An American architect Louis Sullivan, told us “Form follows Function”. In 1896, he wrote an article The Tall Office Building Artistically Considered. Here Sullivan actually said ‘form ever follows function’, but the simpler (and less emphatic) phrase is the one usually remembered. For Sullivan this was distilled wisdom, an aesthetic credo, the single “rule that shall permit of no exception”. The full quote is thus:

It is the pervading law of all things organic and inorganic, Of all things physical and metaphysical, Of all things human and all things super-human, Of all true manifestations of the head, Of the heart, of the soul, that the life is recognizable in its expression, that form ever follows function. This is the law.

I love this law. I think about it often when I treat patients. Why do I look at architecture as a massage therapist? Let me explain.

We can see easily how “Form follows Function” with regards to our bodies. Exercise is a prime example. Let look at a bicep curl with weight. As the bicep is subjected to increased resistance, the weight, the muscle fibers respond by getting bigger. The bigger the weight, the bigger the bicep will get. Thus the form of the bicep changes as a result of the function it is being asked to perform. Therefore, in architecture determining the shape of the building, or the form, results from the function of its interior. This is the same with our body as we can see. So indeed, form follows function.

However I also believe that function follows form, particularly when I’m looking at the body. Consider the 2 images below.

Look around you. How many people do you see who have a posture such as the person on the right? And consider their symptoms. Do they have digestive problems, poor bowel movement, shortness of breath, or heart palpitations. If our posture is collapsed, consider the organs within. Do you really expect a diaphragm, lungs, or our liver to function properly if their space is being crushed? In this case the function of tissue is influenced by the form, our posture. Indeed the reverse is true, Function follows Form.

Neuromuscular Therapy looks at both. By assessing your posture, your gait and the muscle tone surrounding we can determine the best approach to resolving your pain and discomfort. As with architecture we are built in a structural form, containing levers and pulleys. And within our body we have rooms in which our organs are housed. By taking rules from the architectural world and applying it to our body, we can help restore your proper structure. And once again you will be standing tall!

So remember,

Form follows function and function follows form.

As always if you have any questions, comments or concerns please do not hesitate to contact me.

In Health,

Peter Roach, RMT, CNMT, Laser Therapist

I read this wonderful article and wanted to share it with you. It is writen by Clifton K. Meador, MD. in the Autumn 2011 Journal of The Pharos of Alpha Omega Alpha Honor Medical Society. The author (A!A, Vanderbilt University, 1954) is clinical professor of Medicine at Vanderbilt University School of Medicine, clinical professor of Medicine at Meharry School of Medicine, and executive director of the Meharry-Vanderbilt Alliance.

In 1994, I recorded a fictitious interview with the person whom I imagined to be the last well person on earth.1 I mistakenly thought well people were disappearing and I wanted to call attention to their disappearance. I missed the big picture and now want to correct my misconceptions. Well people are not disappearing; instead, a new species of man is emerging: Homo clinicus.

An evolution of the symbiotic relationship between man and medicine has been going on for some time. Lewis Thomas deserves the credit for an early spotting of the new species, first observed in America. He called our attention to this phenomenon in the 1970s.

Nothing has changed so much in the health-care system over the past twenty-five years as the public’s perception of its own health. The change amounts to a loss of confidence in the human form. The general belief these days seems to be that the body is fundamentally flawed, subject to disintegration at any moment, always on the verge of mortal disease, always in need of continual monitoring and support by health-care professionals. This is a new phenomenon in our society.2p43

There has been a progression of terms for this new species. First, there was the “early sick” then “the worried well.” That was followed by “the worried sick.” We now have arrived at a definable new species that differs from pre-clinical man. Preclinical man lived largely with medicine out of his consciousness. In fact he lived to avoid medicine. Those of us who are still preclinical will recall the earlier saying, “An apple a day keeps the doctor away.” That is almost pure preclinical thinking. Preclinical man only went to the doctor when he was sick or injured. It was up to preclinical man to decide if he was sick or well. It did not take a physician to make that decision. If he felt all right he was well; if he felt sick he was sick. Not so with clinical man. Feelings are no longer a reliable guide to health. Feeling good is not enough. There must be objective data that nothing is wrong. That’s the problem. Something is always wrong if you look long and hard enough at or inside any human. As a medical resident told a colleague, “A well person is someone who has not been worked up. We can always find something wrong, if we look hard enough.” 1

Clinical man is neither sick nor well. He is simply in clinical limbo. As you will see in the definitions of this new species below, he is always under medical surveillance. Clinical man requires it. More importantly, medicine requires it. Clinical man either has something that is not quite right or something that needs to be rechecked.

Medicine and man have evolved in a symbiotic manner—like the whale with those little fish that swim in and out of the whale’s mouth. The fish need the whale for food particles and the whale needs the fish for dental hygiene—something like that. There is nothing strange about this symbiosis of medicine and man. Big medicine needs clinical man and clinical man needs big medicine. That’s just the way it is. Where would all the endoscopists be without clinical man? And what about all those proceduralists who do interventions and biopsies? What would we do with all the CAT scans and MRIs and PET scans without clinical man? How would all the surgi centers and imaging centers and standalone diagnostic centers survive without a long line of clinical men? Don’t forget the insatiable needs of big pharma and the relentless mongering of created, pseudodiseases on television.

Clinical man goes to the doctor when not sick. That’s part of the definition of the new species. No longer able to decide by themselves, they come in increasing numbers to find out if they are sick or well. Some even demand to know what disease might loom in the future for them.

Here are a few of the characteristics of clinical man:

1. Knows his cholesterol level within 10 milligrams percent
2. Has been biopsied in at least one nonpalpable organ by age fifty
3. Has been biopsied in a palpable organ by age forty
4. Has had at least one major orifice endoscoped within the past twelve months
5. Is always waiting on a biopsy report or a repeat of a borderline or false positive lab result
6. Never goes more than twelve months without medical contact

How did this evolution from an avoidance of medicine to medicine becoming a necessity occur? It is actually quite simple: medicine has been assigned successes by television and the public that are not attributable to medical care. Nearly all of the increases in health and life expectancy from birth are traceable to public health measures, clean water and milk, vaccinations, and a myriad of positive effects of the age of modernization.

It is a strange irony that at a time of maximum health, more people than ever are coming to see doctors. Preclinical man will soon be extinct.

References

Meador CK. The last well person. N Engl J Med 1994; 330: 440–41.

Thomas L. On the Science and Technology of Medicine. In: Knowles J, editor. Doing Better and Feeling Worse: Health in theUnited States. New York: W. W. Norton; 1977: 35–46.

The author’s address is:

Meharry-Vanderbilt Alliance
Bio-Medical Building
1005 D. B. Todd Boulevard
Nashville, Tennessee 37208
E-mail: clifton.meador@vanderbilt.edu

In Health,

Peter Roach, RMT, CNMT, Laser Therapist

Even good for Frankenstein

Did you know that using K Tape is also great for kids!

Take for example my daughter. Weeks ago she came back from playing a soccer tournament. Four games in 5 hours and lots of running around. The following day she was complaining of knee pain, somewhere around her kneecap. After an examination I believed she had a bit of patellofemoral syndrome, an irritation just under the kneecap (patella).

To quote my daughter;

“The tape really helped my knee. Since Daddy put on the tape it has seemed to take away the pain.”

This is only one of many uses for K tape to perform it’s magic. Patellofemoral pain is a common knee problem. If you have this condition, you feel pain under and around your kneecap. The pain can get worse when you’re active or when you sit for a long time. You can have the pain in one or both knees.

With a little bit of blue tape over the kneecap symptoms can cleared up in a few days to a week. Of coarse with children it is so much quicker. They seem to heal faster. But the effects are almost immediate. In the case of patellofemoral syndrome the tape can act as a lifter, if you will, drawing the patella away from the femur thus decreasing irritation. Then the body can heal. Irritation – no healing. No irritation – healing begins.

Benefits of K Tape

• 100% acrylic heat sensitive adhesive/no latex
• Stretches along longitudinal axis only
• Thickness and weight approx. same as skin
• Can be worn for several days, tolerates showering
• Upper extremity lasts 2‐3 days
• Lower extremity lasts 3‐5 days
• Proprioceptively educates a weak muscle  (Arndt-Schult Law – weak stimuli activate neurological activity, strong stimuli inhibit) & Hilton’s Law
• Reduces pain through receptor feedback (Golgi tendon)
• Relaxes muscles
• Reduces edema
• Improves ROM

Ask me if K Tape, along with your Neuromuscular Therapy will benifit you.

In Health,

Peter Roach, RMT, CNMT, Laser Therapist

Definition:
a. The act of traveling from one place to another; a trip.
b. A distance to be traveled or the time required for a trip

Have you ever thought of your massage therapy as a journey? Or for that matter have you ever thought of seeing any of your practitioners as a journey? I didn’t until a treatment with one of my patients the other day.

She said that coming in to see me for treatment was a journey, and one that she looked forward to, despite sometimes feeling beat up after treatment. As we got to talking about this, I found myself thinking that every treatment I do with every patient is a journey. Think about it. When first seeing a new patient I look at gait, posture, and listen to the symptoms. It’s as if this is the starting point at this place and time, the patient and myself here and now. From here it is really is a matter of getting from point A to point B, and how we are going to achieve this, and the journey we will take.

Every patient has their own destination. For most its being pain free. For others it may be to run faster, jump higher, or to complete the Grand Fondo. Others still it may be to carry on into being able to do everything we have and are doing now till the day we die. But EVERY patient I see has a point, a destination of where they are going or want to go.

Of course with each patient it is a different journey. Some patients I have seen for 28 years, and our journey together has been long and great. And with these patients I suspect that the journey will continue for some time after, as we progress through our lives and are presented with different challenges with our body. And at some point these journeys will also come to an end. As with other long standing patients the journey comes to an end, and no longer do I see or hear from the patient. These journeys are tough ones, as relationships are built through the journey, and loosing these contacts becomes somewhat personal. But over the years, we as Massage Therapists learn that patients will come and go, the ebb and flow of life, but never the less, lives have been touched in some way.

Some journeys with patients are shorter, have a defined lifespan. A recent patient came in with chronic lower back pain. She has had this pain for years. But simply looking at her posture and gait revealed some discrepancies that have not been picked up by other health care practitioners she has seen. Explaining to her what I see and what we need to do starts the journey and sets the road map to where and how will will get her pain free. After several treatments, working on each part of the trip to better health, she eventually is pain free. Amazing! But not so amazing. In order to get from point A to point B there is all the little points in between to get there. Miss one or go in a different order, ie: strengthen a muscle before it is stretched, can mean the difference of not getting to the destination.

Our annual journey to Treasure Island

The journey idea is a good one. Whether or not your therapist or yourself is aware of it, the journey begins. Getting to the destination is the difference between a good therapist and a great one.

Another patient commented that I was always 100% there for them. I seemed engaged and present during our treatment. This also is the difference of making the journey to the end. How may practitioners do you see that are totally present? Your GP, your dentist, your surgeon, your massage therapist. All of these practitioners have to be fully engaged in your treatment and treatment plan to be successful. With prevailing winds and such, an airplane is off coarse 70% of the time as it flies to it’s destination. The pilots ensure the appropriate adjustments are made as the journey continues to make sure we arrive where we are suppose to. And so ever practitioner has to make the adjustments for stresses and events  that may alter the treatment coarse.

For some the journey is smooth and easily laid out. For others it can be a long process. One of my patients came to see me a year ago. I could barely touch her, her body in so much pain that it seemed that mere breath would send her home in pain. But the path was clear. Her posture, her gut and digestive functioning had to be addressed. With the help of other practitioners, this woman is doing more now than dreamed possible. I remember her asking me when she would be reaching this point, way back at the beginning. Massage Therapists hate this question. I hate putting time lines on anything as so much can happen between treatments. We are dynamic individuals so each one is different. But after some persistence I said she would be good by July of this year. I was wrong. She was good by August! And what she can achieve now is truly amazing. But of coarse a new destination is set. She wants to be able to achieve this and that, do more, and so we continue to work. The journey continues.

And for still others the journey keeps going, as with Kramer is a Seinfeld episode, it may be to see how long we can go till we run out of gas. I loved this one.

As always, if you have any question, concerns or comments please do not hesitate to contact me.

In Health,

Peter Roach, RMT, CNMT, Laser Therapist

Often I’m ask by therapists and patients alike how I care for my hands. After almost 28 years of massage, 4 days a week, and 8 hours a day, my hands take a beating. And all too often I see new therapists coming out of school and begin working so hard that after 4-6 months they need to take a break because of tendonitis. So here is what I do.

Pace – be sure to pace yourself. This is the classic Tortoise and the Hare. There is no sense in working hard for 3 months, and then taking a month off to recover. Slow and steady is the call here. There is a lot of years ahead of you, don’t blow out your hands in the first year.

Relax – being tense while treating is a killer. Keep relaxed, be 100% there with your patients, and let your hands go. This is a no brainer, however I’m always shocked when teaching how tight some therapists hold their hands.

Ice (Cold baths) – after EVERY treatment run your hands under cold water for at least 3-5 minutes. And perhaps 10-15 minutes at the end of the day. As with professional athletes, and ice water bath should be part of your daily routine. Is is thought that micro-trauma results with repeated and strenuous activity (ie: massage therapist hands). On one hand this is good because the increase in activity will stimulate muscle cells activity, thus causing muscles to strengthen (think body builders). However there is also a thing called “delayed onset muscle pain” which tends to occur some 24 to 72 hours later. Is is thought that ice and ice baths,

• constrict blood vessels and flush waste left by cellular metabolism
• decrease metobolic activity
• decrease swelling and tissue breakdown

Exercise – after all this manual work you may think that you don’t need any more exercise. But massaging is your job. You must have strong hands and forearms to decrease the stress the small little muscles undergo. And for that matter arms, shoulders and back are also important. Invest in a little time at the gym, or have some exercises to do at home. Not every day but 3-4 days a week. Your hands and body will thank you and treat you nicely in return. And don’t forget to stretch out also.

Address any issues – even with the slightest of pain, tweek, or fatigue, take notice. There are many things I have done in the past to ward off pending pain. These include, and still do for that matter, massage (someone else massaging your hands), ice and ice baths (see above), Laser light applications, and K taping techniques. Any and/or all the above can keep you working without missing a beat.

Diet - there are many supplements I’ve tried and continue to use. Some do not have supporting research, but do have big claims. In my experience I think it’s best to try some of them and see what works for you. Of course the top supplements I use are

• Glucosamine
• Chondroitin
• Methylsulfonylmethane (MSM)
• Hyaluronic Acid
• Green Lipped Mussels

Of course there are many more, but making sure you have ALL your vitamins and minerals help. But play around and see what works best for you.

Finally, Rest – there are times when no matter what I do, my hands just start to feel tired. that’s the time when a little holiday is in order. No muss, no fuss, just rest the hands. Sometimes a long weekend is all you may need.

Listen to what your hands are telling you. Your livelihood just may depend on them.

As always, if you have any questions, comments or concerns please do not hesitate to contact me.

In Health,

Peter Roach, RMT, CNMT, Laser Therapist

Today I had the great pleasure of presenting an hour presentation to the introduction of Taping for Massage Therapists at the Utopia Academy of Massage Therapy. I felt a great sense of honor to be asked to present by a woman that has truly become a colleague that I look to for guidance, Annette Ruitenbeek, RMT, the Acting Dean of Education. It was also a very exciting time around the College as graduating students were finding out the results of their Board exams, making them RMT’s or not. One after another of the students were jumping for joy with the news that they were now joining one of the most amazing professions. Congratulations to all.

My talk was to introduce new RMT’s and students at the Academy alike the uses and benefits of Kinesiology Taping Methods within their practice. The lecture room was packed with students and facility, and I’m sure the group could see my sweaty armpits. However I think the information and introduction came off well.

I began with and introduction of the history of the tape, citing the Kinesio Taping concept developed in the 70’s by Japanese chiropractor Dr. Kenzo Kase, K Taping developed in Germany, SpiderTech taping developed in 1987 by Nitto Denko of Japan and Rock Tape developed in the US.

The common quality of all the tapes is that they all are an elastic tape that has similar properties as the skin. With most of the types of taping methods, training is available here in Vancouver. Through experience using the tape over the last three years, I’ve found some tapes stick better than others, and some of the tapes have different weaves, making them somewhat different to work with.

As explained in the demo, the benefits of using Tape in conjunction with treatment are vast. The elasticity of the tape is virtually the same with all tapes, up to 130‐140% of resting length. The adhesive used is 100% acrylic and heat sensitive. All tapes stretch  along longitudinal axis only, thereby making application very specific to each body part. The thickness and weight of all the tapes are also approximately the same as skin, thereby making the wearer of the tape virtually indistinguishable  between it and their own skin. Tape can be worn for several days, from 3 to 6 days before it comes off, and also tolerates showering, sweating and pool activities. The tape proprioceptively can educate a weak muscle through Arndt-Schult Law and effect structures below the surface via Hilton’s Law. It can also reduces pain through receptor feedback (Golgi tendon and the Gate Theory). We also discussed the challenges of using tape in a Massage Therapy practice. Of all challenges I see the 3 most specific being oils, time and cost.

The types of demonstrations I used were applications to the lumbar spine, specifically for lower back pain, and associated pelvic tilt situations. Shoulder applications to facilitate deltoid and rotator cuff as well as stabilizing the AC (acromioclavicular) joint. I also had planned to demonstrated applications for patello-femoral dysfunction and collateral knee stability however time had run out.

This was a very fun demonstration for me, and I can see that a weekend workshop specifically designed for Massage Therapists is needed. So stay tuned. Perhaps you will be in my next workshop.

As always, if you have any questions or concerns please do not hesitate to contact me.

In Health,

Peter Roach, RMT, CNMT, Laser Therapist

I am please to welcome Dave Campbell to our office.

Dave Campbell has been a Registered Massage Therapist since 1995. A graduate of the West Coast College of Massage Therapy, he has worked alongside chiropractors, physiotherapists and fitness trainers and spent several years in one of Vancouver’s top spas.

Dave uses neuromuscular therapy, fascial mobilization, and myofascial trigger point therapy to provide effective treatment for chronic pain and muscle tension.

How can Dave help you?

1. One-on-one individual attention every visit: One advantage of massage therapy over some other kinds of treatments is the undivided personal attention you receive for your entire treatment time. Your first visit includes a medical history and consultation interview, followed by a physical assessment and treatment plan. Subsequent visits will begin with a short checking-in to see how you responded to your previous treatment and to determine that day’s focus. At all times, your privacy and dignity are assured.

2. Attention to all parts of the body: The body is a single-functioning unit composed of a complex, three-dimensional collection of systems. Each system must be in balance for full function and well-being. The place where a pain is felt may not necessarily be where the restriction is located. While an individual treatment visit may focus on one specific region or system, attention is paid to restoring optimal function to the entire body.

3. Attention to all systems of the body: Consideration of blood flow, lymph drainage, respiration, quality of motion in tissue and joints, promotes a sense of well-being in and connection to the body.

4. Techniques of manual therapy provide drug-free pain relief: Massage Therapy integrates a variety of massage and other techniques – such as Swedish Massage, Neural-Muscular Therapy, Cranio-Sacral Therapy, Myofascial Mobilization, and Trigger Point Therapy – to address your specific needs.

5. It might take some time: Chronic pain and dysfunctions, especially those related to posture or repetitive strain, take time to develop. Some take months or years to become noticeable. By then the muscles, joints and other tissues will have adapted to an unhealthy way of being, and require retraining. This usually includes a combination of massage therapy, stretching and exercise to guide the body toward functional improvement. Don’t worry; you won’t be given anything you can’t handle or that can’t be done in your own home or workplace.

What do patients say about Dave. Have a look.

I feel very lucky to have discovered Dave’s talents as a massage therapist: After four or five sessions I now have complete mobility in my left shoulder.  What’s even better, I no longer wake up in the middle of the night in pain, my shoulder hurting because I had moved the wrong way in my sleep.  Dave not only provided the massage therapy… but he also gave me a number of exercises which would strengthen the muscles and help ensure that I did not reinjure the shoulder.
Joe B, Ph.D. – Vancouver BC (Client since 2010)

While rehearsing a professional play, I developed a very painful neck injury. The director and cast members recommended Dave Campbell. After his skilled treatment I was able to return to work without prescription drugs. A physician later confirmed certified massage therapy was the best treatment and my stage union insurance reimbursed costs. I’m nearing 70 and am happy to vouch for Renewed Balance services. 
Jason L. – Vancouver BC (Client since 2011)

He is an expert at understanding and fine-tuning the instrument that is a performer’s body. You can literally trust that you’ll be in good hands with Dave Campbell!
Lisa B. – New Westminster BC (Client since 2011)

Dave Campbell is simply the best when it comes to good RMT work! As a repeat customer I am very familiar with the long-term benefits Dave’s skillful hands are bringing to my body and general well-being. Thanks Dave!
Dean Paul G. – Vancouver BC (Client since 2011)

I do lots of lifting and carrying in my job and can always trust Dave to get rid of all the knots and kinks that crop up. He always finds the root of whatever particular problem I have and makes it disappear. I travel a lot in my job and have over the years visited other massage therapists, none of whom can match Dave. Whenever I’m home, I make sure to visit him. He really is the best.
Heather M. – Vancouver BC (Client since 2001)

I’ve run two marathons in the past few years, and couldn’t have done it without Dave! The pressure it puts on your body is extreme…and I am injury free. I believe it’s due to his extensive knowledge and years of experience. Any question about how your body connects, he can answer and explain in an accessible way. This translates into an excellent massage, with lasting results!!! If you’re looking for a wise use of your budget, Renewed Balance is the best in the city. Recommend without a doubt!!!
Natasha W. – Vancouver BC (Client since 2008)

I’ve been seeing Dave for years, and wouldn’t think about seeing anyone else.  His experience and knowledge are second to none, and he’s also a heck of a nice guy!  As a weekend warrior, stressed out computer operator, and aging boomer, I have received effective relief for neck, lower back, hip and leg pain/lack of mobility.
Deb W. – Vancouver BC (Client since 2005)

Dave Campbell has been a godsend in alleviating lower back muscle aches and tightness in my hips over the past five years -very knowledgeable in resolving muscle/fascia problems. After each session, I walk out of his RMT clinic as a new man!
Cole W. – Vancouver BC (Client since 2005)

Thank you Dave Campbell RMT for the great massages since 2001. If you want pain relief of muscles, tissues and body this is who to come to.
Grace K. Burnaby BC (Client since 2001)

Dave Campbell is also known as an actor and sound designer in the Vancouver theatre community. Here are some of his favorite roles and productions,

• The Pillowman – Wild Geese Co-Op February 2011
• Twelfth Night – What You Will Co-Op July 2010
• The Way of the World  – United Players September 2009
• Democracy – United Players June 2006
• Socrates on Trial – Vital Spark June 2008
• The American Pilot – Mentors Project October 2007

We are very fortunate to have Dave join us here at Bayswater. Please do not hesitate to give him a call and book an appointment with him. You’ll be glad you did.

In Health,

Peter Roach, RMT, CNMT, Laser Therapist

Treasure Island 2011

Summer time seems to be all but a fading memory. But I find that it is truly a time to run and play, and enjoy the weather. But as September begins and kids are back at school, I too feel that it’s time to buckle down.

During the summer you may have noticed that articles were a little sparse here on our home page. But definitely not forgotten. During the time on “Treasure Island” and various other camping trips all sorts or articles came to mind. I also had many suggestions from patients and colleagues alike. I invite you to send me any ideas or topics you which to have reviewed.

Here are some of the upcoming articles planned for the coming weeks.

• Gait Patterning and the Sassy Walk
• Stories on Healing
• When a patient doesn’t get better
• Kitchen Table Wisdom – a book reveiw
• Massage Therapist Hand care
• Regroving Old patterns
• Faster healing and Cortisol release
• Laser Therapy

Please keep the suggestions coming, and know that I’m back hard at it, both in the office and here in front of the computer.

In Health,

Peter Roach, RMT, CNMT, Laser Therapist

January 14th, 2008 at 10:00 am I stood before the Board of the BC College of Massage Therapists (BCCMT) with my presentation in hand. I was there to explain and defend our use of Low Intensity Laser Therapy (LILT) under the umbrella of modalities we can use as Massage Therapists. After an hour and half, I wrapped up. They would be in touch. Approximately a week later I received a phone call from the BCCMT that they had approved the use of LILT in a Massage Therapy practice.

We have been using LILT in conjunction with our Massage Therapy since that time, with success after success stories. However on approximately Aug 17th, I received a letter from the BCCMT that stated “the clinic will cease offering or providing any laser therapy services to your massage therapy clients …” Nice to come come back from holidays to this!

Compliant to the BCCMT we have discontinued further use of the Laser Probe until investigation has been completed. However I am bewildered that an approval of Laser Therapy in a Massage Therapy practice has come to a cease order from the same College.

At this point we are awaiting contact by an investigator into our usage of LILT. We have discontinued the use of the Laser Probe, but in the mean time have resurrected our argument with regards to this type of modality.

The following is a paper written by J. Dais, July 2009, on the examination of LILT that was presented to the BCCMT. I present this to you for your understanding of LILT and it’s uses, effectiveness and safety of this modality. I would encourage you to read this over and please send me your thoughts about this subject.

Times are changing, technology is changing at a rapid pace. I accept the fact that there are many modalities that are outside our scope of practice as Massage Therapists, but the use of actiotherapy (light therapy), and all it’s advancements since I graduated in 1984 is huge. As a profession we need to keep up with advancements, holding on to our ancient ways of healing, but accepting new ways that help our patients.

Brian Milley of Meditech offered this information:

-          The College of Massage Therapists of Ontario has specifically approved the use of laser therapy as long as you obtain proper training to use it, such as our training seminar http://www.cmto.com/member/CEUNewGuide.htm (see category B)
-          The MTAA, while unregulated, teach laser therapy in their schools.  If you attend such a school, you are able to use Laser Therapy
-          MTAS is like Ontario.  If you do the training, you can use the treatment http://www.saskmassagetherapy.com/?page=1077 .  With a note that you need to make sure you have liability coverage for it.  In many cases in Saskatchewan, before Chiropractors were allowed to use Laser Therapy (they can now), they put the laser business in their massage therapist’s name.
Also approved in Nova Scotia http://www.mtans.com/CEU/CEU.php

Please read the following paper and offer some feedback. The progress of our profession teeters on decisions like this.

Read in it’s full entirety at http://www.bayswater.ca/PDF’s/BCRMTlow_level_laser_therapy.pdf

LLLT Position Paper p. 1 J. Dais, July 2009

Low Level Laser Therapy Position Paper for the CMTBC: An Examination of the Safety, Effectiveness and Usage of Low Level Laser Therapy for the Treatment of Musculoskeletal Conditions

1. Introduction
2. What is Low Level Laser Therapy?2.1. Characteristics of Low Level Lasers
   2.2. Laser Classification
   2.3. Classifications of Some Lasers Sold in Canada
3. Laser Safety
   3.1. Approval of Lasers
   3.2. Safety of Equipment
   3.3. Calibration of Equipment
   3.4. Training of Laser Therapists
   3.5. The Question of Cosmetologists/Estheticians 3.6. Contraindications
   3.7. Low Level Laser Therapy Safety Literature
4. Low Level Laser Evidence for Effectiveness
   4.1. Comments on Past Criticism of the Literature 4.2. Examples of Conditions that Benefit from LLLT4.2.1. Carpal Tunnel Syndrome 4.2.2. Fibromyalgia
   4.2.3. Frozen Shoulder
   4.2.4. Lymphedema post-mastectomy 4.2.5. Myofascial Pain Syndrome 4.2.6. Osteoarthritis

   4.2.7. Pain
   4.2.8. Rheumatoid Arthritis
   4.2.9. Temporal Mandibular Joint Syndrome (TMJ)
   4.2.10. Tendinoses – Lateral Epicondylitis and Achillis Tendinosis 4.2.11. Animal Studies

5. Conclusions
6. Literature Cited

INTRODUCTION

The purpose of this position paper is to provide the Scope of Practice (SOP) Committee of the College of Massage Therapists of BC with current information about the safety, effectiveness and usage of Low Level Laser Therapy (LLLT) for the treatment of musculoskeletal conditions

LLLT Position Paper p. 2 J. Dais, July 2009

in order for the SOP Advisory Panel to be adequately prepared to address the scope of practice of RMTs in relationship to laser therapy as well as light therapy and therapeutic ultrasound.

The BC Massage Therapy Regulation limits the scope of practice of massage therapy through specific prohibition of the use of “medical electricity”, especially “hazardous” forms of energy which the Council states includes (therapeutic) ultrasound, electricity (TENS) and laser (LLLT). However, research studies over and over again report that LLLT is safe with no side effects and thus could be considered “non-hazardous”. Among the many LLLT benefits relevant to massage therapists are a reduction in pain and an increased rate of healing.

In the past, clinical trials looking at the effectiveness of LLLT have often been poorly designed and any benefits seen have been discounted in systematic reviews. However, recently published studies indicate that LLLT is quite effective for a number of musculoskeletal conditions. Furthermore, two Cochrane systematic reviews that initially discounted the effectiveness of LLLT because of poor study designs have been withdrawn in light of the new evidence.

Finally, the use of LLLT is within the scope of practice of a number of regulated professional groups including Physiotherapists, Athletic Therapists, Naturopaths, Chiropractors, Acupuncturists, Medical Doctors, Dentists, Veterinarians and Estheticians, but not Massage Therapists. Also, Registered Massage Therapists in Ontario are permitted to use LLLT in their practice. More interestingly though is the fact that anyone can purchase a low level laser for the treatment of musculoskeletal conditions and use it without the supervision of a trained professional.

Because LLLT is a safe and effective method of enhancing the healing process and reducing pain, it is easy to see why RMTs would want to incorporate its use into their practice.

WHAT IS LOW LEVEL LASER THERAPY?

Low Level Laser Therapy (LLLT) is also known as Low Intensity Light Therapy (LILT), cold laser, phototherapy, light therapy, low-energy laser therapy, photobiomodulation among other

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terms (Meditech/BioFlex). Laser is an acronym for “Light Amplification by Stimulated Emission of Radiation”.

The radiation referred to is electromagnetic radiation which travels in waves of photons and different types of electromagnetic radiation possess different wavelengths and thus different intensities. Electromagnetic radiation includes everything from very short, ionizing gamma rays (given off by nuclear weapons), x-rays, ultraviolet rays, as well as non-ionizing visible light, infrared waves (heat), and very long radio waves. Ionizing radiation damages cells through the breakage of bonds, while non-ionizing radiation does not. High intensity wavelengths generate heat.

Lasers produce a small, concentrated, monochromatic (one wavelength) beam of electromagnetic energy which concentrates the wavelengths in one area. The range of wavelengths of electromagnetic radiation varies between types of lasers and spans the spectrum of visible light and includes infrared light as well (Robertson, 2006). Different manufacturers claim that their products give off more effective wavelengths that others and they often patent their wavelength.

Laser radiation can be absorbed, reflected and refracted just like any type electromagnetic radiation including visible light. The monochromatic beam passes unaltered through air, but when it hits liquid the electromagnetic radiation it is altered. For example, when it hits tissue the radiation can be absorbed by the cells (Robertson 2006).

Characteristics of Low Level Lasers

Typically, lasers used for therapeutic purposes fall in the red and near-infrared ranges of electromagnetic radiation and thus in the non-ionizing range. The wavelength range for red light is 630 – 700 nm and the range for near-infrared radiation is 700 nm to 1 mm. Therapeutic lasers use these wavelengths because other wavelengths are absorbed by melanin pigment in skin, hemoglobin in blood or water in the tissues and thus don’t reach the mitochondria of the targeted tissues. In addition, studies have shown that wavelengths in the red through near-infrared spectrum (630-900 nm) are best absorbed by the iron or copper atoms associated with the cytochrome system in mitochondria for ATP production (more about this later) (Meditech Physics Presentation DVD).

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With true lasers, the intensity of the light remains consistent even when the source of the beam is moved away from the target; a characteristic called coherence. The wavelengths of light from light emitting diodes, or LED lasers, spread out in all directions when pulled away from the target (non-coherent) and are thus thought to not penetrate tissue as well. However, these types of “cold lasers” do not give off heat and can be held directly against the skin. More powerful lasers can give off heat; even enough heat to cut tissue and damage the retina.

Laser Classification (US FDA)

Lasers are classified based on these different properties (coherence of the beam, depth of penetration, wavelength) as well as their power, duration of the “on time” when pulsed, and their effect on the eye.

• Class 1 lasers (for example barcode readers and some types of LED or super-luminous diode therapeutic lasers) do not affect tissues, have the lowest power rating and eye protection is not required for their use.
• Class 4 and 5 lasers at the other end of the laser spectrum are surgical lasers that cut tissue. They are very high powered and must be used under extreme precautions.
• Laser pointers for classroom use are usually class 2 or 3A lasers with a relatively low power rating, but can cause temporary visual disturbance when pointed at eyes.
• Some therapeutic lasers are classified class 3B and as mentioned with laser pointers, the beam could affect the eyes and protective eyewear should be worn. The class 3 infrared wavelengths A and B refer to near infrared or short wavelengths (A) and far infrared or long wavelengths (B). Class 1, 2 and 3(A and B) lasers do not harm tissue (Robertson, 2006). They are also considered the best balance of power output (less than 500mW) and safety (ChiroEco, 2005).Thus, therapeutic lasers that fall into class 1 do not harm tissue and do not affect the eyes. The document covering the use of lasers for laser hair removal states that “class 1 lasers cannot emit harmful accessible radiation levels and are exempt from all control measures” (Laser Hair Removal Guidelines).

  Therapeutic lasers that fall into class 3B do not harm tissue, but protective eyewear is necessary for the therapist and the client. Some companies (Meditech/BioFlex) have built in safe-guards to prevent the class 3B laser probes from turning on unless they are pressed right on the skin surface.

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There are two types of therapeutic lasers typically used for the treatment of musculoskeletal conditions. The first type are helium-neon lamps that give off a visible red light with a wavelength range of about 630-700 nm. The second type of therapeutic laser is the light emitting diode (LED) laser which is a semi-conductor laser made from gallium and aluminum arsenide (GaAlAs). They give off electromagnetic radiation wavelengths that range from 630nm (red light) to 1550nm (infrared light or heat). Sometimes several smaller laser diodes are grouped together to form larger emitters or cluster probes to treat larger areas of the body (Robertson, 2006). When the wavelengths are in the near-infrared range (700 nm-1 mm), the laser is considered at class 3B laser device. A company’s LLLT device may contain these two separate types of lasers utilizing the red light and near-infrared light benefits.

Other relevant features of therapeutic lasers that relate to safety are their power (rate at which energy is produced and range from 250-1500W), their output power (related to the class of laser with class 1 having the lowest) wavelength of light beam, and pulse lengths. Note that the input power entering the device, is not indicative of the output power. The output power is in the milliwatt (mW) range while the input is 1000 times greater and of course could cause damage.

It is important to note that with higher power outputs (that could cause tissue damage) the beneficial effects are lost. More power does not mean faster healing. Thus most therapeutic lasers have a power output of 500 mW (those for home use are usually much lower). Because the power output is relatively low at 500 mW or less, therapeutic lasers are also known as cold lasers because they do not give off enough thermal energy to heat up the tissue being treated. (Q Laser). The Mediflex/Biotech laser diode has a output power of 180 mW and the superluminous LED has a power of 8.5 mW (Meditech physics presentation), definitely falling into the cold laser category.

Wavelengths likely to penetrate tissues deeper than the skin range from 650 nm to 1500 nm (Robertson 2006). For example, BioFlex uses 660nm, 830 nm and 840nm to maximize the absorption of light by different molecules. The red light wavelengths (660 nm) are more likely to be absorbed by other molecules and thus do not penetrate deeply versus the near-infrared wavelengths of 830 and 840 nm (Meditech/Bioflex Presentation). This 830 nm wavelength seems to be used by a number of different products (Meditech, MicrolightLaser) however one

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company, Theralase, has a laser with a 905 nm wavelength that gives a 4 inch depth of penetration (http://www.theralase.com/brochures/tlc%201000%20-%20sell%20sheet%20– web.pdf).

Low level lasers are thought to promote healing and reduce pain possibly through the reduction of inflammation. Healing may come about by increased cell proliferation. Gao et al. (2009) reviewed the LLLT literature to look at the effects on tissues (human and other systems) at the cellular level. They found evidence supporting laser-induced proliferation of different cell types such as fibroblasts, muscle cells, osteoblasts and keratinocytes (skin cells) and came up with a mechanism of action. “Low power laser irradiation (LPLI) promotes proliferation of multiple cells, which (especially red and near infrared light) is mainly through the activation of mitochondrial respiratory chain and the initiation of cellular signalling”. Dosage is also very important; too much and the effect is lost.

Classifications of Some Lasers Sold in Canada

Class 1 laser diodes sold in Canada that should be deemed safe and effective. Meditech/BioFlex lasers: first two stages of treatment (http://practitioners.meditech- bioflex.com/laser-therapy/choosing-a-laser-therapy-system.php)
Q1000: http://www.21stcenturyhealing.com/coldlasertherapy/safety.html)

Class 3B (that may harm the eyes)
Meditech/BioFlex lasers: (http://practitioners.meditech-bioflex.com/laser- therapy/choosing-a-laser-therapy-system.php) third stage of treatment Theralase: TLC-1000 (http://www.theralase.com/brochures/tlc%201000%20- %20sell%20sheet%20–web.pdf)
PainThor Photomedicine system (http://www.painthor.com/the-package.html) Terraquant (http://www.terraquant.org/)

LASER SAFETY
Approval of Lasers
Any laser sold in Canada must be approved by Health Canada. This information is usually included on the laser manufacturer’s website such as for the BioFlex Laser sold by Meditech The Meditech website states that “Meditech manufactures BioFlex Systems under the ISO 13435 quality system, which meets the requirements of Health Canada, the FDA and the EEU (CE Mark)” and that “Meditech holds permission to market BioFlex Systems in Canada under a

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Canadian Device Licence” (http://patients.meditech-bioflex.com/equipment/bioflex-home-laser- therapy-equipment.php). Theralase even includes their Health Canada Certificate on their website (http://www.theralase.com/certificates/healthcanadacertificate.pdf). Their model, the TLC-1000, is a class 3B laser diode. The US FDA’s guidelines for laser devices distributed for human (and animal) treatment state that lasers must meet Mandatory Performance Standards which include “safety features and labelling to provide adequate safety to users and patients”. Thus, FDA certification of the laser devises means that it has “passed a quality assurance test and that it complies with the performance standard” (FDA Laser Information, 2009).

Many jurisdictions (PEI, Saskatchewan) do not regulate LLLT and this means that individuals other than regulated practitioners can purchase and use lasers for the purpose of laser therapy. The Health Professions Act of Alberta does not include laser therapy as a restricted modality and this has been interpreted to mean that individuals other than regulated practitioners can use them (FAQ on Lasers Alberta).

The Ontario Act even explicitly permits Massage Therapists to use low intensity laser therapy (http://www.cmto.com/regulations/ModComplementSecA.htm).

The US FDA points out that individual states regulate who can use lasers for various therapeutic procedures. Medical lasers are prescription devices available for sale only to licensed practitioners. They recommend that these individuals check with their state medical licensing board to determine who qualifies as a licensed practitioner in your state (FDA Laser Information).

One thing to note, therapeutic lasers are typically approved by Health Canada and the US FDA for the treatment of very specific conditions such as carpal tunnel pain not pain in general. Thus a laser that has received approval, has usually done so for the treatment of usually one condition. For example, the first laser approved by the FDA for home use is the Q1000 specifically to treat osteoarthritis, of the hand (ChiroEco, 2009). This is a Class I laser device and the FDA approved it because there is no risk of harm to the eyes.

Safety of the Equipment

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Concerns about the dosage of lasers have been addressed by the various manufacturers. In the past, researchers have reported that lasers did not perform as expected, but the problem was that they underperformed. In one 1999 study, 60% of laser diodes and 31% of superluminous diodes were within 1 to 79% of the expected levels of power – an unacceptable range (Robertson 2006).

Improvements have been made to maintain consistent output. The Meditech/BioFlex website states that “the BioFlex system has both an internal feedback loop that directly measures the quantity of light being emitted and a feedback loop that measures the current within the device to ensure proper dosage” (http://practitioners.meditech-bioflex.com/laser-therapy/choosing-a-laser- therapy-system.php). Also with the Meditech/BioFlex class 3B laser probe that is used in the last stage of treatment, the beam can only be engaged when the tip of the probe is pressed against the tissue (personal communication Milley).

Calibration of Equipment

Calibration and monitoring of the equipment is required by Health Canada and the US FDA. Meditech recommends that the equipment be shipped back to every 20-22 months for a calibration check and adjustment if necessary at a cost of $100 per system plus shipping (Bryan Milley, personal communication). There are also private laser safety companies that can test equipment shipped into them (http://www.laserproductsafety.com/)

Training of Laser Therapists

Health Canada requires that everyone operating a laser device be properly trained. The Matrix Institute for Laser Therapy provides laser therapy training to healthcare professionals who are licensed in their field: Medical Doctors, Psychologists, Chiropractors, Dentists, Nurses, Naturopathic Doctors, Oriental Medicine Doctors, Dieticians/Nutritionists, Physiotherapists Acupuncturists, Reflexologists, Medical Technologist or Clinical Laboratory Scientist, Medical Assistants, Massage Therapists, Sports Medicine, Estheticians/Cosmetologists. They do note however that “it is the sole responsibility of the students practicing Laser Therapy to comply with Federal and State laws” (http://www.matrixths.com/whocantrain.aspx). With Meditech/BioFlex lasers, training is required for each clinic operating a laser system. They provide certification for those operating their laser devices once they have completed the training

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(Bryan Milley, personal communication). This company seems to be the most aggressive at marketing in Canada and has offered training courses in BC for various professionals. The Theralase website includes good training videos (http://www.theralase.com/sub.php? lasertherapy=15) .

Note that in BC, some Registered Massage Therapists are advertising that they are also Certified Laser Therapists and other RMTs are advising their clients/patients on the best use of their home lasers for the treatment of conditions.

The Question of Cosmetologists/Estheticians

At a minimum, class 1 lasers have been approved for home use, so anyone can buy them. But who else can use lasers? As noted above, a number of regulated health care professionals with many years of college or university training can use lasers as a part of their scope of practice. But so can cosmetologists and estheticians in British Columbia and they have significantly less education than any of these professionals as well as registered massage therapists . An example of the requirements to become a licensed cosmetologist in BC would be the Northern Lights College. It has a 10 month program and the entry requirement is 67% or higher in Grade 10 English, Math and Science (Northern Lights). They can then write the Cosmetology Industry Association of British Columbia Certificate of Qualification exam and then be eligible to take a LLLT certification course and not only use LLLT themselves, but oversee unlicensed, uncertified staff who use the equipment. They are deemed safe with only 10 months of school and without necessarily graduating from high school. (Note that the entry requirements for massage therapy colleges in BC require high Grade 12 graduation with English 12 and Biology 11 and/or 12 is highly recommended. The programs are approximately 3000 hours (Okanagan College). Also note that the BC Government deregulated the Cosmetology Act as of December 31, 2003 (http://www.ciabc.net/exams.html).

Cosmetologists or estheticians use class 3B lasers (and even class 4) for laser hair removal or tattoo removal. Class 4 labels can damage the skin and are considered hazardous.

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There are a variety of laser systems on the market that have a number of different applications. Lasers purchased by estheticians also have other capabilities such as pain management: Harmony Laser system by Alma (http://www.almalasers.com/harmony_xl.jsp) , Q1000 laser (http://www.stumblingglass.com/hygiene-health/article3027.htm) , Theralase (http://www.theralase.com/brochures/tlc%201000%20-%20sell%20sheet%20–web.pdf) all of which have the capability of modifying the wavelength and power output to treat pain and inflammation. This is even clearly stated on their websites. All an esthetician has to do is order the appropriate probe and change the setting and then they can treat patients with knee pain. (Note that I have received anecdotal accounts of this practice told to me in confidence!)

Contraindications

Although the literature doesn’t mention any adverse effects, some websites associated with the sales of therapeutic lasers or sites for laser therapy do mention some possible side-effects. The Canadian Laser Therapy’s website indicates that “there are two basic contraindications: patients on photoactive medication and women in their first trimester of pregnancy” (Canadian Laser Therapy). Meditech/BioFlex also lists tattoo surfaces as a contraindication as the pigments in the tattoo could absorb heat and possibly lead to burning of the skin. They also recommend setting changes darker skin tones (Meditech/Bioflex).

MicrolightLaser® therapeutic laser system website also refers to other possible contraindications. Here is the excerpt:

1. PACEMAKERS – While some have suggested caution in using LLLT in the presence of pacemakers, no evidence has been presented. Because LLLT uses light, no influence on the pacemaker results from its use.
2. EPILEPSY – Pulsed visible light can have an effect on certain individuals susceptible to this condition, however, invisible, non-pulsed laser light (as is provided by the ML-830) has had no reported detrimental effect on seizure-susceptible patients.
3. DIABETICS – While this has been suggested as a contraindication, no evidence has been found to show that LLLT could aggravate symptoms. In fact several studies have shown dramatic improvement in healing of wounds of diabetics with LLLT.
4. CHILDREN – The concerns originally expressed for use of LLLT near growth plates in children have been found to be unwarranted. No detrimental bone growth effect has been documented, and in fact, LLLT in children has been found to be beneficial in pediatric fractures. (http://www.westwood-clinic.com/LaserTherapy.html):

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Laser Light Therapy Canada’s website gives a list of contraindications for the use of their Diobeam 830 model (http://www.laserlightcanada.com/).

Do not

• • • • •

• • • •

treat:
Directly into eyes (retinal exposure to Class 3B laser may cause eye damage)
Over a pregnant uterus
Over any suspicious lesion or cancer
Over thyroid gland
Over an area injected with steroids or other anti-inflammatory medication in previous week
Someone hypersensitive to light in the 830nm wavelength region
Patients with seizure disorders triggered by light
Patients taking medications for which sunlight exposure is a contraindication
Over open wounds or herpes simplex unless unit covered with a clear protective barrier

Finally, the Chiropractic Clinical Guidelines for evidence-based treatment of adult neck pain not due to whiplash mentioned risk factors that are absolute contraindications to cervical low-level laser therapy: “Cardiovascular disease, hypertension, coagulopathy, ulcer, recent severe hemorrhage, renal insufficiency, severe hepatic disease, neoplasia, epilepsy, cutaneous pathology, pain of “central” origin, pregnancy” (Peacock et. al. 2005).

Low Level Laser Therapy Safety Literature

I didn’t find a single published study that reported adverse effects associated with the use of any of the classes of therapeutic laser. Here is a sampling of the many papers that reported no side effects to LLLT. Yousefi-Nooraie et al. (2007) in their Cochrane Review of LLLT for nonspecific low-back pain reported that none of the seven studies with a total of 384 people reported any side-effects with the use of low level lasers. Similarly, the Brosseau et al. (2005) Cochrane review of the effects of laser therapy for rheumatoid arthritis reported no side in the 5 placebo-controlled trials they examined (222 subjects, 130 of which received laser therapy).

In a RCT by Dundar et al. (2007) to study the effect of the GaAsAl low level laser on myofascial pain syndrome, laser therapy was found to be no more effective than the placebo but the authors indicated that no side-effects were observed! Gur et al (2002) also reported no side effects in their randomized, single-blind, placebo-controlled study to examine the effectiveness of LLLT for fibromyalgia. The study included 40 subjects and a Ga-As laser was used.

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LASER EVIDENCE FOR EFFECTIVENESS
Comments on Past Criticism of the Literature
Prior to mid-2008, the evidence to support the use of LLLT for tissue healing (such as muscle tears, hematomas, tendinopathies) and pain control has been questionable. Three LLLT
Cochrane Reviews, one for the treatment of low back pain (Yousefi-Nooraie et al. 2008), one for the treatment of rheumatoid arthritis (Brosseau et al. 2005) and one for the treatment of osteoarthritis (Brosseau et al. 2007) concluded that the methodologies of most of the randomized, controlled clinical trials were poorly designed. However, in recent months two of these reviews have been withdrawn. In the case of Brosseau’s 2007 review of LLLT for osteoarthritis there were two reasons for withdrawal including “comments received have suggested the presence of a substantial number of additional trials claiming positive results that need to be reviewed, and that, if eligible, could affect the (previously unfavorable) conclusions.” One of these studies by Hegedűs et al. (2009) just came out in the last month.

It was also concluded by Brosseau et al. (2005) that:

“Clinicians and researchers should consistently report the characteristics of the LLLT device and the application techniques used. New trials on LLLT should make use of standardized, validated outcomes. Despite some positive findings, this meta-analysis lacked data on how LLLT effectiveness is affected by four important factors: wavelength, treatment duration of LLLT, dosage and site of application over nerves instead of joints.”

Cochrane systematic reviews and other systematic reviews are often the basis for the decisions of medical insurance companies to provide coverage for a treatment. But what if these systematic reviews are invalid? Bjordal et al (2005) criticized the Cochrane review process in regards to their systematic review of LLLT for the treatment of rheumatoid arthritis. Note that Bjordal was lead author in a systematic review of LLLT for elbow tendinopathies – not a Cochrane Review (Bjordal et al. 2008) and thus has some experience in the area. Bjordal et al. looked at the validity of this Cochrane review by testing it against a nine-item checklist for systematic reviews. One of the key findings was that the review group only included clinicians who had previously performed LLLT trials that failed to find any benefits of LLLT. The review group also included data from questionable studies which produced results that “systematically favored the negative review conclusion”. It was concluded that the rheumatoid arthritis Cochrane review was not

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valid and Bjordal et al. suggested that in the future there should be “representation of experts and different views on efficacy in the review group and extensive use of sensitivity analyses could probably improve quality control of reviews in areas of controversy”.

Based on these negative Cochrane reviews, medical insurance companies refused to reimburse for low level laser therapy. Cigna’s latest Medical Coverage Policy (Cigna 2009) document states:

“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. Large, well-designed clinical trials are needed to demonstrate the effectiveness of LLLT for the proposed conditions.” (Cigna 2009)

Although the Cigna policy included a fairly extensive reference list, their reference for the Cochrane Review on LLLT for osteoarthritis was dated 2005 suggesting they were unaware of the 2007 update or the withdrawal of that 2007 review (which incidentally was available on PubMed prior to the July 15, 2009 effective date of the policy).

Critics of LLLT research studies, especially medical insurance companies that require a huge burden of proof before they will cover something new, will focus on a phrase commonly included at the end of RCTs; the authors often recommend that more research is needed, especially trials with larger sample sizes. This is common practice in all health science research especially if the clinical trial in question was the first to be carried out for a particular treatment or condition. The goal is to ensure external validity by having other independent researchers attempt to repeat the study and hopefully achieve the same outcomes. Additionally, when future researchers (including the authors of the original study) want to perform another study in the same general area, it supports their funding application to reference past studies that recommend further research be done.

Examples of Conditions that Benefit from LLLT

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Among the many benefits associated with LLLT are a reduction in pain and an increase in range of motion (osteoarthritis, TMJ, myofascial pain syndrome of the neck), an increased rate of healing for a number of tendinopathies including Achilles tendinosis/itis and lateral epicondylitis, reduce lymphedema post mastectomy, decreased symptoms of carpal tunnel syndrome (paresthesia and numbness) with increased grip strength and finally reduced creatine kinase

levels with pre-treatment before vigorous exercise.

Carpal Tunnel Syndrome

In a review of 7 laser therapy clinical trials using photoradiation to treat carpal tunnel syndrome (CTS) Naeser (2006) reported that the 5 studies that demonstrated low level laser therapy was effective at reducing pain used a higher power than the 2 that did not show a benefit over the control group. A more recent, better designed study involving 80 subjects and a sham laser control group concluded that LLLT reduced the carpal tunnel syndrome symptoms of paresthesia and numbness as well as improved hand grip and electrophysiological parameters (Shooshtari, 2008). Evick (2007) found that LLLT over the carpal tunnel area improved hand and pinch grip strength and Chang (2008) concluded that the same thing plus that LLLT alleviated carpal tunnel syndrome pain and symptoms.

Fibromyalgia

A single-blind, RCT with 40 female subjects was conducted to see if LLLT could reduce the symptoms of fibromalgia (Gur et al. 2005). Those in the control group received placebo laser while the treatment group received a Ga-As laser treatment daily for two weeks (excluding weekends). The author’s concluded that laser therapy was a safe and effective way to relieving pain, muscle spasm, morning stiffness, and total tender point number associated with fibromyalgia.

Frozen Shoulder

A preliminary RCT with 63 subjects examined the effects of LLLT on frozen shoulder. The control group received placebo laser and the active laser group was treated with a 810-nm Ga- Al-As laser with a continuous output. The author determined that there was a significant

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decrease in pain and disability in the treatment group versus the placebo control group (Stergioulas 2008).

Lymphedema – Postmastectomy

Kozanoglu et al. (2009) reported positive effects with low level laser therapy for the reduction of limb size and pain with of patients with postmastectomy lymphedema. Also the benefits of LLLT lasted longer than pneumatic compression, the usual treatment and the control in this study.

Myofascial Pain Syndrome

Low level laser therapy has also been used to treat myofascial pain syndrome of the neck (Gur et al. 2004). In this double-blind RCT with 60 subjects, treatment with a Ga-Ar laser (904 nm) resulted in reduced pain, improved function and improved quality of life as compared with the placebo laser control group.

Osteoarthritis

In response to Brosseau et al.’s (2007) Cochrane Review (discussed earlier) that criticized the methodology of past low level laser therapy studies on the effects of osteoarthritis, Hegedűs et al. (2009) performed a double-blind, RCT which was just published this June. They concluded that LLLT for osteoarthritis of the knee reduces pain and increases microcirculation in the treated area. Also a systematic review of the literature by Jamtvedt (2008) examined various physiotherapy interventions for osteoarthritis of the knee and noted that there was high quality evidence that exercise and losing weight can reduce pain, but that there was also moderate- quality evidence that low-level laser therapy can do so as well (along with TENS and acupuncture).

Pain

In a review of 22 RCT involving the biological and clinical effects of photoradiation (LLLT) in acute pain to due soft tissue injury Bjordal et al. (2006) reported that in 19 of 22 studies that photoradiation reduced inflammatory pain in the subjects. They looked at a variety of biochemical markers, neutrophil numbers, formation of edema and hemorrhage. They

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commented that adequate dosage was important to see an effect. In a small study by Junior et al. (2009) eight subjects received pretreatment of the rectus femoris muscle by an LED multi-diode or cluster laser before undergoing high-intensity exercise. They found that the subjects had significantly lower levels of post-exercise creatine kinase (CK) compared to the placebo cluster group and the active single-diode laser group. However, other outcome measures were not affected (Wingate tests and post-exercise blood lactate). In a systematic review of non-invasive therapies for neck pain, Hurwitz et al. (2008) stated that for neck pain other than whiplash, the evidence suggests that low-level laser therapy was more effective than no treatment or sham treatment. In a study of general knee pain, Montes-Molina et al. (2009) reported that interferential laser therapy (using two identical laser probes located opposite each other on the knee joint) was no better than the conventional method of just one laser probe over the affected area.

Rheumatoid Arthritis

Brosseau et al.’s (2005) Cochrane Review of the effects of LLLT for rheumatoid arthritis, reported that it reduced pain and morning stiffness with a minimum four-week treatment program, but other clinical findings were inconsistent. Yamaura et al. (2009) investigated the mechanism behind how LLLT reduced joint pain in rheumatoid arthritis. They concluded that it may involve “reducing the level of pro-inflammatory cytokines/chemokines produced by synoviocytes. This mechanism may be more general and underlie the beneficial effects of LLLT on other inflammatory conditions”.

Temporal Mandibular Joint Syndrome (TMJ)

Thirty-five subjects were assigned to either the treatment group receiving LLLT along with a daily exercise program or the placebo group which just followed the exercise program. Significant improvement in TMJ symptoms were obtained in the treatment group that received LLLT both in “subjective parameters such as pain and number of tender points, as well as in objective functional parameters such as mouth opening and lateral motions”. The placebo group only experienced pain reduction (Kulekcioglu, 2003).

Tendinosis – Achilles Tendon

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In an RCT of 52 recreational athletes with chronic Achilles tendinopathy, low-level laser therapy combined with an eccentric exercise regimen was shown to accelerate clinical recovery (reduce pain intensity during exercise post-treatment) compared to eccentric exercise (EE) alone. The results at 4 weeks were similar to the EE group lacking LLLT at 12 weeks (Stergiolas 2008).

Tendinosis – Lateral Epicondylitis

The authors of more recent publications have taken the advice of systematic reviewers into consideration and have used more rigorous methodology in their studies. A case in point is the recent evidence regarding the treatment of lateral epicondylitis (tennis elbow or lateral elbow tendinopathy) with LLLT. Past studies were weak leading to systematic reviews drawing the conclusion that laser therapy wasn’t effective. However, recent findings by authors such as Shooshtari (2008) who’s study involved 80 subjects and a sham laser control group concluded that LLLT reduced the carpal tunnel syndrome symptoms of paresthesia and numbness as well as improved hand grip and electrophysiological parameters. This had lead to the most recent systematic review by Bjordal et al (2008) concluding that LLLT “administered with optimal doses of 904 nm and possibly 632 nm wavelengths directly to the lateral elbow tendon insertions, seem to offer short-term pain relief and less disability in lateral elbow tendinopathy, both alone and in conjunction with an exercise regimen”. The authors also state that “this finding contradicts the conclusions of previous reviews which failed to assess treatment procedures, wavelengths and optimal doses”.

In a RCT comparing LLLT to bracing and ultrasound in the treatment of lateral epicondylitis, 68 subjects were divided into the 3 groups (with subjects in each group also performing exercises throughout the study). The authors concluded that laser therapy was more effective at reducing pain than the brace, had a longer lasting effect than the brace and was more effective at improving grip strength than the brace or ultrasound treatment.

Animal Study – Myofascial Trigger Points

In an animal study by Chen et al (2008) eight rabbits with one myofascial trigger point in each biceps femoris muscle were treated on one side with a gallium-aluminum-arsenate (GaAlAs) laser (six treatments with a wavelength of 660-nm, continuous-wave, at 9 J/cm2). The contralateral side received a sham laser “treatment”. The end-plate noise recorded by the

LLLT Position Paper p. 18 J. Dais, July 2009

electromyograph was significantly reduced on the laser treated side post-treatment. The author’s concluded that “laser irradiation may inhibit the irritability of an myofascial trigger point in rabbit skeletal muscle. This effect may be a possible mechanism for myofascial pain relief with laser therapy.”

CONCLUSIONS

Many of my findings correspond to those of found in George Bryce’s Hazardous Energy Reserved Act for Physical Therapists: Implications for Massage Therapists and other Health Professions. I am at a loss to figure out why his comments were ignored back in 2003. One of the biggest issues was that the distinction wasn’t made between the different types of lasers on the market and their risk of harm; there is clearly a difference between lasers that harm tissue and those that don’t.

1. Low level lasers require electricity for function, but give off wavelengths of red light or infrared light. Thus they are not considered to conduct electricity into the body (unlike TENS machines).
2. Class 1 lasers do not harm the eyes. They also do not produce heat and thus do not harm tissue.
3. Although Class 3B lasers can harm the eyes (thus goggles are recommended), most brands (including Meditech/BioFlex) include safety precautions that prevent accidental exposure. Also, Class 3B laser devices are in the low output power range (below 500 mW) so do not give off heat. If they do not give off heat, they cannot damage tissue in the treatment area. (Note that highly focused class 3B lasers used by cosmetologist for laser hair removal can harm tissue.)
4. There are a number of possible contraindications to LLLT, especially class 3B lasers. A definitive list should be developed.
5. Low level lasers function by providing electromagnetic energy to energy systems within cells to increase cell proliferation and reduce inflammation. Many well designed RCTs support this effect by LLLT for the treatment of many musculoskeletal conditions as do animal studies. There is evidence to support the use of class 3B lasers in the treatment of tendinoses, knee pain, lymphedema post-mastectomy, rheumatoid arthritis, TMJ, osteoarthritis, fibromyalgia, and carpal tunnel syndrome. Most of these rigorous studies have been published just in the last year.

LLLT Position Paper p. 19 J. Dais, July 2009

1. Cochrane systematic reviews have previously criticized LLLT research and thus claimed the evidence did not support its effectiveness in the treatment of osteoarthritis and low back pain. These two Cochrane reviews have recently been withdrawn in light of new evidence.
2. Critics of LLLT research studies will focus on the typical authors’ statement at the end in the conclusion that recommends that further larger clinical trials should be carried out. This is common practice in all health science research especially if a clinical trial was the first in a particular research area. The goal is to ensure external validity by having other independent researchers attempt to repeat the study and hopefully achieve the same outcomes.
3. Low level lasers have been deemed safe and effective by Health Canada and the FDA and many models can be purchased by the general public for home use.
4. Cosmetologists in BC with much less education and training than Registered Massage Therapists can use even higher powered class 4 lasers for hair and tattoo removal. These lasers do harm tissue. The laser systems they can buy can also deliver the dosage for LLLT and who’s to stop them from using them for this purpose.
5. Additionally, anyone can work under a certified laser therapist and treat clients as long as they follow safety guidelines in their facility. What is to stop a Registered Massage Therapist from taking the certification course and then hiring someone (without training of any type) to actually perform the laser therapy?
6. Through the use of class 3B lasers Registered Massage Therapists in BC would be able to provide additional benefits to their clients by increasing the rate of healing and reducing inflammation.

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So many sticks!

Lucy, my 5 year old Airedale loves sticks. And loves water. Combined she goes nuts and will swim out into any ocean to retrieve a stick. However a few weeks ago she lept  into the ocean, got the stick, but came out lame, holding her back left leg in the air. Muscle pull, sprain, strain, whatever you want to call it, she had one of them. After a thorough check I determined it to be a muscle strain. This of coarse reminded me of being in the office. So many times patients ask the difference between all of these. We’ve all gone over on our ankle, but many people are not sure what to do when this happens. So in this weeks segment I will explain the differences and what it means to your recovery.

Sprains

A sprain is an injury to a joint ligament. Ligaments are the strong bands of tissue that connect one bone to another at a joint. The severity of the injury can be classified by the amount of tissue tearing, joint stability, pain and swelling. The mildest sprain (first degree) has little tearing, pain or swelling, and joint stability is good. The second degree sprain has the broadest range of damage, with moderate instability, and moderate to severe pain and swelling. The most serious sprain is a third degree sprain. The ligament is completely ruptured and the joint is unstable. There may be severe pain at first, but afterward there may be no pain. There will be a lot of swelling with this type of sprain, and often other tissues are damaged.

Signs and Symptoms of Sprains

The usual signs and symptoms of a muscle sprain include pain, swelling, bruising, and the loss of functional ability (the ability to move and use the joint). Sometimes people feel a pop or tear when the injury happens. However, these signs and symptoms can vary in intensity, depending on the severity of the sprain.

Sprain Severity

Grade I Sprain:

A grade I (mild) sprain causes overstretching or slight tearing of the ligaments with no joint instability. A person with a mild sprain usually experiences minimal pain, swelling, and little or no loss of functional ability. Bruising is absent or slight, and the person is usually able to put weight on the affected joint.

Grade II Sprain:

A grade II (moderate) sprain causes partial tearing of the ligament and is characterized by bruising, moderate pain, and swelling. A person with a moderate sprain usually has some difficulty putting weight on the affected joint and experiences some loss of function. An x-ray or MRI may be needed.

Grade III Sprain:

A grade III (severe) sprain results in a complete tear or rupture a ligament. Pain, swelling, and bruising are usually severe, and the patient is unable to put weight on the joint. An x-ray is usually taken to rule out a broken bone. This type of a muscle sprain often requires immobilization and possibly surgery. It can also increase the risk of an athlete having future muscles sprains in that area.

Strains

A strain is damage to muscle fibers and to the other fibers that attach the muscle to the bone. Other names for a strain include “torn muscle,” “muscle pulls” and “ruptured tendon.” Muscle injuries are classified from first (least severe) to third (most severe) degree strains. A first degree strain has little tissue tearing, mild tenderness and pain with full range of motion. As with the sprains, the second-degree strain has a wide variability. Muscle or tendon tissues have been torn, resulting in very painful, limited motion. There may be some observable swelling or a depression at the spot of the injury with a second degree strain. The third-degree strain involves complete rupture of a part of the muscle unit. Motion will be severely decreased or absent. Pain will be severe at first, but the muscle may be painless after the initial injury.

Common Types of Strains

Ankle Sprains
: The ankle is one of the most common injuries in professional and recreational sports and activities. Most ankle sprains happen when the foot abruptly turns inward (inversion) or outward (eversion) as an athletes runs, turns, falls, or lands after a jump. One or more of the lateral ligaments are injured.

Wrist Sprains
Wrists are often sprained after a fall in which the athlete lands on an outstretched hand.

Acute Treatment of Strains

There are several decisions that you must make when you injure yourself. Among the first of these is how serious the injury is and whether you should go to a healthcare provider. Look for deformities, significant swelling and changes in skin color. If there are deformities, significant swelling or pain you should immobilize the area and seek medical help. Many fractures will not cause a deformity, thus if there is any doubt or concern you should get medical attention.

Stage One

Management of both sprains and strains follows the “PRICE” principle.

P – Protect from further injury
R – Restrict activity
I – Apply Ice
C – Apply Compression
E – Elevate the injured area

This principle limits the amount of swelling at the injury and improves the healing process. Splints, pads and crutches will protect a joint or muscle from further injury when appropriately used (usually for more severe sprains or strains). Activity restriction (usually for 48-72 hours) will allow the healing process to begin. During the activity restriction, gentle movement of the muscle or joint should be started. Ice should be applied for 15 to 20 minutes every hour to hour and a half. Compression, such as an elastic bandage, should be kept on between icing; you may want to remove the bandage while sleeping, though keeping it compressed even during the night is best. Elevating the limb will also keep the swelling to a minimum. Acute treatment is the first stage of rehabilitation.

IMPORTANT:

If you suspect more than a mild injury, cannot put weight on the limb, or it gives way, you should consult with a healthcare provider.

Rehabilitation

Following the first 48 to 72 hours, it is important to start the next stage of rehabilitation. The second stage of rehabilitation focuses on gentle movement of the muscle or joint, mild resistive exercise, joint position training and continued icing. When you are able to move without pain you can progress to the next stage of rehabilitation.

During this stage you may gradually return to more strenuous activities, such as strengthening. A simple guide to how much you can do is pain. Pain should remain low during rehabilitation; if pain increases it usually means you have attempted to do too much.

Throughout your recovery you can still maintain an aerobic training program. Options for training include stationary bicycling, swimming, walking or running in the water. If the injury is more than mild sprain or strain it is best to consult your healthcare provider.

Stage Two (after initial 48-72 hours swelling has stopped increasing and pain decreases)

Range of Motion

Towel pull with toes
Draw the alphabet with ankle

Mild Resistive Exercises

Foot press—up, down and each side, against a solid object (no motion of the ankle) Tubing exercises in all motions (pain free)

Joint Position

Standing with eyes closed—partial squats and shifts from side to side

Stage Three (pain free; can walk without limp)

Range of Motion

Stretching with Towel

Strengthening

Toe Raises
Hops—start forward and back, short hops

Weights—Heavy tubing or cuff weights

Joint Position

One-legged stand with eyes closed

Understanding what is going on with your injury promotes quick and proper care. If you have any questions or concerns please do not hesitate to contact me. Oh, and Lucy, she is back to her energetic, clown like self.

In Health,

Peter Roach, RMT, CNMT, Laser Therapist