A lot of patients ask questions such as, "Why doesn't my doctor do laser therapy?" or, "Why doesn't my primary care physician offer laser therapy?" or, "Why didn't the orthopedic doctor know anything about this when I went and asked them about it?"
Those are great questions. We wrote this blog post to help answer them. This won't cover everything, but we're going to spend some time looking at guidelines for health care providers. Guidelines are put in place to give doctors some level of lateral limitations and make sure they're moving ahead with treatment that's been proven to work and that has proven to be safe and cost-effective. Guidelines that are well-designed can really help your doctor know what type of treatment you should be pursuing or what kind of testing you should be getting.
If healthcare guidelines are being followed, why isn't laser therapy included in them? If it were, many more physicians would know about laser therapy and would be using it. There isn't a lack of evidence because, just a few years ago (2020), there were more than 380 studies published on laser therapy in that one year. That's incredible! That's a huge amount of research! But that is actually part of the problem. There's a ton of new research coming out (to date, publications have not slowed down since 2020), and the guidelines are left behind in the dust.
In this post, we'll be referring to an article that came out in July of 2020. It's title is "Guidelines versus evidence: what we can learn from the Australian guideline for low-level laser therapy in knee osteoarthritis? A narrative review." This was published in Lasers in Medical Science. In it, the authors absolutely demolished a healthcare guideline that came out in 2018, which had recommended that laser therapy not be used for knee osteoarthritis. These researchers just tore it apart, and it is a pretty incredible criticism of how we handle our healthcare guidelines, along with some of the problems that could arise from just utilizing the guidelines instead of working hard to look at the research every day.
What is Knee Osteoarthritis?
Knee osteoarthritis is a degenerative condition of the knee. It's a wear-and-tear disorder. It is not inflammatory rheumatoid arthritis. It is osteoarthritis: wear and tear that is sometimes stimulated because of an injury that leads to degenerative change. Bone spurs form around that joint, cartilage loss happens, the joint space shrinks, the knee starts grinding and crunching, and it becomes very painful. That's knee osteoarthritis. Every year, thousands of knee replacements are undergone around the country and around the world because of this condition.
Problems with the Guidelines
This particular Australian guideline from 2018, which provides doctors guidance for what to do about knee arthritis, recommended things like massage and hydrotherapy and recommended against things like prolotherapy and acupuncture. It also recommended against the use of laser. That must have really irritated somebody because they started digging into this guideline and found massive problems—huge problems. Just because laser therapy is not part of the standard of care, or just because your doctor doesn't know much about it, does not mean that it doesn't work, nor does it mean that there's no evidence for laser. In this particular article, the researchers found huge problems with the guideline, NOT with the laser therapy evidence!
It all started with the fact that the researchers who put the guidelines together didn't do a comprehensive search of the literature. This 2018 guideline didn't use any studies newer than 2012! They also missed dozens of studies in their search that could have supported laser therapy (because there was good evidence for laser therapy before 2012, too). Moreover, they took so long to put this guideline together that, in this review, the critical researchers said, "the lengthy timeframes associated with guideline development by committee and the folly of publishing guidelines that are not reviewed and updated regularly has a huge impact on what is actually acceptable to use in clinic."
So, if your doctor is looking at guidelines, they may see that a guideline says they shouldn't use laser therapy. And they don't necessarily have the time to go read all the studies themselves, so they don't realize that guideline's evidence search is flawed.
Another problem was the subjective interpretation of the evidence. The guidelines said laser costs too much, takes too long to perform, and that medical professionals have to be the ones delivering it. Well, that's not really any different from a lot of other treatments that are done. It only takes 20 to 30 minutes maximum for a laser therapy treatment to be delivered to the knee.
And many healthcare providers can deliver laser therapy either alone or at the same time that they're doing exercises with you or helping to stretch you out or assigning some home-exercise programs, even using other modalities at the same time. And, yes, it does need to happen two to three times a week in the beginning, but if you do get laser therapy two to three times a week, these researchers said that the therapeutic benefits of laser are based on modulating the underlying pathology. That means changing the actual disease itself. They say it provides tissue repair, modulation of inflammation, and neural blockade or pain blocking, which is cumulative over several sessions. So, the effects from one session carry on into the next one. They all build on each other to help not only with pain, but also to help with tissue repair.
In contrast, many of the recommended treatments in the guidelines are for symptom management, only lasting a few hours or a few weeks at best, like a nonsteroidal anti-inflammatory drug, which would include treatments like cortisone injections.
As far as costs, the cost is actually very low. For a patient, this service is often covered by insurance, but total cost matters too because there's no free lunch. When you consider some of the costs associated with opioid drugs and surgeries (addiction, overdose, surgical risks, infections, lengthy rehab, missed time at work, etc.), laser comes out much cheaper. As a matter of fact, there is a reduction in the need for knee replacements in patients that get laser over a six-year period; that's a huge amount of economic benefit! It costs much less to deliver noninvasive laser therapy to a patient's knee than to replace that knee. Not only that, but those knee replacements do not last forever, so patients who get one knee replacement often need to receive a second or sometimes even third replacement for that knee. And three is typically the max number of knee replacements a patient can have.
Another thing that these critical researchers pointed out as a problem with the guidelines is that no experts in the field of laser therapy were consulted in forming this opinion. You wouldn't ask highly skilled electricians to weigh in on plumbing methods any more than you'd ask surgeons to weigh in on laser therapy if they don't know how it works.
Lastly, these critical researchers said, "the inflexibility of a guideline, which is not updated when new information becomes available, is a failure of evidence-based practice." Evidence-based practice means using methods and techniques that are proven and supported by scientific evidence. These researchers say that, if you can't update your guidelines, those guidelines will be wrong.
The Guidelines Must be Updated!
These researchers concluded by saying the guideline they reviewed is flawed and should be corrected immediately to support the use of laser therapy in knee osteoarthritis. Again, we're not talking about just relieving pain, but actually resolving tissue damage, modulating inflammation, and making the patient better with a non-drug, non-invasive treatment with minimal to no side effects. There's no downside here. So, the next time you hear that laser therapy is not real, or that it's a sham, or that it's not supported by evidence, just know that we still have a lot of human failings that can happen even in the formation of guidelines. That said, we guarantee you, the folks that formed that guideline really did work hard. They tried hard, but they were asked to do a very large, difficult task. If they don't know enough about some of these modalities, like laser therapy, they may come to the wrong conclusion, and that is evidently what happened here.
We at LTI are looking forward to seeing more studies like this: more publications that are critical of the guidelines when such professional criticism is appropriate. When we know, based on ample evidence, that laser therapy works (as we do), we should be supporting laser therapy and updating these treatment guidelines in accordance to that evidence-based knowledge.
Thankfully, more doctors are learning about laser therapy and adding it to their practice. We are hearing from more doctors more and more frequently! As it becomes increasingly popular, patients' access to laser therapy will also increase, and we love that because we at LTI want to connect patients with laser providers. One way we try to do that is through our clinic map. View it here to check if there's a laser therapy provider in your region.
