News & Updates

A Review of the Effectiveness of Laser Therapy in the Treatment of Disc Herniations

There is a high probability that you, or someone you know, is currently suffering from “back pain”. More than likely it is low back pain, as this affects nearly two thirds of the population at some point during their lifetime (Coste et al., 1994: Hillman, 1996). Low back pain is the fifth most common symptom for which patients visit physicians, with approximately one quarter of adults reporting low back pain lasting at least 1 day in the past 3 months (Deyo et al., 2006). Due to this high prevalence, low back pain has an enormous associated healthcare cost. In the United States, the total direst healthcare costs attributable to low back pain were estimated a 26.3 billion in 1998 (Luo et al., 2004).

The news isn’t all bad, as the majority of low back pain cases typically improve rapidly in the first month (Pengel et al. 2003). Up to one third of patients however report persistent back pain of at least moderate intensity one year following an acute episode and 1 in 5 report substantial limitations in activity (Van Korff and Saunders, 1996). These statistics indicate that 5% of the people with back pain account for 75% of the healthcare costs (Frymoyer and Cats-Baril, 1991). Low back pain has obvious lifestyle and financial burdens and when it is accompanied by radiation of pain and numbness in the lower extremities, it can be truly debilitating. Lumbar disc herniations account for only 4% of low back pain patients but account for a high percentage of low back pain costs.

A Painful disc herniation results when a tear allows the migration of the nucleus pulposus (protrusion), causing nerve root irritation. Lumbar disc herniations typically occur in individuals between the ages of 30-40 years, (Adams and Hutton, 1992) when the nucleus pulposus is still fluid and the annulus is weakened by activity and age. Due to this relatively you demographic, poor treatment outcomes can result in decades of suffering for these patients.

Clinical guidelines have been implemented by the American College of Physicians and the American Pain Society to assist physicians in the diagnosis and treatment of low back pain (Chou et al. 2007). These guidelines recommend a series of steps in order to diagnose and treat patients presenting with low back pain, including lumbar disc herniations. The major problem in diagnosis is that back problems are seldom simple and often complex, Even a routine disc herniation occurring in a teenager while sneezing during a moment of relaxation of the musculature, can result in nerve root compression and subsequent scar tissue formation. Treatment can be even more problematic as there are a multitude of treatment options ranging from surgery to bed rest.

Once again the prognosis isn’t necessarily negative as most patients suffering from lumbar disc herniation with radiculopathy improve within the first 4 weeks with noninvasive management (Vroomen et al., 2002: Weber, 1983). The majority of these herniations will go unnoticed and will heal through natural processes (Saal et al., 1990). For those cases that do not heal, there is very little that modern medicine offers to resolve this pathology.

Lumbar discectomies are the most common surgical procedure performed for patients experiencing back and leg symptoms (Weinstein et al.,2006). These are elective surgeries that are performed if symptoms are progressive and/or associated with nerve root compression (stenosis)(Amundsen et al.,200: Atlas et al., 2005). The United States performs a greater number of discectomies than any other developed country (Deyo and Weinstein, 2001). Despite the growing number of surgeries, several studies have compared surgical and nonoperative treatment with limited evidence-based conclusions in favor of either approach (Hoffman et all., 1993:Weber, 1983: Buttermann, 2004). More recently a number of centers across the United States complete a large clinical trial with the goal of determining the best practice for lumbar disc herniations titled the “spine Patients Outcomes Research Trial” or “SPORT”. This study was divided into a randomized controlled trail where patients were wither sent for lumbar discectomy or received “conservative” treatment. Despite the expenditure of several million dollars on this multi center, prospective, randomized, controlled clinical trail, the SPORT investigators admitted, “conclusions about the superiority or equivalence of the treatments under study are not warranted based on the intent-to-treat analysis”. The results of this study found that both groups (surgical and conservative) improved substantially over two years without statistically significant difference between the two (Weinstein et al., 2006). The “conservative” treatment was not without risk as 60% of this group received NSAIDS with half of this group prescribed COX-2 inhibitors which are linked to heightened risk of cardiovascular side effects. (Fosbol et al., 2008) Laser therapy was not used within the conservative treatment for any patient in the randomized trial.

Surgical discectomy, as mentioned above, should be the last option as the effectiveness of this technique does not appear to be superior to conservative management. An article published in the New England Journal of Medicine found that unlike other surgical techniques, there is no therapeutic window for the timing of discectomy surgery if conservative techniques provide no symptom relief for painful disc herniations (Deyo, 2007). F. Kahn believes that “you should seldom operate for pain” per se and this axiom holds true for patients suffering from disc herniation. Recent publication are beginning to demonstrate the effectiveness of laser therapy for the treatment of these patients.

Prior to the existence of imaging studies, little was known about the healing mechanism of disc herniations. Imaging studies have confirmed what has been long suspected that disc herniations can decrease in size and even disappear spontaneously, leading to decreased pressure on the nerve root (Teplick, 1985). In adult discs, blood vessels are normally restricted to supplying only the outer layers of the annulus. Low oxygen tension at the center of the disc leads to an anaerobic metabolism, resulting in high concentrations of lactic acid and a low pH. These deficiencies in metabolite transport, limit both the density and metabolic activity of disc cells (Urban et al., 2004). Collagen turnover time in articular cartilage is approximately 100 years (Verzijl et al., 2000) and is theorized to be even lower in the disc (Adams and Roughley, 2006) The result is that intervertebral discs have a limited ability to recover from metabolic or mechanical injuries such as herniations.

There have been a number of mechanisms investigated to indicate how disc herniations heal, although it is now generally accepted that the herniated disc fragments are reabsorbed (Doita et al., 1996, Grondblad et al., 1994). Histological investigations have shown the presence of granulation tissue with abundant vascularization surrounding the fibrocartilaginous fragments (Doita et al., 1996). Within the granulation tissue, the prevailing cell types are macrophages with fibroblasts and endothelial cells (Grondblad et al., 1994). These cell types have been demonstrated to be positively affected by laser therapy. The stimulation of macrophages and fibroblasts could be the primary mechanisms by which laser therapy heals disc herniations (Young et al., 1989). Inflammatory markers such as IL 1, IL 6 and TNF alpha are also present at the site of disc herniations leading to higher prostaglandin E2 concentrations. Two studies have demonstrated that inflammation is greatly reduced 75,90 and 105 minutes after active laser therapy, compared to levels prior to treatment (Bjordal et al., 2005). The reduction in inflammation appears to be another method by which laser therapy promotes healing in disc herniation.

There are a number of clinical publications on the effectiveness of laser therapy in treating low back pain and lumbar disc herniations. The majority of theses articles are published on chronic (non-specific) low back pain either alone (Toya et al., 1994: Soriano et al., 1998: Basford et al., 1999) or with exercise (Gur et al., 2003, Djavid et al., 2007). These positive publications seem to be absent when looking at reviews from either the American Pain Society/American College of Physicians (Chou and Huffman, 2007) or the Cochrane Collaboration (Yousefi-Nooraie et al., 2008). In the review of laser therapy for low back pain performed by the American Pain Society/American College of Physicians 4 trials were reviewed (566 patients) where laser therapy was effective and one trial (140 patients) where laser therapy appeared to be no more beneficial than a sham laser device. The conclusions from this was: “Noninvasive therapies (low-level laser therapy) have not been shown to be effective for either chronic or subacute or acute low back pain” (Chou and Huffman, 2007). A letter to the authors regarding their bias against laser therapy and pro pharmaceuticals (Bjordal et al., 2008), only prompted the authors to downgrade the evidence supporting acetaminophen and cite the Cochrane study (Yousefi-Nooraie et al., 2008) to support their stance on laser therapy. The Cochrane study found that “three high quality studies (168 people) separately showed statistically significant pain relief with laser therapy in the short-term (less than 3 months) and intermediate term (less than 6 months) when compared with sham laser therapy” (Yousefi-Nooraie et al., 2008). Two small trials (151 people), also included in the Cochrane review, independently found that the relapse rate in the LILT group (low intensity light therapy) was significantly lower than in the control group at the six-month follow-up. The conclusion from these publications is that “based on these trials, with a varying population base, laser therapy dosages and comparison groups, there is insufficient data to either support or refute the effectiveness of laser therapy for low back pain.” The resounding statement from both of these meta-analyses were “more studies are required” and “larger trials on specific indications are warranted”. Lacking in the conclusion was any suggestion of “how many patients and studies” are required to provide sufficient evidence. A recent study examining the effectiveness of laser therapy in treating lumbar disc herniations measured using clinical evaluation and magnetic resonance imaging (MRI) found that “low power laser therapy is effective in the treatment of patients with acute lumbar disc herniations” (Unlu et al., 2007).

The financial justification for the use of laser therapy as the first line of defense in disc herniations is overwhelming. Data collected from the SPORT trial found that the average surgical procedure cost $15,139, which rises to $27,341 when other costs such as diagnostic test and missed work are factored in (Tosteson et al., 2008). The cost of conservative treatment in that same study averaged $13,108. Compared with the most extreme example of a herniated disc patient who received 40 treatments the total cost was $3,200. When diagnostic tests and healthcare visits are factored into this equation the total cost of laser therapy is closer to $5,700. This is a savings of over $20,000 versus surgery and $7,500 over the standard conservative treatment. It should be noted that the average number of treatments to resolve disc herniations is 14.

This review of the current literature clearly indicates some of the shortcomings of meta-analyses and the performance of studies without standardized methodology. At the Meditech Clinics in Toronto, in excess of 100 isolated disc herniations, ranging from acute to chronic in nature are treated per annum. Some of these patients have endured several years of a variety of therapies, including physiotherapy, chiropractic, craniosacral, massage, acupuncture and over 25% have even been subjected to one or more surgical procedures.

Conclusions:

• Medical convention has demonstrated that the relief of symptomatic disc herniations continues to be problematic. Both conservative and surgical solutions in the majority of cases appear to be equally ineffective.
• In clinics where Meditech’s Bioflex Laser System is used to treat an extensive number of disc herniations with LILT, significant improvement/cure rates in excess of 90% are achieved. The average cost of treatment is approximately $1,500 per patient.
• The controlled clinical studies that we are initiating are designed to provide objective evidence that post laser therapy disc herniations can longer be visualized on MRI.
• The application of appropriate therapy requires a comprehensive understanding of the anatomy, pathology and biomechanics of the spinal column.
• Based on our experience, we feel that laser therapy presents the most logical and effective therapeutic approach in managing this pervasive medical condition

Dallas, TX - October 10 - In an effort to better serve those in need Dr. Jodie has recruited the skills of RMT, Ms. Sharon Razo to the office. Ms. Razo has been in practice for 16 years and is a certified St. Johns Neuromuscular Therapist.

DALLAS, TX - March 1, 2007 - Jodie Chiropractic Center After 2 years at 14785 Preston Rd., Jodie Chiropractic Center has relocated their office to 5495 Beltline Rd. Suite 240. This move marks dramatic growth for Jodie Chiropractic that includes a full re-branding effort.Jodie Chiropractic was founded on integrated Chiropractic Medicine to achieve the most effective results for all types of injuries. Whether dealing with an existing condition, or trying to prevent future problems, Jodie Chiropractic works with the individual to take control of their own physical well being - treating the cause of the problem, not just the symptoms. To learn more, go to www.jodiechiropratic.com or call 214 273-4790.