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Laser Therapy - A John Barnes Link?
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Laser Therapy - A John Barnes Link? - December 5, 2005 4:52:00 AM
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JLS_PT_OCS
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So, recently I have been researching the use of low level laser therapy (LLLT) since a therapist in our area wants to buy a unit.
I found other debates we had on this very good, I will try to post links to them at the end of this.
I was watching a DVD put out by the Erchonia company, who market a 635nm, 5mw laser (not an LED or SLD) for rehabilitation. These parameters have the most support for them recently in some clinical trials, though to be sure there are quite conflicting studies unless we are talking wounds, where the data are little more clear.
Anyway, the DVD was a presentation by Dr Joe Kleinkort PT, PhD. He is president of the pain management special interest group of the Orthopedic Section of the American Physical Therapy Association. So, presumably, this gentleman must be at the cutting edge of evidence based practice and the treatment of chronic musculoskeletal pain. As a confirmed skeptic, I was rather excited to hear what he had to say on the DVD, as most of what I had from the company were unpublished clinical trials or those of poor quality in unknown journals, and those were "irrationally exuberant" to say the least. I thought Dr Kleinkort would really give me the bottom line and some good ideas on how to use the laser in daily practice.
He gave a good summary of the history of laser therapy and 'Energy Medicine' (red flag number one). He also did a good job delineating the differences between lasers, SLD, and LED devices, which was good.
He went into great detail about the physiological mechanisms of laser therapy, reviewed the copious basic science showing cellular and inflammatory changes, permeability changes, blood flow increases, and even a few about stimulation of cellular DNA. This made good sense to me in the context of using it for local treatment as well as remote treatment along the relevant peripheral nerves to the area of complaint. He drew comparisons to acupuncture and the use of the device as a laser acupuncture treatment. All of this fit well with our understanding of the physiology of pain and was entirely biologically plausible. I was happy. However, that wasn't the end of the DVD.
He did start to make some extraordinary claims (specifically, completely curing 89% of migraines, and relieving most frozen shoulder symptoms in two treaatments), but since he had provided such good info thus far and it was a video for Erchonia after all, I was willing to let it slide.
However, it quickly got worse. He began to discuss the skin and "connective tissue matrix" as a non-nerve organ of the body which transmitted impulses faster than nerve tissue and HAD A MEMORY OF PAST TRAUMA. He then asked if any therapists had experienced a patient getting "irrationally emotional" when being treated, and he stated that that was the memory stored in the soft tissue being re-experienced by the patient. I couldn't believe it. He went on to say that it was important to treat the dura also, which held memories, and stated that any craniosacral practitioner would immediately recognize that to be true and see the applicability of the laser.
I saw some video of him treating a patient, and he was literally just waving this device in a rather haphazard sort of way all over the general area of complaint the sample patients had. I was dumbfounded.
Could laser therapy, despite it's growing body of scientific evidence, just become a tool for the myofascial and craniosacral quacksters?
Thoughts???
J
_____________________________
Jason Silvernail DPT, OCS, CSCS
"It isn't what you're able to do that requires your courage but rather what you have come to understand and are willing to express." - Barrett Dorko,PT
**I no longer post on RehabEdge**
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Re: Laser Therapy - A John Barnes Link? - December 5, 2005 5:26:00 AM
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Barrett
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Jason,
In 1905 Einstein said rather famously to a fellow physicist, "I am very happy to see that our colleagues are looking carefully at my theories, even if it is in hopes of destroying them."
Can you imagine a similar attitude by anyone in the "alternative" community? That community is obviously where the proponents of laser therapy for pain have decided to anchor their boat, and when their theory grows irrational (as you note,it doesn't necessarily start there) it is where they retreat. Dr. Kleinkort has free access to this forum and, I presume, a computer available. Invite him here, and let's see what he chooses to do.
_____________________________
Barrett L. Dorko P.T.
http://barrettdorko.com
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Re: Laser Therapy - A John Barnes Link? - December 5, 2005 6:21:00 AM
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JLS_PT_OCS
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Barrett-
Great idea. I have invited him via email.
I hope to see him here, or perhaps another member of the Pain Management group at the Orthopedic Section, as a Dr Tom Watson PT did appear briefly on Evidence in Motion to address the previous chronic pain thing. He was very vocal in support of his colleague, but provided little in the way of support for arguments.
Let's see if we can get a dialogue going.
Perhaps I have mis-interpreted the DVD information?
:)
J
_____________________________
Jason Silvernail DPT, OCS, CSCS
"It isn't what you're able to do that requires your courage but rather what you have come to understand and are willing to express." - Barrett Dorko,PT
**I no longer post on RehabEdge**
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Re: Laser Therapy - A John Barnes Link? - December 5, 2005 9:43:00 AM
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SJBird55
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I doubt you misinterpreted anything, Jas. I remember how disappointed I was regarding that chronic pain article.
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Re: Laser Therapy - A John Barnes Link? - December 5, 2005 11:04:00 AM
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Wisecracker
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My experiences mirror your's Jason. I found conflicting literature, though some was quite promising. I attended an Erchonia "conference". Wow, I was wholly underwhelmed. All sizzle and no steak. I left thinking that this was AK with a flashlight. (AK is the science fiction of muscle testing and deriving a Dx from apparent strength vs weakness). It's a bloody shame, as it appears to have some clinical merit.
BTW, my brother-in-law is laser engineer for a cable modem company, and says you can build a cold laser in the 635 to 810 nm range for about $500.00.
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Re: Laser Therapy - A John Barnes Link? - December 5, 2005 3:49:00 PM
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JLS_PT_OCS
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AK with a flashlight! That's great WC!
The "skeptical chiropractor's" take on LLL therapy!
Well. Dr Kleinkort did send my a reply to my invitation here. He asked me to keep his email confidential, which I will, but I will summarize it for you without quoting him to give you the general gist.
He did pretty much what I expected him to:
1. He backpedalled on all his claims of efficacy. Said he would revise his 89% migraine thing, and said the frozen shoulder was just one case of his
2. He threw out some unrelated point about there being over 2000 studies (yeah, but they're mostly conflicting, of poor quality, and published in low quality journals not indexed on medline)
3. He said that somebody won a nobel prize in 2000 for proving that fascia was like a polymer (this was his defense to saying that memories were stored in the "connective tissue matrix"). Well, rotten cottage cheese looks like brain, that doesn't mean it stores memories for people to re-experience!
4. He said everthing had been proven by his clinical experience (ah, the old empiricist argument again)
5. He also said he could refute my points, but indicated that it would take way too much effort and time.
Here is my response to him:
"Well, Dr Kleinkort, I appreciate you taking the time to write me back. I realize it might have been quite a shock to see how strongly worded my post was, and that it might be hard to come back from that into a discussion. Sorry if I set some things up for failure in that way. I wasn't "offended" by the material in the DVD, I believe the word I used was "dumbfounded".
However, I stand by my post and the issues it brings up, and I am disappointed that you don't feel, given your position in the APTA, that you have a responsibility to promote appropriate evidence-based practice standards and stand by your treatments with science and outcomes. I am also disappointed that you seem to think sheer numbers of studies (of which I'm sure you know, most are conflicting) and your personal clinical experience is a substitute for evidence in modern practice. I believe that you made statements regarding the body's physiology and about healing that are not biologically plausible (such as dura and connective tissue storing memories that might be re-experienced) and you promoted to therapists the kind of alternative medicine approach which neither examines itself very carefully nor allows others to do so."
I closed with a polite holiday wish. I'm a nice guy that way. :)
At any rate, we appear to have the James Randi situation where the only people who will really step up to the plate are the pleasantly misinformed practitioners, and the professionals who have too much to lose who deep down know they can't hang with science and evidence just don't show up. Too bad.
I think it's really a shame that such a promising modality is ending up in the hands of those at the alternative end of the spectrum like this. Maybe, like spinal manipulation and acupuncture, it will be judged by the people who use it and not by it's own merits, which could seriously hinder it's acceptance. I really think that it has possibilities, but if this is the kind of practitioner that is pushing it, I don't expect it to get far.
J
_____________________________
Jason Silvernail DPT, OCS, CSCS
"It isn't what you're able to do that requires your courage but rather what you have come to understand and are willing to express." - Barrett Dorko,PT
**I no longer post on RehabEdge**
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Re: Laser Therapy - A John Barnes Link? - December 5, 2005 4:03:00 PM
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drbuddy
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Ah, Erchonia, the extremely overpriced laser pointer. You can get a laser of that parameter at Radioshack for $15.
Red lasers are good for wound healing, and not very much beyond that. Red laser will not penetrate much past the surface of the skin. I wish I had some links to research on this, but this is info I gathered from talking to a few laser researchers that tested various wavelengths of laser.
Erchonia laser for frozen shoulder? Highly unlikely.
I dont know why, but it seems as if the homeopaths, AK docs/therapists, and "energy technique" type of docs/therapists have latched onto the lower powered red lasers.
Jason, if you want to know all you can about lasers so you can make an informed decision, purchase or get a hold of a book by Jans Tuner and Lars Hode. You can find it on [URL=http://www.laser.nu.]www.laser.nu.[/URL] You'll also find many links and abstracts related to laser therapy.
Personally, I continue to see great results with my laser unit from [URL=http://www.usalasertherapy.com.]www.usalasertherapy.com.[/URL] Every patient I have seen with epichondylitis, wrist pain, hand pain, stenosing tenosynovitis, and related disorders has had almost full resolution of symtpoms (even at 4 and 8 week follow ups). Knee arthrosis has also responded very well, with greater than 50% improvement in most cases (even the more severe cases). I havent had any frozen shoulders, so cant comment on that. I have had a few migraines, but manipulation usually takes care of that (if it is cervicogenic).
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Re: Laser Therapy - A John Barnes Link? - December 5, 2005 4:09:00 PM
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drbuddy
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"I think it's really a shame that such a promising modality is ending up in the hands of those at the alternative end of the spectrum like this. Maybe, like spinal manipulation and acupuncture, it will be judged by the people who use it and not by it's own merits, which could seriously hinder it's acceptance. I really think that it has possibilities, but if this is the kind of practitioner that is pushing it, I don't expect it to get far."
This is the major factor that is holding back this modality. You have too many laser manufacturer's putting out overpriced junk equipment making unsubstantiated claims just to sell it. Unfortunately, these companies are able to find lecturer's to push their equipment at their seminars.
Then, some of us end up buying this junk, it doesnt work, and we end up concluding that it is an ineffective modality.
Remember, laser is highly dependant on the correct does reaching the target tissue. The correct wavelength allows for adequate penetration and the correct time/power ensures the proper dose is administered.
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Re: Laser Therapy - A John Barnes Link? - December 6, 2005 1:11:00 AM
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Barrett
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From: Cuyahoga Falls, Ohio
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Jason,
Many years ago I was hired to do a single workshop for a company that produced a back brace I occasionally used. They flew me to a distant city and paid me well before they figured out I wasn't going to say I used this thing all the time. Once told how I might remain in their employ I simply quit, knowing I needed to both sleep and look in the mirror. Doing what they wanted would have made this difficult.
The famous "When Thoughtfullness Dies" thread comes to mind here and I'd recommend it to new readers. It's in the Bullypit. There we discussed the consequence of a weak or absent theory and the meaninglessness of claims of success. This thread included.
_____________________________
Barrett L. Dorko P.T.
http://barrettdorko.com
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Re: Laser Therapy - A John Barnes Link? - December 6, 2005 2:21:00 AM
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JLS_PT_OCS
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I agree on all points, Barrett.
Buddy- it's funny, according to Erchonia, every laser other than theirs is piece of junk. Or at least they go to great lengths to explain why theirs is so good and everyone else's is insufficient.
I guess until a good study comes out, we're left with nothing but opinions and unsubstantiated claims of success on all sides.
I think you're exactly right when you comment on the large...variation in products available and what that does to it's standing in the minds of science-based practitioners.
I think what bothers me the most about this whole thing is that Dr Kleinkort isn't a mom and pop PT clinic down the road advertising "integrative therapy" or some other load of garbage for affluent suburbanites who love the placebo effect. He is a Fellow of the American Academy of Pain Management (a credential that means less and less to me as the minutes tick by) and as president of a special interest group of a Section of the APTA, presumably he is someone we should look to for an example of how to practice and teach. What message is the APTA and the Orthopedic Section sending by permitting him his position?
This epidemic of practice variation is really a serious thorn in our side, and we will continue to be embarrassed by people like this until we can better police ourselves. But I guess that's another thread. :)
J
_____________________________
Jason Silvernail DPT, OCS, CSCS
"It isn't what you're able to do that requires your courage but rather what you have come to understand and are willing to express." - Barrett Dorko,PT
**I no longer post on RehabEdge**
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Re: Laser Therapy - A John Barnes Link? - December 6, 2005 3:08:00 AM
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FLAOrthoPT
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why are therapists so afraid to feel with their hands and work with their hands? why the focus on modalities anyway?
And to all a good night-
Ben
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Re: Laser Therapy - A John Barnes Link? - December 6, 2005 3:44:00 AM
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David Adamczyk
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Barrett,
No one is going to enter a room when they see the barrel of a gun pointed at their head. I think that this is an excellent thread. It is too bad for RehabEdge that Dr Kleinkort did respond to Jason in the Forum. I am not surprised that he responded via email, because it is obvious that he was going to get his head blown off before the discussion even got started.
I am posting this message publicly in the Forum because we want to emphasize to ALL members the policy of RehabEdge is that debate can occur in the Forum without personal attacks.
Dave
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Re: Laser Therapy - A John Barnes Link? - December 6, 2005 3:58:00 AM
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Barrett
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David,
I'm uncertain what you mean here. No one was pointing a gun at Dr. Kleinkort. It is his theory that will bear the brunt of our comments, and that, quite simply, is how science progresses. Einstein never suggested that anyone was out to destroy him. Are you suggesting Dr. Kleinkort was personally treated in any other way? Was my characterization of his action inaccurate?
Our theories should lead lives separate from our own and not be tied to our personal "feelings" or individual belief systems. In this way we can speak of another's practice without fear of being accused of ad hominem attacks-something I have never engaged in here.
I'm on my way to Shreveport in a few minutes. There a therapist will come up to me, espouse a theory of management that they regularly employ and I will say, "Tell the world and see what happens." I give them this URL, and they never do.
_____________________________
Barrett L. Dorko P.T.
http://barrettdorko.com
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Re: Laser Therapy - A John Barnes Link? - December 6, 2005 4:21:00 AM
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David Adamczyk
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From: Cleveland
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I was referring to your comment about Dr Kleinkort hiding in the corner with his hands covering his ears, which I deleted from your post.
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Re: Laser Therapy - A John Barnes Link? - December 6, 2005 4:26:00 AM
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Barrett
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I said he was "cornered," not that he was hiding there. To me, this is markedly different. His refusal to discuss his theory is tatamount to deafness, and this is his choice.
_____________________________
Barrett L. Dorko P.T.
http://barrettdorko.com
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Re: Laser Therapy - A John Barnes Link? - December 6, 2005 6:08:00 AM
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JLS_PT_OCS
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I think there is a careful balance to be struck here, such that those who maybe are not as confident can feel comfortable coming here to discuss issues, even if a disagreement exists.
I think it's probably hard to simultaneously be about scientific reason and evidence based practice AND encourage everyone to "share their experience".
I know David is probably trying to keep that balance, and I know it is a delicate task of judgment that I am glad I don't have to do.
I believe those of us posting here have made a careful attempt to avoid ad hominem approaches to the argument, and perhaps my posts have been a bit too caustic to encourage a more free debate. I think my perception of the severity of the issue and the source's position in our professional association only added to the impact of what I had read. So certainly, I share a part of the responsibility.
Perhaps needless to say, Dr Kleinkort has not further contacted me after a brief reply to my last posting, where we were both cordial but I think realize we are not likely to make much progress with the debate. I believe he knows my argument with him centers on his teaching and theory and not on him personally. I don't want to speak for him in this regard, but as he has not shown up here, I guess that's as close as we'll get.
I believe our profession, at this point in it's evolution, will benefit more from a more confrontational approach, but maybe that's just because that's what I like. :)
J
_____________________________
Jason Silvernail DPT, OCS, CSCS
"It isn't what you're able to do that requires your courage but rather what you have come to understand and are willing to express." - Barrett Dorko,PT
**I no longer post on RehabEdge**
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Re: Laser Therapy - A John Barnes Link? - December 6, 2005 9:25:00 AM
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drbuddy
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"why are therapists so afraid to feel with their hands and work with their hands? why the focus on modalities anyway?"
I wouldnt say focus, but rather they are an adjunct to care. If something can aid the healing process, why not use it?
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Re: Laser Therapy - A John Barnes Link? - December 6, 2005 9:51:00 AM
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JSPT
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I'll throw in my 2 cents since I did my Master's case report on the MicroLight Laser. I looked at quite a few articles and, as most have pointed out, results were mixed. The big hang-up in the literature would seem to be the parameters of the device. I did not come across many articles which used the same wavelength of light or (supposedly) delivered the same amount of energy.
The clinic which had the device during my internship paid almost $10,000 and mostly purchased it for PR (we had 28 referrals in a 6 month period). The PT's there were heavy into modalities, so it was a good fit for them. Between the research I have read and the clinical experience I had with one device, I wouldn't be rushing out to buy one. Some people really believed it worked, and they got better. Others never gave it a chance, and they didn't. I have found the same to be true for exercise, ultrasound, SWD, and MFR.
I don't see LLLT becoming a staple of pain-related therapy to the degree that ultrasound is, but in stubborn cases, I wouldn't hesitate to try it.
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JS
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Re: Laser Therapy - A John Barnes Link? - December 6, 2005 11:10:00 AM
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FLAOrthoPT
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for a lot of reasons, very few machines we use as adjunct can sense and relay any information, they are static in their parameters and do not change based on changes they are supposedly bringing about. The only thing sensitive enough to treat while diagnosing is our hands, we can constantly change pressure, direction, amplitude, etc. I also think that the more we use modalities the more the puiblic and physicians identify therapy by modalities. How many chiro articles saying that PT does not work actually used a PT, how many of them actually called modalities therapy? Patients also become reliant on these placebos, sorry adjunct machines, and typically fall in the rut of fix me rather than what can we do together ot manage this problem. I do, obviously, have a big thing against these adjunct methods of healing, and have a hard time believing that the amount of heat or circulatory change brought to a foot during the day while walking and in shoes and socks is much different that a infrared laser. Ok, got to go play some poker and wow isn't it nice to play people in person rathe rthan a virtual game, probably the same reason why patients should feel their therapist rather than electrode wires..
Ben
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