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Three Part Question

[In patients with chronic simple low back pain] is [percutaneous laser therapy better than placebo] at [reducing pain, increasing mobility and speeding a return to normal function]

Clinical Scenario

A 35 year old man presents to his general practitioner with chronic lower back pain of 3 months duration. He has a normal neurological examination and no symptoms to suggest a serious cause. You suggest some NSAIDs and advice to stay active. He returns to the department 3 weeks later still complaining of ongoing back pain. You ask one of your community physios to have a look and he offers to take him on for out-patient physio and Laser therapy. You wonder if there is any evidence to support the use of Laser in back pain patients.

Search Strategy

Medline via OVID interface on ATHENS 1966-Feb 2005
Cochrane Edition 1 2005 online via NELH
EMBASE via OVID interface on ATHENS 1996-Feb 2005
CinAHL via OVID interface on ATHENS 1982-Feb 2005
Medline, Embase, CinAHL.
[exp Low Back Pain/ or lumbar pain.mp. or exp Back Pain/ or back pain.mp. or exp Back Pain/ ] and [laser.mp or exp LASERS] Limit to humans, english and abstracts
Cochrane
back-pain and laser

Search Outcome

Medline
55 citations. 3 relevant papers found.
Embase
60 citations. No new papers found.
CinAHL
12 citations. No new papers found.
Cochrane
11 citations. One uncompleted protocol registered.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Gur A 2003 Turkey	75 patients with chronic low back pain. Randomised to laser plus exercise or laser alone or exercise (25:25:25). A gallium-arsenide laser was used 5 times a week for 4 weeks.	PRCT	Notable baseline values	Average duration of back pain was more than 15 months	No blinding to therapy, though assessment was blinded. Extensive periods of time spent with therapist in laser groups. Small numbers for a 3 arm trial
			Pain	All improved. No difference between groups.
			Roland disability score	All improved. No difference between groups.
			Modified Oswestry disability questionnaire	All improved. No difference between groups.
			Clinical examination	All improved. No difference between groups.
Klein RG 1990 USA	20 patients with chronic low back pain. Randomised to either low energy laser (gallium-arsenide) biostimulation with exercise or placebo laser with exercise. Groups were comparable in all measured parameters at baseline.	PRCT	Post treatment pain on 7.5cm VAS	1.7cm for laser vs. 2.1cm for placebo p=0.493	Small numbers. Patients recruited by advertisment. Does not state when patients were followed up, just that they had a period of exercise therapy before being assessed again.
			Post treatment disability on 24 point scale	3.6 for laser vs 2.9 for placebo p=0.919
			Mobility assessed using a computerised system. Flexion, rotation and extenfsion assessed	No difference between laser and placebo.
			Maximal velocity in rotation, flexion and extension	All improved, but no differences between laser and placebo found.
Basford JR 1999 USA	63 adults with back pain of more than 30 days. Aged 18-70. No neurology. Participants had treatment 3 times a week for 4 weeks. Control patients had sham laser at the same points as intervention patients.	PRCT. double blinded.	Patient follow up	56/63 followed up to 1 month.	Relatively short follow up time. Effects seems greatest at interim analysis. Not acute patients.
			Interim Oswestry back score	17.2 for laser vs. 22.9 for control p=0.10
			Interim lumbar mobility (Schobers test)	14.0cm for laser vs 14.4cm for control p=0.092
			Interim patient perception of benefit on VAS (lower score indicates less pain)	29.1 for laser vs 41.6 for control p=0.05
			1 month Oswestry back score	14.7 for laser vs. 22.9 for control p=0.04
			1 month lumbar mobility	14.0 for laser vs. 14.2 for control p=NS
			1 month patient perception of benefit	28.3 for laser vs. 37.8 for control p=0.101

Comment(s)

Laser therapy has been advocated for a number of musculoskeletal disorders. It's use in back pain has been controversial. There appears to be little evidence presented in the above papers to advocate it's routine use in the treatment of back pain. However, the numbers are small in these studies and there may be a small effect not identified owing to a type II error, although any difference in outcome is then likely to be small. All the papers have short follow up periods. Future studies should attempt to determine outcome over a longer period of time.

Editor Comment

A number of small studies in foreign language journals were found on repeat searching. Examination of abstracts only suggested that the conclusions of this BET would be unlikely to change.

Clinical Bottom Line

There is little objective evidence to support the use of low power percutaneous laser in the treatment of chronic lower back pain.

Level of Evidence

Level 2 - Studies considered were neither 1 or 3.

References

1. Gur A, Karakoc M, Cevik R, Nas K, Sarac AJ, Karakoc M Efficacy of low power laser therapy and exercise on pain and functions in chronic low back pain Lasers in Surgery and Medicine 2003;32(3):233-238
2. Klein RG, Eek BC Low-energy laser treatment and exercise for chronic low back pain: a double blind controlled trial Archives of Physical Medicine and Rehabilitation 1990;71(1):34-37
3. Basford JR, Sheffield CG, Harmsen WS Laser therapy: a randomised, controlled trial of the effects of low-intensity Nd:YAG laser irradiation on musculoskeletal back pain. Archives of physical medicine and rehabilitation 1999;80(6):647-652