Talk:Low-level laser therapy

title?

Should the title of the article not be "Low Level Laser Therapy" as opposed to "Photobiomodulation"? If they refer to the same concept, there are far more citations to the former on pubmed.—The preceding unsigned comment was added by 216.185.64.86 (talk • contribs) 13:17, August 24, 2006.

Possible sources

• Karu, T, T (1999). "Primary and secondary mechanisms of action of visible to near-IR radiation on cells". J Photochem Photobiol B 1999 Mar 49(1) 1-17. 49 (1): 1–17. doi:10.1016/S1011-1344(98)00219-X. PMID 10365442.
• Lane N., N (2006). "Power Games". Nature. 2006 Oct 26;443(7114):901-3. 443 (7114): 901–3. doi:10.1038/443901a. PMID 17066004.

N.B.

Note that there is a very large talk page archive (2013-2017) for this article. Not sure why the anomalous 2006 sections above were left up. Valerius Tygart (talk) 14:40, 8 July 2017 (UTC)

Moved from Roxy's talk page

Changes made to LLLT page only included missing information. Regarding reimbursement, Blue Cross Blue Shield Association has changed their policy to indicate that LLLT is considered 'medically necessary'. Plenty more can be cited if further evidence is required. The treatment of Oral Mucositis included citations from multiple papers, including a systematic review and is further supported by the policy changes by Blue Cross Blue Shield Association. The Blue Cross Blue Shield of Western New York medical policy states this (emphasis mine):

"A recent systematic review of RCTs on LLLT for prevention of oral mucositis included 18 RCTs, generally considered at low risk of bias, and found statistically significantly better outcomes with LLLT than control conditions on primary and secondary outcomes. In addition, three double-blind, RCTs published in 2015 found significantly better outcomes in patients undergoing LLLT than undergoing sham treatment prior to or during cancer treatment. The evidence is sufficient to determine qualitatively that the technology results in a meaningful improvement in the net health outcome."

Please review changes and tell me which content you feel is not supported by the citations and evidence.

edit: in case you are concerned about the use of static PDFs, you can search Blue Cross Blue Shield of Western New York's medical policy here, look for Low Level User therapy, you can do the same for Blue Cross Massachusetts and Blue Kansas City.

Academia salad (talk) 11:43, 6 February 2018 (UTC)

the above was posted at my talk page. -Roxy, the dog. barcus 14:26, 6 February 2018 (UTC)

Hm, there are some useful refs there, and some not useful ones. Will look more later. There are some things here to work with. Jytdog (talk) 15:49, 6 February 2018 (UTC)

I reverted the recent change to the article, as briefly hinted by my edsum, because of the clear WP:COI of the editor, and the fact that they are a WP:SPA editor. The edits appear designed to promote the business of the editor concerned. Furthermore, I fail to see the relevance of the reimbursements portions to an encyclopeadia article. The article is also a mish mash of apparent misinterpretation, contradictions and contraindications which only serve to confuse, and needs a good broom. Mr Salad, have you ever read WP:MEDRS? -Roxy, the dog. barcus 23:08, 6 February 2018 (UTC)

I agree that the page needs a good spring clean. I had not read WP:MEDRS, but a quick scan suggests that secondary sources are preferred over primary sources, which makes sense. I’ll read it more carefully when I get the time. In the meantime, here is a systematic review published in the peer reviewed Supportive Care in Cancer on oral mucositis, a systematic review published in the peer reviewed journal The Lancet about the management of neck pain, and a systematic review in the peer reviewed BMC on interventions in osteoarthritic knee pain. I didn’t add the reimbusement section, I just updated it. I understand concerns over COI, I'm happy to limit my activity to discussion on this Talk page. Academia salad (talk) 14:15, 7 February 2018 (UTC)

you got it on MEDRS. We summarize what high quality secondary sources say - reviews in good journals, statements by major medical/scientific bodies are best. We reach for things like insurance company evaluations when there are not other good secondary sources (we can count on the insurance folks to be critical and independent of manufacturers, at least). If you want to take a shot at proposing content based on the refs that fit the bill, to update the content, that would be amazing. Jytdog (talk) 03:55, 9 February 2018 (UTC)

I'd be happy to, but I could use some guidance. One of the problems with reporting from all the sources is that a lot of them don’t take dosage into account when reviewing evidence. Dosage is critical to the efficacy of LLLT/PBMT. This is well put in a systematic review in the Lancet, where they say "effectiveness depends on factors such as wavelength, site, duration, and dose of LLLT treatment. Adequate dose and appropriate procedural technique are rarely considered in systematic reviews", but it is also addressed in "Meta-analysis of pain relief effects by laser irradiation on joint areas.", "Low level laser treatment of tendinopathy: a systematic review with meta-analysis.", and "A systematic review of low level laser therapy with location-specific doses for pain from chronic joint disorders." However I don't feel I should just cut out papers that do not account for dosage. Do you have any recommendations?

--Academia salad (talk) 15:51, 15 February 2018 (UTC)

Tricky. per MEDMOS we generally don't do discuss dosing in order to avoid becoming an instruction manual. But in this case where dosing is crucial (it is "low level LT" after all) something in the "medical use" section mentioning how dose plays into efficacy and safety, sourced to those MEDRS refs, would be fine. With regard to refs that omit dosing, are you are aware of discussion in the biomedical literature where people who don't take those things into account, justify not taking them into account?

In general it is true with all medical procedures that the skill of the physician (referring to "proper technique") is by far the biggest factor determining outcomes. This is not surprising and efficacy and safety should take into account how the procedure is done "in the wild", by experts and novices and middle-experienced people -- anybody who does it. Jytdog (talk) 16:32, 15 February 2018 (UTC)

I am not aware of any papers that justify not taking dosage into account, but there are papers and reviews that acknowledge that dose should have been taken into account. It is not difficult to find some of these papers as examples and I could provide some examples. A good example of the specific concern I have is the paper "Is low-level laser therapy in relieving neck pain effective? Systematic review and meta-analysis.”, which is currently cited on the Wikipedia page as evidence against the effectiveness of LLLT.

The paper by Kadhim-Saleh et al. was rebutted by the authors of the original paper "Efficacy of low-level laser therapy in the management of neck pain: a systematic review and meta-analysis of randomised placebo or active-treatment controlled trials", in "Methodological shortcomings make conclusion highly sensitive to relevant changes in review protocol”, citing specific problems with the paper, including that "Kadhim-Saleh et al. appeared to give no serious consideration to the appropriateness of LLLT technique including dosage a priori in selection criteria or analysis protocol." and "They cited meta-analyses published over 20 years ago to demonstrate the consistency of their claim with previous reviews that found no effect from LLLT despite 80–90 % of RCTs on LLLT being published after these citations." I would strongly recommend reading all three papers, but then paper by Kadhim-Saleh et al. is not a paper I would include on the wikipedia page.

I was wondering what the best practice is for cases like that? Academia salad (talk) 10:23, 20 February 2018 (UTC)

References

Too much negativity

I tried to clean up a few things, but got reverted by Valerius Tygart here. I can understand calling this "a form of alternative medicine", but the linked article says "and where the scientific consensus is that the therapy does not, or cannot, work because the known laws of nature are violated by its basic claims". This is not the case here; far from a consensus that it does not or cannot work, there are a number of cited MEDRS secondary sources showing that it is sometimes effective, and that number of plausible mechanisms are being studied. Another effect of the revert was to restore "appear to be limited to a specified set of wavelengths" which is not at all what the cited source says; I had changed it to say "Beneficial effects of LLLT have been found at several wavelengths and not at others." And I had taken out "but in most cases no better than placebo", as I didn't see that the cited sources supported that. This feels like the reverting editor is just biased against "alternatives" to the usual medical practices, even when there's evidence that they do sometimes work. Dicklyon (talk) 04:09, 23 February 2018 (UTC)

There is some evidence for a few things such as this review in BMC cancer[1]

But not for other stuff[2] Doc James (talk · contribs · email) 13:45, 23 February 2018 (UTC)

Hi, @Doc James:, there is good quality evidence from secondary sources for LLLT being effective in the prevention of severe oral mucositis,[3][4], including a guideline by MASCC[5]. Alongside that, the Blue Cross Blue Shield Association[6][7] considers LLLT "medically necessary for the prevention of oral mucositis". Given that the alternative medicine page provides the description "practices claimed to have the healing effects of medicine but which are disproven, unproven, impossible to prove, or are excessively harmful in relation to their effect", I would argue that the use for OM alone should push it out of the category of alternative medicine as it is clearly proven to work.

In interest of disclosure, I have a COI as listed on my user page. I intend to open up a discussion on other uses of LLLT at a later date on this talk page to review evidence for other uses of LLLT.

As an aside, you don't seem to use full citations for the talk page, is that the preferred way for talk pages? I've used the method you used for this reply, but I can do whichever is better in the long run. Academia salad (talk) 15:17, 23 February 2018 (UTC)

Doc James, please also note that a lack of evidence of effectiveness is not remotely like "where the scientific consensus is that the therapy does not, or cannot, work because the known laws of nature are violated by its basic claims". If that's what alternative medicine is, this is not. An altnertive strategy would be to fix the alternative medicine article, as its definition seems overly negative, and is used to imply that all alternative medicines can't work. Dicklyon (talk) 00:48, 24 February 2018 (UTC)

Blue Cross Blue Shield Association is not a sufficient source. But the others are okay.

Yes the url to pubmed is sufficient for talk pages. Doc James (talk · contribs · email) 04:10, 24 February 2018 (UTC)

Suggestions for 'medical uses' section.

I'd like to propose some changes to the 'medical uses' section. As listed on my user page, I have COI.

Currently, the way this section is written, a single source is used to broadly dismisses LLLT as being no better than "other low tech ways of applying heat". But the source does not cite any specific papers/reviews to support that claim. I recommend changing the lead to not specify what LLLT has been promoted for. I recommend changing it to a non-specific 'many different treatments'. Hopefully this reduces the chance of people being misled to think LLLT is effective/not effective for anything not listed. I am also recommending areas which evidence shows LLLT is effective.

CHANGE: Various LLLT devices have been promoted for use in treatment of several musculoskeletal conditions including carpal tunnel syndrome (CTS), fibromyalgia, osteoarthritis, and rheumatoid arthritis. They have also been promoted for temporomandibular joint (TMJ) disorders, wound healing, smoking cessation, and tuberculosis. While these treatments may briefly help some people with pain management, evidence does not support claims that they change long term outcomes, or that they work better than other, low tech ways of applying heat.

TO: LLLT has been promoted for many different treatments, for which there are varying levels of evidence.

ADD: Evidence supports the use of LLLT for the treatment of various tendinopathies,[8][9], such as shoulder tendinopathy,[10]and tennis elbow. [11] A review found tentative evidence that LLLT may help frozen shoulder.[12]

ADD: LLLT appears to be effective for treating joint pain [13] and "can significantly improve the functional outcomes" for people suffering temporomandibular joint dysfunction [14], and can “provide symptom management” for people with osteoarthritis.[15] Reviews have found benefits for nonspecific chronic low-back pain.[16][17]

ADD: There is some evidence that LLLT is effective for breast cancer related lymphedema.[18]

Feedback is appreciated. Academia salad (talk) 17:33, 1 March 2018 (UTC)

Do any of your sources above comply with WP:MEDRS? -Roxy, the dog. barcus 17:49, 1 March 2018 (UTC)

Unless I've mis-copied or misread, they should all be secondary sources (systematic reviews), as per WP:MEDRS. Academia salad (talk) 18:00, 1 March 2018 (UTC)

I've looked at the first one of those, number [8] and found this in its conclusion - "Assuming the lack of themes and samples associated with the studies found in this review, and the fact that well-known databases were used, it is suggested that further research are made using low-intensity laser therapy in patients with this condition to best assess this therapy." - If the rest of your "WP:MEDRS sources" are as good, I'd say that we wont be changing the page at all. -Roxy, the dog. barcus 18:31, 1 March 2018 (UTC)

I would be very leery of allowing an editor with a self-acknowledged COI to drive numerous changes to this article. (Shouldn't that mean that he/she voluntarily refrains from editing the article?) LLLT has not been "clearly proven to work" in OM. The cited article merely asserts "increasing evidence". I also disagree that, even if it did, it would "push it out of the category of alternative medicine". AM is, simply put, medicine that has not been shown to work. If 99% of promoted uses of LLLT remain unvalidated, LLLT remains 99% alternative medicine. The overall picture of LLLT (which, presumably, the average Wikipedia reader wants when seeking out the article) has not really changed recently. Stephen Barrett (at Quackwatch, a reliable secondary source) updated his page on LLLT about 13 months ago. His conclusion that "there's no reason to believe that they [LLLT modalities] will influence the course of any ailment or are more effective than other forms of heat delivery" remained unchanged. BTW, here is the paragraph he updated in Feb 2017:

One FDA-cleared LLLT device—the QLaser—has been promoted with curative claims that resulted in civil and criminal prosecution. The primary marketer, Robert L. Lytle (better known as Dr. Larry Lytle), had begun manufacturing and distributing low-level laser devices in 1997, shortly before the South Dakota Board of Dentistry had revoked his dental license for fraud and substandard patient care. In 2014, a federal complaint charged that Lytle, doing business as QLasers PMA and 2035 PMA, had marketed a dozen devices with illegal claims that they could treat "over 200 different diseases and disorders," including cancer, cardiac arrest, deafness, diabetes, HIV/AIDS, macular degeneration, and venereal disease. However, court documents indicate that although the FDA obtained a permanent injunction [4], Lytle continued selling the devices to and through other distributors. In January 2017, he and three distributors were charged with conspiracy in connection with the sale of QLaser devices and one of the three pleaded guilty [5,6].

Dicklyon insists there's "too much negativity" in the LLLT article. Hmmmm. LLLT has "alternative medicine" written all over it. Even if it is ultimately shown to work in some limited contexts (something about which I am personally doubtful), it remains a scam, plain and simple, for the "over 200 different diseases and disorders" for which is has been (& is being) promoted. I am all for carefully introducing well sourced updates regarding positive (& negative) developments in LLLT as time goes by, while always maintaining the relevant context & avoiding promotion. But I think the article (as of a few days ago) strikes just the right tone. Valerius Tygart (talk) 14:36, 8 March 2018 (UTC)

I did not give my proposal the time it deserved, I had it on a to do list for ages and made the mistake of rushing it to get it off my to do list.

But:

• This review for shoulder tendinopathy has good reviewing methodology, reporting and high quality testing of articles found — they use the PEDro scale, which is is robust and well regarded. The evidence here is a mix of high and moderate (13 RCTs of high quality and 4 of moderate quality) and has a positive conclusion in favour of LLLT - both alone and in combination with physiotherapy.
• This is a well written review for lateral elbow tendinopathy, it finds the evidence is positive in favour of LLLT - both alone and as an adjunct therapy - for short term pain and reduced disability. Of particular interest and a credit here is their analysis and commentary on treatments and dose parameters (and how these vary between studies).
• This review shows good evidence for reducing lymphedema and moderate evidence for reducing pain, it's a high quality systematic review with good methodology and is well written. It does report heterogeneity of studies in terms of treatment protocols, laser parameters and methods of applications.

How do you feel about those?

Valerius wrote "Shouldn't that mean that he/she voluntarily refrains from editing the article?". This is why I am not editing the article directly but instead communicating via this page as Jytdog recommended. I am more than willing to work within the framework Wikipedia provides for people with COI to contribute. If I make mistakes, please let me know and assume best intentions. Academia salad (talk) 18:46, 9 March 2018 (UTC)

@ Academia salad: Your #1 (Haslerud) is already cited in the article. No edit recommended. Your #2 (Bjordal) is also already there (cited 5 times). No edit recommended. Your #3 (Baxter) is new. It could be added to the two articles after the first sentence in the "Cancer" subsection. If so, I suggest quoting or paraphrasing the caution given in that article: "Due to the limited numbers of published trials available, there is a clear need for well-designed high-quality trials in this area." Such is MHO. Valerius Tygart (talk) 00:30, 12 March 2018 (UTC)

Medicine or Alternative Medicine?

I'm disappointed in the change Valerius made to the article, reverting a previous change made by Dicklyon. Valerius stated earlier that "[Alternative Medicine] is, simply put, medicine that has not been shown to work" and stated "LLLT has not been 'clearly proven to work' in OM. The cited article merely asserts 'increasing evidence'." The words "increasing evidence" were taken from the abstract of this systematic review published by the Multinational Association of Supportive Care in Cancer. The full quote states that the "increasing evidence allowed for the development of two new guidelines supporting this modality" and, in the discussion section, goes on to say:

Based on the current scientific information, the panel was able to reach the following decision: “The panel recommends that, for centers able to support the necessary technology and training, LLLT be used to prevent oral mucositis, in HSCT patients receiving high-dose chemotherapy with or without TBI. […] A systematic review with meta-analysis concluded that there is consistent evidence from small high-quality studies that red and infrared LLLT can partly prevent development of cancer therapy-induced OM. It indicated that LLLT significantly reduces pain, severity, and duration of symptoms in patients with OM."

A recommendation like that is not issued for medicine that has not been shown to work. Hopefully the evidence from this systematic review dispels the fallacy that "there's no reason to believe that they [LLLT modalities] will influence the course of any ailment or are more effective than other forms of heat delivery".

Valerius’ argument continues that "If 99% of promoted uses of LLLT remain unvalidated, LLLT remains 99% alternative medicine". I do not agree with that method of sorting treatments between medicine and alternative medicine. If aspirin was promoted for 200 pathologies that it has not been proven to be effective for, that would not make Aspirin alternative medicine.

I do not dispute that there are illegitimate claims made of LLLT, however if it is the intention of this page to reflect current thinking on LLLT the page should not lead with a phrase that lumps it in with reiki, faith healing and psychic surgery. LLLT, at minimum, has been proven to clinically effective for the treatment of mucositis and therefore does not meet Wikipedia's definition of alternative medicine. Academia salad (talk) 17:17, 15 March 2018 (UTC)

The comparison is not really to AMs like "reiki, faith healing and psychic surgery", but to AMs like acupuncture, chiropractic, and osteopathy, all of which have had ad hoc panels and committees make "recommendations" & formulate "guidelines" over the years, but for none of which has the scientific medical community at large been convinced of their efficacy. They remain "alternative medicines" on Wikipedia & elsewhere. I would suggest that — for purposes of Wikipedia articles — a controversial "medicine" moves from being an "AM" to "not-AM" when the relevant national or international specialty or sub-specialty College or Society (e.g., American Society of Clinical Oncology, International College of Surgeons, etc), or their subordinate working groups or panels, endorse it. At the very least, it should have received a solid positive evaluation from a non-biased, non-profit group such as the Cochrane Reviews. BTW, if aspirin were to be touted, without reliable evidence, as a treatment for schizophrenia & became a popular fad for that condition, then yes, it would be an "alternative medicine" for that indication. Valerius Tygart (talk) 22:24, 18 March 2018 (UTC)

An international non-profit non-biased association whose specialty is supportive care for cancer treatments, known as the Multinational Association for Supportive Care in Cancer (MASCC), endorses LLLT for the prevention of Oral Mucositis. Demonstration of a lack of bias of MASCC towards LLLT is illustrated in their recommendations on a number of different treatments, for and against, and found here.[19]. The MASSCC’s endorsement of LLLT for Prevention of OM is supported by their systematic review, previously referenced. Moreover, this endorsement does not stand alone, supported, for example, by a meta-analysis in Current Opinion in Oncology,[20] which concludes that "It is now imperative to include photomedicine using LLLT as a possible mode of prophylactic and therapeutic intervention in the management protocol of oral mucositis in cancer patients."

Whether or not the intention is to compare LLLT to psychic surgery or chiropractic, when the article contains "is a form of alternative medicine" within the first 10 words, it is comparing it to any and all fields which are described as alternative medicine. It is describing LLLT as "disproven, unproven, impossible to prove, or excessively harmful in relation to their effect". But as shown, at minimum LLLT has been proven to be clinically effective for the treatment of oral mucositis and therefore does not meet the definition of alternative medicine.