Sundhedsudvalget 2020-21
SUU Alm.del Bilag 200
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J Pain Manage 2020;13(1):57-62
ISSN: 1939-5914
© Nova Science Publishers, Inc.
Low level laser therapy and myofascial pain
Richard Evan Steele
, MD, MPH
Klinikken Livet, Sejs, Silkeborg, Denmark
An effective treatment modality leading to freedom from
pain for whiplash syndrome, tension headache and post-
concussion syndrome is presented. The background and
theoretical basis of low level laser therapy is presented.
Five cases representing patients treated with low level laser
therapy are reported. The need for financing is discussed.
Keywords:
Inflammation, myofascial pain, whiplash
syndrome, tension headache, post-concussion syndrome
Abstract
Introduction
There are at least 300,000 and possibly 500,000 to
600,000 Danes suffering from more or less chronic
myofascial (myos is Greek for muscle and fascie is
Latin for ligament) pain. This figure is gleaned from
my experience as a municipal medical consultant with
approximately 10,000 cases over my table, where
about half of these had myofascial pain syndromes as
their presenting issue
–
whiplash syndrome, tension
headache, post-concussion syndrome, lower back pain
and many others. The number is derived by taking the
percentage of the population locally and multiplying
this by the total population.
The most common and well-known examples
of myofascial pain are whiplash syndrome, post-
concussion syndrome, and tension headache. This is a
very poorly researched area, and my observations are
based on my own experience. Other less common
myofascial pains include frozen shoulder, mouse arm,
tennis and golf elbow, lower back pain, facet joint
syndrome, groin pain, bursitis coxae, unspecific joint
pain in general and unspecific muscle pain. I have
been unable to find literature to document this. This
also is based upon my own experience.
All of these syndromes are characterized by a
lack of specific treatments and so far, no generally
applicable, effective solution has been described.
Correspondence:
Richard Evan Steele MD, MPH, PDC,
BCSPHM Tele: +45 2216 1923.
Email: [email protected]
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58
Richard Evan Steele
the symptoms disappear. This is evidenced by my
experience.
The past efforts have not been satisfactory.
Although also not based in the literature, no treatment
modality to date has been successful. The same
applies to tension states that cause pain in other body
parts than in the neck and in the head. It is clearly
more difficult to detect tension in the deeper muscles,
but a thorough history and prior examination with
blood samples (exclusion of cancer, rheumatoid
arthritis and vitamin D deficiency), ultrasound, X-ray,
CT and/or MRI scan, which exclude more serious
causes of pain, are usually negative in myofascial pain
patients. When all studies show normal results, one
can conclude that muscle tension and/or inflamed
tendons and/or joints are the cause of the pain.
LLLT made its debut in Hungary in the early
1960s. A Hungarian surgeon Edre Mester (EM) has
been credited with using it for the first time (2). It was
shortly after the ruby laser was put into use. During
experiments with mice where he wanted to demonstr-
ate the effect on induced skin tumors which he could
not detect, however, he noted difference in the hair
growth rate in the treated group compared with the
untreated group (3). Since then, attempts have been
made to use LLLT over a number of conditions, of
which myofascial pain is the area where the greatest
effect is achieved (4). There are numerous laser
devices on the market, but the device that is best
documented and with EU approval is LX2 from Thor
Laser in the UK. LLLT has been the subject of study
at the Harvard University School of Medicine, which
has published an account of the mechanism of action
(5). It is a biphasic light source with a visible element
of 720 nm and an invisible laser light of 613 nm. The
visible light does not penetrate the skin, but the laser
beam reaches 5-6 cm. under the skin, depending on
the tissue type. There is no complete clarity on how it
works, but there is no doubt that it acts as a powerful
antioxidant locally. The role of antioxidants in reduc-
ing inflammation is well described (6). It is less clear
that myofascial pain is dependent on inflammatory
processes, but what else should it be? It is further
well-described that LLLT acts anti-inflammatory (7).
The muscles reveal varying degrees of affection
by stress. It can be purely mental stress that affects the
muscles and various physical stresses that become
chronic pain syndromes. Head trauma, including
Again here, there is no literature documenting this,
but the issues are plain for anyone dealing with these
patients. This article has three purposes. The first is to
describe the importance of examining the condition of
the muscles when facing patients with myofascial
pain. The second is to describe low-level laser therapy
(LLLT) as an effective therapeutic form for myo-
fascial pain, and the third is to illustrate the effect of
this treatment with some examples.
No one knows how many patients with tension
headache have been diagnosed with migraine, but
there is no doubt that this misdiagnosis exists. This is
again one of those truths that everyone knows, but
that no one has been able to document. This is one of
the common elements of our methodology, that we
are perfectly capable of documenting what we do
right, but horribly incapable of documenting what we
do wrong. It is wasteful and/or deleterious for our
patients. The main reason for this misdiagnosis is the
lack of examination of the condition of the neck
muscles, which is the cause of tension headaches. In
my experience, none of the patients I have examined
have ever had their neck muscles examined by any of
up to 35 different doctors and other therapists.
Examining the muscles of the neck, one can
determine whether or not platysma, the scalenes and
trapezius muscles have normal consistency or, as is
the case with patients with tension headaches, have
increased tension and often with myoses. It takes a
little training to complete a sufficient examination,
but everyone with reasonable fingertip sensibility,
knowledge of anatomy and pathophysiology can
easily learn to do a qualified exam of the tension
status of the neck. Specifically, myoses on the medial
scalene can cause visual disturbances that contribute
to the misdiagnoses (1).
The examination technique requires palpation of
the named muscles with a light hand, so that the
muscle structure can be felt through the skin. It is
decisive to examine the entire muscle. There is often a
significant difference from side to side, which makes
the discovery easier, as the difference is clearly felt. I
find it most expeditious to do the exam on a gurney
with a head holder so that the patient relaxes as much
as possible during the exam.
Once such tensions have been established, there
is a basis for referring to a clinic with experience in
resolving the tensions. When the tension is resolved,
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Low level laser therapy
concussion and whiplash, affects the neck muscles in
varying degrees of severity as tension and/or myoses
in the neck region. There is no obvious logical
explanation for why post-concussion patients have the
same tensions in the neck as whiplash patients, but
that this is the case is clear to anyone working with
both groups (8, 9).
A patient who could probably have been cured,
but who could not afford the treatment, and where
the municipality would not provide subsidies, is
explained below. Most of us have met such patients,
and the attitude is generally that one must learn to live
with it.
A middle-aged man was hit some years ago by a
car that did not yield as it should, while the man was
riding on a scooter. The collision was so forceful that
the patient was thrown over the car and landed first on
his head, then on his left shoulder. The helmet he was
wearing shattered. He was whisked to the emergency
room, which did not reveal any broken bones or
evidence of internal injuries, and he was sent home. In
the weeks following the accident, the symptom
complex that the patient was afflicted by developed.
The symptoms are severe, constant back pain, left
shoulder and upper arm pain, and fingers that sleep
more or less constantly, which is most pronounced on
the left side. In addition, he suffers from dizziness
almost constantly, which is worst when he is tired,
and frequent headaches. He needs rest often, but
cannot find peace. He sleeps badly at night due to
pain and tension, and must often rest during the day
for that reason. From the objective examination: The
body from the diaphragm and below is unaffected.
The left arm can be moved slightly backwards, but
not to the opposite hip. It cannot be pressed over the
horizontal passively (due to pain) or actively. Good
strength over the elbow, wrist and fingers. Right arm
is normal. All the muscles in the neck are very sore,
and with pronounced myoses in the platysma,
scalenes and trapezius, which are hard as wood on the
left side and quite firm on the right side. Down the
back, all muscles are very tense and hard from the top
down to the sacroiliac joint, no soreness below this
level.
This was a pronounced muscle-related problem
with severe myoses, which had been attempted treated
with physiotherapy and painkillers without effect. The
condition is treatable with LLLT and massage. At
59
least 30 treatment sessions would have been
necessary, presumably taking 45 minutes per session
although more treatments cannot be ruled out, dep-
ending on the result. The end-result would probably
have been full recovery and return to workability, but
at least a significant improvement would be achieved,
and most likely a freedom from medication. The
patient wanted to give the treatment a try, but since
there was no financing available, the case did not
continue.
Methods
Treatment with LLLT is delivered via a probe which
is placed on the skin over the target muscle. It is not
important that the skin is bare, but it does help to
identify the underlying structures. The apparatus has
two settings that are adjustable, that is the frequency
of the flashes of the given light and the duration of the
treatment. The frequency can be set from 2.5 Hz up to
continuous over 12 increments, and the duration can
be between five seconds and five minutes, also over
12 increments. Only two of the settings were used in
this study that is 2.5 Hz lasting 30 seconds, and
continuous lasting two minutes. Treating a whiplash
patient, which typically takes half an hour, typically
includes a full treatment for all three scalene muscles,
and varying portions of platysma and trapezius. These
are treated with 2,5 Hz for 30 seconds per site. C3,
C4, and C5 are given continuous light for 2 minutes
per site. The probe heats up during use, but not to a
dangerous level. It heats up to about 39°C before
giving off as much heat as it creates. The tolerance of
this heat varies extremely in patients. I switch
between two identical probes so that one can cool off
while the other is in use. A 40 mm probe delivers 5 W
and penetrates 5 to 6 cm under the skin. A 65 mm
probe delivers 1 W and penetrates approximately 1
cm under the skin. Experience dictates that treatment
every other day is optimal. The duration of the
treatment in terms of number of sessions varies
extremely, from 10 to over 100 sessions until freedom
from pain. Meanwhile, an average number is from 30
to 40. To date, no damage or side effects have been
reported with LLLT. The only danger that has to be
prevented is looking directly into the laser beam
which can damage the retina.
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Richard Evan Steele
a series of treatments with LLLT and massage and the
physical training I directed for the patient, he was
completely free of the medicine and had a slight
headache approximately once a week that did not
require medication. His neck muscles were without
myoses, but still a little tense. The treatment was
completed 2 years ago, and the condition has
remained pain free.
Patitent 2 was a middle aged man who two years
before the exam in my clinic, was involved in a
classic rear-end
collision that hit the patient’s car with
such speed that neither of the cars could drive from
the scene of the accident. The patient was wearing a
seat belt and airbags were released. As usual for these
cases, the primary examination at the hospital was
without special findings. Approximately one year
after the accident, the patient was awarded 8%
disability and had been diagnosed with incipient
dementia due to his reduced memory and concentr-
ation (common accompanying symptoms of whiplash
syndrome). Again, no one in the process had exam-
ined the patient's neck muscles. When I met the
patient, he had severe tension in the neck muscles and
myoses in the medial and posterior scalenes as well as
in the trapezius near his cranium and in the MCL.
After a series of 32 treatments he had become pain
free, his neck muscles relaxed, and he had regained
his memory and concentration. The treatment has
been completed three years ago and the condition has
remained pain free.
Patient 3 was a young woman suffering from
whiplash syndrome after two rear-end collisions. She
had constant headaches, strained neck muscles and
was depressed all the time. After a few treatments she
felt much better, and her treatment could end after
nine sessions. The patient had no longer any pain and
a relaxed neck. She had regained her energy and was
happy again (an unusually short process). The
treatment has been completed three years ago and the
condition has remained pain free.
Patient 4 was a middle-aged man who suffered a
concussion of medium severity approximately three
years previous to his appearance in the clinic. He had
been examined by neurologists, neurosurgeons and
his own GP and treated with various measures,
including physiotherapy and strong painkillers. He
suffered from severe, daily headaches, difficulty in
concentration and memory and pain in the neck and
Results
There have been 178 patients in my clinic until now,
and of these 25 with whiplash syndrome, 19 with
post-concussion syndrome and 23 with tension
headache. All of these patients have become pain-
free, none of them have relapsed. The rest of the
patient population is a mix of various diagnoses, all of
which have myofascial origins. There have been a
number of scar tissue patients, and patients with
eczema which have all improved significantly. None
of the patients have continued with the same medicine
that they took when they came to the clinic after
ended treatment. This attests to the power of the
treatment. Some patients have presented with pain
syndromes that do not make any sense in a traditional
medical model, but LLLT helped them nonetheless.
The following five examples will illustrate the
effect of treatment with LLLT. These have been
chosen to represent their case type. Any of the N=178
could have been chosen. The point is to illustrate the
power of the treatment.
Patient 1 was a young man who had fallen off a
horse 4 years earlier and had hit his head and neck
and his back on the hard ground underneath. There
were no immediate signs of major damage and no
visible wounds. In the weeks following the fall, the
boy developed a severe, constant headache, which
was the subject of numerous studies. Among other
things, a syringomyeli was detected at the L1 level,
low pressure in the spinal canal and a moderate
Scheuermann. None of these conditions could be
linked to the headache. Various neurosurgical
departments, pediatric wards and other specialists had
found and accepted indication for treatment with
Tradolan, Ibumetin and Paracetamol as well as
Omeprazole to protect against the side effects of the
Ibumetin. There was no focus on the neck muscles.
On one out of approximately 100 pages of docum-
entation in the case, there was one sentence describing
the tense neck muscles by a physiotherapist. This
passage did not have any consequence that one could
glean from the documentation. When I met the
patient, he had a very knotty neck, where especially
the medial scalene was a chain of myoses, which was
extremely sore. There were, as is usual for this type of
patient, large myoses in trapezius both near the
cranium and in the mid-clavicular level (MCL). After
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Low level laser therapy
back. His physical condition made him so depressed
that he had seriously considered taking his own life.
After approximately 10 treatments, his medication
could be reduced. The headache and neck tension
gradually disappeared. Life returned little by little,
and after 40 sessions he could be discharged without
medication and without pain. His memory and
concentration had returned and he could get back to
his working life. The treatment was completed 3 years
ago and the condition has remained pain free.
Patient 5 was a middle-aged woman who slipped
and fell on ice in the winter and hit the back of her
head. She had a very bad time during the ensuing
days. It went better for a short while, but after a few
weeks, headaches and neck tension started. This
increased over a couple of months and remained
unchanged until she presented in the clinic about half
a year after the accident. She had been at a pain center
where they had put her on treatment with pain
medication. In my clinic she was treated with LLLT
and massage. It took about seven sessions before she
could feel any improvement, and after approximately
11 treatments, she could discontinue one of two
painkillers. After approximately 18 treatments, she
could stop using the other, and within a few weeks
she was completely free from headaches. After 34
sessions, she had fully recovered and was able to go
to work again. She was happy and cheerful again. The
treatment is completed two years ago, and the
condition has remained pain free.
All 178 patient records have the same level of
documentation and follow-up. LLLT in the hands of
an experienced clinician is an effective treatment for
myofascial pain.
61
documentation and the good experience, the treatment
has not yet been taken on any payer's agenda in
Denmark, so the treatment must be patient-financed,
which excludes most people with chronic pain from
the treatment. Most of the patients with myofascial
pain have quite limited funds to pay with as they live
either on sick pay, cash benefits or disability pension
(evidenced by my extensive experience with these
patient groups).
There are three main reasons why public clinics
have not taken LLLT on the program. The first and
most important is lack of knowledge of the therapy
and its effect, which this article attempts to address.
The second is the time spent with the individual
treatment, typically half an hour, sometimes less,
sometimes more. The third is the price of the equip-
ment, which is around DKK 80,000.
LLLT is widespread in the UK, USA and Canada
but not yet in the Scandinavian countries. Payment
from public or insurance-based payers would allow
many more to afford the treatment, thus bringing
many back to productive lives that are now unable to
work.
Ethical compliance
The authors have stated all possible conflicts of
interest within this work. The authors have stated
all sources of funding for this work. If this work
involved human participants, informed consent was
received from each individual. If this work involved
human participants, it was conducted in accordance
with the 1964 Declaration of Helsinki. If this work
involved experiments with humans or animals, it was
conducted in accordance
with the related institutions’
research ethics guidelines.
Discussion
A thorough knowledge of anatomy and patho-
physiology is crucial. In practice, this means that one
must be medically trained to achieve the best results.
To date, there is no agreement on the effect of laser
therapy in the literature, but in my experience
amazing results were obtained with this technique. In
my clinic, there is thus a 100% success rate with
whiplash, tension headache and post-concussion
syndrome (N = 178 at the time of writing). Freedom
from pain is the dependent variable. In spite of the
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Submitted:
December 02, 2019.
Revised:
January 01,
2020.
Accepted:
January 07, 2020.