- Dr. Jason Rountree
Why doesn't my doctor use laser therapy?
Updated: Jan 6, 2021
Today, I want to talk about something I hear all the time from patients. Why doesn't my doctor do laser therapy? Or why doesn't my primary care physician utilize laser therapy? Why didn't the orthopedic doctor know anything about this when I went and asked them? Those are great questions. And this blog may help a little bit. This won't cover everything, but I want to spend some time looking at guidelines for health care providers. Now guidelines are put in place to give your doctor some level of left and right lateral limits and make sure they're moving ahead with treatment that's been proven to work and that has proven to be safe and cost-effective. And guidelines that are well-designed can really help your doctor know what type of treatment you should be pursuing or what kind of testing you should be getting.
So, if we have these healthcare guidelines, why don't they list laser therapy? If they did, many more physicians would know about laser therapy and then be using it. It isn't a lack of evidence, because this year alone, there's been more than 380 studies published on laser therapy. That's incredible. That's a huge amount of research. And that right there is almost part of the problem. There's a ton of new research coming out. And many times the guidelines are left in the dust.
Today I'm referring back to an article that came out in July of this year. It's titled "Guidelines versus evidence: what we can learn from the Australian guideline for low-level laser therapy in knee osteoarthritis? A narrative review." This was published in Lasers in Medical Science in July of 2020, just recently. And they absolutely demolished this guideline that came out in 2018, which had recommended that laser therapy not be used for knee osteoarthritis. These researchers just tore it apart, and it is really a pretty incredible read and a criticism of how we handle our health care guidelines and some of the problems that could arise from just utilizing the guidelines instead of working hard to look at the research every day.
What is Knee Osteoarthritis?
Knee osteoarthritis is a degenerative condition of the knee. It's a wear and tear disorder. It's not inflammatory rheumatoid arthritis. It is osteoarthritis, wear and tear, sometimes stimulated to start happening because of an injury that leads to degenerative change. Bone spurs form around that joint, cartilage loss happens, the joint space shrinks, the knee starts grinding and crunching and becomes very painful. That's knee osteoarthritis. And every year there are thousands of knee replacements being done around the country and around the world because of this condition.
Problems with the Guidelines
This particular Australian guideline from 2018, which provides doctors guidance for what to do about knee arthritis, recommended things like massage and hydrotherapy and recommended against things like prolotherapy and acupuncture. It also recommended against the use of laser. And that must have really irritated somebody because they started digging into this guideline and found massive problems, huge problems. Now I won't go into every bit of detail but let me just tell you- just because laser therapy is not part of the standard of care, just because your doctor doesn't know much about it, does not mean that it doesn't work. It does not mean that there's no evidence out there for it. In this particular case, researchers found huge problems with the guideline, NOT with the laser therapy evidence!
And it started with the fact that the researchers putting the guidelines together didn't do a comprehensive search of the literature. This 2018 guideline didn't use any studies newer than 2012. They also missed dozens of studies in their search that could have supported laser therapy and further they took so long to put this guideline together that in this review, the critical researchers "said the lengthy timeframes associated with guideline development by committee and the folly of publishing guidelines that are not reviewed and updated regularly has a huge impact on what is actually acceptable to use in clinic. "
So, if your doctor is looking at guidelines they may see that a guideline says, no, you shouldn't use laser therapy. And they don't necessarily have the time to go read all the studies themselves. And they don't realize that guideline's evidence search is flawed.
Another problem was the subjective interpretation of the evidence. The guidelines said it costs too much. It takes too long to perform, and then you have to have a medical professional delivering it. Well, that's not really any different from a lot of other treatments that are done. It only takes 20 to 30 minutes maximum for a laser therapy treatment to be delivered to the knee
And many healthcare providers can deliver laser therapy, either alone or at the same time that they're doing exercises with you or helping to stretch you out or assigning some home exercise programs, even using other modalities at the same time. And yes, it does need to happen two to three times a week in the beginning. But if you do get laser therapy two to three times a week, these researchers said that the therapeutic benefits of laser are based on modulating the underlying pathology. That means changing the actual disease itself. They say it provides tissue repair, modulation of inflammation, and neural blockade or pain blocking, which is cumulative over several sessions. So, the effects from one session carry on into the next one. And they all build on each other to not only help with pain, but to help with tissue repair.
In contrast, many of the recommended treatments in the guidelines are for symptom management, only lasting a few hours, like a nonsteroidal anti-inflammatory drug, or a few weeks at best, which would be things like cortisone injections.
And as far as costs, the cost is actually very low. For a patient, this service is often covered by insurance. But total cost matters too- there's no free lunch! When you consider some of the costs associated with opioid drugs and surgeries (addiction, overdose, surgical risks, infections, lengthy rehab, missed time at work, etc), laser comes out much cheaper. As a matter of fact, there is a reduction in the need for knee replacements in patients that get laser over a six-year period with a huge amount of economic benefit. It costs much less to deliver noninvasive laser therapy to a patient's knee than to replace that knee.
Another thing that these critical researchers pointed out as a problem with the guidelines is that no experts in the field of laser therapy were consulted in forming this opinion. Now we, you wouldn't ask highly skilled electricians to weigh in on plumbing methods any more than you'd want surgeons weighing in on laser therapy if they don't know how it works.
And lastly, these critical researchers said "the inflexibility of a guideline, which is not updated when new information becomes available, is a failure of evidence-based practice." Evidence-based practice means using methods and techniques that are proven and supported by scientific evidence. These researchers say, if you can't update your guidelines, they are wrong.
The Guidelines Must be Updated!
These researchers concluded by saying this guideline is flawed and it should be corrected immediately to support the use of laser therapy in knee osteoarthritis. Again, we're not talking about just relieving pain, but actually resolving tissue damage, modulating inflammation, and making the patient better with a non-drug, non-invasive treatment with minimal to no side effects. There's no downside here. So, the next time that you hear that laser therapy is not real or it's a sham, or it's not supported by evidence, just know that we still have a lot of human failings that can happen even in the formation of these guidelines. And I guarantee you, the folks that formed the guidelines really did work hard. I'm sure they tried hard, but they were asked to do a very large, difficult task. And if they don't know enough about some of these modalities, like laser therapy, they may come to the wrong conclusion, and that is evidently what happened here.
I'm really looking forward to seeing more studies like this more papers published like this that are critical of the guidelines when that is appropriate. When we have evidence that we know that laser therapy works, we should be supporting laser therapy and the updating of these treatment guidelines.
Thankfully, here in the Flathead Valley, more and more of our doctors are learning about laser therapy and referring patients to Montana Laser and Medical Center so that their patients can get the absolute best laser therapy care available. If you would like to find out more or see if laser therapy might be an option for your knee pain, please give us a call!