunt tool that can be both useful and abused. After all, there are meta-analysis that show Acupuncture works, something that certainly lies outside the realm of what science can measure (Chi, energy flow, meridian points, etc.).

    I might also point out that just because something is being studied at Harvard does not mean that it is useful, real, or valid. Do you know what logical fallacies are? You made a big one.

    As I said, it’s clear that lasers work for some things, but when they are being used as a cure-all it’s a joke. As Dr. Ross pointed out, depth of penetration can be as much as 8mm, but I would also point out that at least two companies selling LLLT devices put the penetration at 3mm only. That is, in fact, one of the problems with this therapy – there is no standardization. What dose? What wavelength? What time? Where? Currently I can go to a number of clinics where I live (a small town of 15k) and get laser therapy to treat ASTHMA. Yeah, right. Show me the harvard paper on that…

    • Dr. David Kunashko says:

      The American Physical Therapy Association (APTA) has listed LLLT as their second ranked evidence based modality to treat Achilles tendonitis.
      The WHO Neck Pain Task Force listed LLLT as the only modality that is effective for neck pain.
      There are several other evidence based guidelines that recommend LLLT.
      Wavelengths and dosages are standardized (red and infrared in the 660nm and 800 nm range) – refer to the WALT.
      Depth of penetration has been studied Photomed Laser Surg. 2013 Feb 26. [Epub ahead of print] Penetration of Laser Light at 808 and 980 nm in Bovine Tissue Samples. Hudson DE, Hudson DO, Wininger JM, Richardson BD.
      There are several well established and scientific associations for LLLT (NAALT, WALT, EMLA, etc) that promote the science of LLLT.
      The fact you don’t know the “wavelengths”, “dosages”, that are used merely indicates you haven’t done your homework. You can’t make yourself an expert by reading a few abstracts and misinformed web sites. LLLT has been an effective treatment modality used routinely in countries like Russia, Germany, etc and they have a long history of publishing their research. You make your own logical fallacy by publishing an opinion that is based on your own pre-determined conceptions of what is effective. Exactly what kind of evidence do you need?
      Are you implying the APTA doesn’t do their homework before publishing clinical guidelines??
      In fact, LLLT can be used to treat most inflammatory conditions based on the metabolic stress induced by increased motochondrial NO. Read any one of Hamblin’s or Tiina Karu’s papers and you will have a more informed opinion.

    • Dr. David Kunashko says:

      I reviewed the website that you refer to. I noticed that your reference to LLLT treats “atherosclerosis” and several other conditions was taken out of context.
      In fact, the website clearly indicates LLLT can treat wounds and dermal ulcers SECONDARY to Compression/trauma, Atherosclerosis, Diabetes, Venous Stasis and Lymphedema. Your comment is very misleading since the website refers to the treatment of wounds and ulcers and not the other conditions you misquoted.

  7. Harriet Hall, MD says:

    Bart Farkas has nailed it. There is evidence that low level laser therapy is effective for pain (although systematic reviews are mixed even for that), but little or no published evidence to support the use of low level lasers for the other conditions on that long list. In short, the claims go way beyond the evidence. LLLT is not quackery, but exaggerated claims for it are indeed quackery.

    • Dr. David Kunashko says:

      Most (but not all) of the medical conditions listed above can be treated effectively with LLLT – and there are many clinical trials to support this. I ask you to search LLLT in pubmed to read some of the abstracts. Pain is treated with LLLT when used in dosages that are inhibitory to nociceptive nerve fibres. In lower dosages, LLLT displaces NO from the Cu subunits of cytochrome C oxidase thereby increasing the efficiency of ATPase. This of course causes a cascade of secondary messengers to prevent cell apoptosis and improve cellular function.

  8. Bart Farkas says:

    Dr. Kunashako,

    You are a chiropractor who makes money from this therapy.

    At any rate, we can agree to disagree. Dr. Steve Novella M.D. (Yale Medical School), Dr. Mark Crislip MD (Infectious Disease Portland), Dr. Steven Barrett MD (Quackwatch.org) and now apparently Dr. Harriet Hall MD all agree with this position. Since I am not a medical doctor I reference these folks as learned, concerned and science-based experts who take the same position. I did read the Bovine tissue penetration depth study before writing the article, but how does that related to the myriad LLLT products that aren’t standardized now?

    As for the scientific associations that support your assertions… NAALT (North American Association for Laser Therapy). Well now, a quick glance at the website shows their sponsors (http://www.naalt.org/sponsors.htm) What do you know? Nearly all of their sponsors make lasers. Do you see a conflict of interest here? Of course these organizations support myriad uses for lasers – they’re paid for by laser manufacturers.

    My main point is that you make money from this, therefore your ardent position against what I have said is at the very least biased. I have nothing to gain or lose from this. My article pointed to the blanket-approach to selling LLLT and the long list of ‘cures’ this therapy can perform. As someone with a science background you above all should know that some of the claims mentioned are ridiculous and the advertising as a cure to pain is also disingenuous. Many of these ads out there suggest that LLLT is a cure-all that can help nearly _any_ problem someone has. That, my friend, looks a lot like something that is designed to drive customers to the scammer, excuse me, alt-med practitioner who can then extort money from them by using this therapy to the specific complaint they have. I’m not for a second suggesting that you do this. I would hope that if someone comes to you for treatment for asthma that you would not attempt chiropractic manipulation or LLLT to treat them.

    • Dr. David Kunashko says:

      For every “MD” you throw at me, I can list many “pro” MD LLLT users.
      LLLT is merely a therapeutic tool that has excellent validity to treat a wide range of musculoskeletal and inflammatory conditions. Your reference to “sponsors” is not fair. You would be hard pressed to visit a local “MD’s” office and not find a drug company’s stamp on their “educational” posters, promotional anatomical models, etc etc.
      I use LLLT because it improves the healing time of any injury or degenerative disorder. It’s safe and effective and does not lead to gastric bleeding and hepatotoxicity. My point here is that you are not an expert in LLLT. And neither is Dr. Hall or the other MD’s you listed. I agree there are many conditions listed on websites, etc that are not accurate, however, that doesn’t mean LLLT is not an effective therapy. I advocate awareness of unscrupulous, non-evidence based therapies. LLLT does not fall into this category.

  9. Harriet Hall, MD says:

    David Kunashko,

    I think you are missing the point. No one is denying that LLLT is useful for some conditions. The point is that claims go beyond the evidence. For instance, your claim that LLLT “improves the healing time of any degenerative disorder.” Can you provide any evidence that LLLT improves the healing time or the clinical course of rheumatoid arthritis? It’s my understanding that once the joint damage has occurred in RA, it does not “heal.”

    • David says:

      I was trying to emphasize LLLT is an effective treatment for more than just pain and there is a good body of research that I believe you are not aware of. It’s not a panacea, but it is a viable option that is safe and risk free for a wide variety of conditions.

      LLLT has the ability to affect chondrocytes and synviocytes such that inflammation is decreased and cell viability is improved – leading to decreased signs and symptoms. There is evidence of improvement of hyaline cartilage. Here is one of many research papers on this topic:

      Photomed Laser Surg. 2010 Aug;28(4):527-32. Effect of GaAlAs laser irradiation on the epiphyseal cartilage of rats. Cressoni MD et al

      Of course, like any viable treatment, results vary from patient to patient.

      WRT RA, here is some of the research:

      Lasers Med Sci. 2012 Apr 27.
      Low-level laser therapy in different stages of rheumatoid arthritis: a histological study. Alves AC et al

      Lasers Med Sci. 2011 Sep;26(5):707-17.
      Low-level laser irradiation treatment reduces CCL2 expression in rat rheumatoid synovia via a chemokine signaling pathway.
      Zhang L et al

      Phys Ther. 2011 May;91(5):665-74.
      Ex vivo soft-laser treatment inhibits the synovial expression of vimentin and α-enolase, potential autoantigens in rheumatoid arthritis. Bálint G et al

      Lasers Surg Med. 2009 Apr;41(4):282-90.
      Low level light effects on inflammatory cytokine production by rheumatoid arthritis synoviocytes. Yamaura M et al

      Phys Ther. 2004 Nov;84(11):1016-43.
      Ottawa Panel Evidence-Based Clinical Practice Guidelines for Electrotherapy and Thermotherapy Interventions in the Management of Rheumatoid Arthritis in Adults.

      • Art Tricque says:

        David, all of these references are interesting. And they all seem to be small in-vitro/animal studies. Looks like these if a lot more research that has to be done with human trials — Phase 1 through Phase 3 — before LLLT could be considered an effective treatment and suitable for general use with patients.

  10. Gerry Ross says:

    As the past president of NAALT I completely disagree that we are controlled by the manufacturers. At our recent 3 day conference the first 2 days were scientific papers and all presenters had to disclose any conflicts of interest so that all paers presented were excellent scientific papers. All papers were peer reviewed by a panel and the best were selected. On Saturday 4 papers were presented that had links to manufacturers so everyone was aware of this. NAALT. WALT and ASLMS are the INDEPENDENT bodies trying to bring pure science to the field.

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  • Bart Farkas

    A full-time writer, Bart G. Farkas has authored over 100 print books and at least as many magazine articles over the years. Originally a Registered Nurse working in Trauma ICU in Calgary, Bart's been writing full-time since 1995 and lives in Sherwood Park, AB. From 2009 to 2011 Bart worked full-time for the James Randi Educational Foundation and has been a member of the JREF and an active skeptic since 1998. Working with IIG Alberta founder Tamara Pawluk, Bart helped to establish the first Independent Investigations Group (IIG) in Canada and currently works as the Publishing Czar and Public Relations point person for the group. He is 1/4 of the Podcast 'talent' for Inside Belief, a bi-weekly podcast that examines the nature of paranormal and alt-med beliefs. Bart has three wonderful children and lives with his girlfriend, fellow skeptic Tamara Pawluk.