Low Level Laser Therapy in Treatment of Osteoarthritis of the Knee

A double blinded, randomized and controlled trial in patients with knee osteoarthritis was conducted to evaluate the efficacy of infrared low level laser therapy (LLLT) (also known as cold laser or therapeutic laser).  90 patients were randomly assigned to three treatment groups by a non-treating clinician.  The first group was given LLLT consisting of 5 minutes at 3 Joule dose, the second group was given LLLT consisting of 3 minutes at 2 Joule dose, and the third group was given placebo LLLT.  All groups were also given an exercise program.  Patients received 10 treatments and the exercise program was continued during the 14 week study.

Patients were evaluated with respect to pain, degree of active knee flexion, duration of morning stiffness, painless walking distance and duration, WOMAC Osteoarthritis Index scale.  Statistically significant improvements were made in all parameters such as pain, function and quality of life measure post therapy compared to pre therapy in both active laser groups.  Improvements in all parameters of the active laser groups as opposed to the placebo laser group were also statistically significant.  This study demonstrated that different dose and duration of laser therapy regimes were safe and effective for treating osteoarthritis of the knee.

Citation: Lasers in Surgery and Medicine33:330-338 (2003)

Manipulation or Microdiskectomy for Sciatica?

A 2010 clinical study compared the clinical efficacy of spinal manipulation against microdiscectomy in patients secondary to lumbar disc herniation.  Forty patients who met the criteria (failed at least 3 months of nonoperative management including treatments with analgesics, lifestyle modifications, physiotherapy, massage therapy and/or acupuncture) were randomized to either surgical microdiskectomy or standardized chiropractic spinal manipulation. 

Significant improvements in both treatment groups compared to baseline scores were observed in all outcome measures.  After one year follow up, there did not appear to be a difference in outcome based on the original treatment received.  60% of the patients who had failed other medical management benefited from spinal manipulation to the same degree as if they underwent surgical intervention.  Of the 40% left unsatisfied, surgical intervention conferred excellent results. 

The conclusion of the study was patients with lumbar disc herniation failing medical management should consider spinal manipulation followed by surgery if warranted. 

Citation: http://www.jmptonline.org/article/S0161-4754(10)00211-3/abstract

Canada's Costly Spine Surgeon Backlog

A May 13, 2011 Globe and Mail article written by Lisa Priest emphasized the waste and mismanagement in our health care system in regards to back pain.  Back pain is very common, with 80 % of the population suffering from a severe episode in their life.  Upwards of 85% of this back pain is diagnosed as mechanical or non specific back pain.  The small minority have more severe neurological or bony involvement, yet high tech tests such as MRI or CT are ordered by doctors, and with a 60% false positive rate, often find abnormalities that have nothing to do with the symptoms, but lead to a referral to a spine surgeon.

The unnecessary tests are leading to massive health care costs - $24 million a year in Ontario alone.  The avalanche of referrals has caused 60 of the 120 spine surgeons in Canada to close their practices to new patients at some point.  In an unscreened practice, upwards of 90% of the patients that attend a spine surgeon are not surgical candidates, creating a logjam for patients who truly need the referral and surgery. 

 Dr. Daryl Fourney of Saskatoon states that “the overwhelming majority of people with spine problems can be treated with physical treatments, whether it be exercises or spinal manipulation or medications”.  Dr. Fourney pioneered a program in Saskatchewan to train family physicians to discern which patients need to see a spinal surgeon.  There is an incentive built in, with access to diagnostic imaging and expedited surgical referrals for their patients.  The province has started to see a reduction in referrals to spine surgeons.

Hence the prescription to reverse the gridlock is a triage system, made up of primary care physicians, physiotherapists and chiropractors, to help differentiate patients who potentially need surgery.   Patients who then do not require a referral to a spine surgeon would be sent to other health care providers for treatment, and tracked to see if the treatments are working.  The Ontario government estimates this would require $3 million a year, but save the health system upwards of $20 million or more in unnecessary testing and referrals. 

Atlas Realignment and Blood Pressure Reduction

A 2007 pilot study in the Journal of Human Hypertension showed a sustained blood pressure lowering effect with a procedure designed to correct atlas vertebrae misalignment similar to that seen by giving two different antihypertensive drugs at the same time.  The study design was randomized, double blind, with a placebo control and had 50 participants.

The practitioners in the study were from the National Upper Cervical Chiropractic Association (NUCCA) who limit their practice to precise, delicate manual alignment of the C1 or atlas vertebrae.  Unlike other vertebrae which interlock, the atlas relies on soft tissue to maintain alignment, and therefore is vulnerable to displacement.  Minor misalignment of the atlas vertebrae can potentially compromise the brainstem neural pathways and vertebral arteries.  

The study was 8 weeks in duration, with a blood pressure baseline originally taken and weekly thereafter along with atlas measures pre and post adjustment.  Outcomes in changes from the treatment showed a reduction of systolic blood pressure (-17 +/- 9 mm Hg NUCCA vs -3+/- 11 mm Hg control) and diastolic blood pressure (-10+/- 11 mm Hg NUCCA vs -2+/- 7 mm Hg control).  Most antihypertensive drugs yield an 8 mm Hg drop in blood pressure.  What is most impressive is that the reduction in blood pressure persisted at 8 weeks and was not associated with pain or pain relief or any other symptoms that could be associated with a rise in blood pressure.  

Citation: Journal of Human Hypertension (2007),1-6

Therapeutic Laser Therapy

Therapeutic Laser Therapy, is also known as Cold Laser Therapy or Low Level Laser Therapy.  Laser therapy works by injecting photons of visible and invisible light deep into tissues.  Cells contain chromophores and cytochromes in the mitochondria, which has the ability to absorb the light energy and convert it to chemical energy.  This chemical energy is utilized by the tissue on a cellular level to accelerate healing and reduce pain.  There is over 2,000 clinical studies that have proven the success of therapeutic lasers in the healing of neural muscular-skeletal conditions. 

The biostimulating effects of laser include:

• Reduction of pain by increased endorphin release
• Decrease inflammation by increasing lymphatic circulation
• Increased vasodilation to allow oxygen rich blood to injured tissue
• Accelerate tissue regeneration by increased production of enzymes and ATP, used for cell energy
• Speed up the healing process by increased collagen synthesis, which is the basis of all muscles, ligaments and joints

The benefits of laser therapy include:

• non invasive, not painful
• no side effects as the cell cannot be overstimulated
• safe as cold laser does not produce heat and therefore  cannot cause tissue damage
• few contraindications
• effective as able to penetrate up to 4 inches below the skin

The Health Canada approved and Canadian made laser that I just purchased is a Theralase TLC-1000 http://www.theralase.com/. While with all therapies, the individual results may vary, low level laser offers another type of treatment at our multi-disciplinary clinic.

Myth #4: Chiropractic is Addictive

One criticism of chiropractic is that once you start going, you will go for the rest of your life.  The fact of the matter is that there is no cure for back pain, and there is a reoccurence rate of 80% of back pain within one year of the acute episode.  Our bodies are under constant stress, physically from our work, home and play; chemically from the food we eat to the environment we are in; and also mentally from the fast paced lifestyle of today.  Hence chiropractors often recommend two types of maintenance care following an acute episode. 

Supportive care is defined as treatment for patients who have reached maximum improvement, but who fail to sustain this improvement or progressively deteriorate when treatment is withdrawn.  Preventative care is treatment for a patient who has no present symptoms, but seek to prevent pain and disability, promote health and enhance quality of life.  More people are taking charge of their bodies and imbracing wellness and optimal health as opposed to the reactionary medical model who seek care after disease has taken place. 

A well designed medical trial on manipulation in essence adopted the chiropractic model of an initial course of intensive manipulation followed by maintenance treatment at a reduced frequency, and reported this to be effective.  This trial covered three contentious issues in maintenance care:  whether the benefits of spinal manipulation derive from specific treatment or placebo effect; whether there are objective biomechanical benefits of manipulation and whether continued care has a legitimate role.  To view an abstract of this article, click  http://www.ncbi.nlm.nih.gov/pubmed/21245790

Myth#3: Chiropractic is dangerous

Much publicity has been given to neck manipulation and risk of stroke.  This serious complication is extremely rare, with statistics of vertebral artery damage following neck manipulation at 1 in 1 million adjustments or 0.0001%. The 2000-2010 Task Force on Neck Pain and its Associated Disorders reviewed 32,000 research papers and provided the first definitive evidence on actual risk rate and causation of neck manipulation and vertebrobasiliar artery (VBA) stroke.

The Task Force  analyzed the database covering 109 million person years that recorded all primary medical care practitioner (PCP) and chiropractic (DC) visits and all the VBA stroke admissions in the province of Ontario for eight years.  They concluded that there was no evidence of excess risk of VBA stroke associated with chiropractic compared to primary care.  The slight increase of risk associated with patients consulting either a PCP or DC is "likely due to patients with headache and neck pain from VBA dissection seeking care before their stroke".  They explain that any motion can lead to a stroke where there has already been damage to a vertebral artery, such as turning to back up the car, extending the neck at the hair dresser, or simple range of motion testing which can lead to release of the embolus and cause a stroke. 

For a summary of this report go to http://www.chiropracticcanada.ca/ecms.ashx/Doc/EntireStrokeStudy.pdf