Back Pain

Ann Intern Med. 2017 Feb 14. doi: 10.7326/M16-2367. [Epub ahead of print]

Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice Guideline From the American College of Physicians.

Qaseem A1, Wilt TJ1, McLean RM1, Forciea MA1; Clinical Guidelines Committee of the American College of Physicians.

Author information

  • 1From the American College of Physicians and Penn Health System, Philadelphia, Pennsylvania; Minneapolis Veterans Affairs Medical Center, Minneapolis, Minnesota; and Yale School of Medicine, New Haven, Connecticut.



The American College of Physicians (ACP) developed this guideline to present the evidence and provide clinical recommendations on noninvasive treatment of low back pain.


Using the ACP grading system, the committee based these recommendations on a systematic review of randomized, controlled trials and systematic reviews published through April 2015 on noninvasive pharmacologic and nonpharmacologic treatments for low back pain. Updated searches were performed through November 2016. Clinical outcomes evaluated included reduction or elimination of low back pain, improvement in back-specific and overall function, improvement in health-related quality of life, reduction in work disability and return to work, global improvement, number of back pain episodes or time between episodes, patient satisfaction, and adverse effects.


The target audience for this guideline includes all clinicians, and the target patient population includes adults with acute, subacute, or chronic low back pain.


Given that most patients with acute or subacute low back pain improve over time regardless of treatment, clinicians and patients should select nonpharmacologic treatment with superficial heat (moderate-quality evidence), massage, acupuncture, or spinal manipulation (low-quality evidence). If pharmacologic treatment is desired, clinicians and patients should select nonsteroidal anti-inflammatory drugs or skeletal muscle relaxants (moderate-quality evidence). (Grade: strong recommendation).


For patients with chronic low back pain, clinicians and patients should initially select nonpharmacologic treatment with exercise, multidisciplinary rehabilitation, acupuncture, mindfulness-based stress reduction (moderate-quality evidence), tai chi, yoga, motor control exercise, progressive relaxation, electromyography biofeedback, low-level laser therapy, operant therapy, cognitive behavioral therapy, or spinal manipulation (low-quality evidence). (Grade: strong recommendation).


In patients with chronic low back pain who have had an inadequate response to nonpharmacologic therapy, clinicians and patients should consider pharmacologic treatment with nonsteroidal anti-inflammatory drugs as first-line therapy, or tramadol or duloxetine as second-line therapy. Clinicians should only consider opioids as an option in patients who have failed the aforementioned treatments and only if the potential benefits outweigh the risks for individual patients and after a discussion of known risks and realistic benefits with patients. (Grade: weak recommendation, moderate-quality evidence).

J Back Musculoskelet Rehabil. 2016 Jul 21. [Epub ahead of print]

The effects of two different low level laser therapies in the treatment of patients with chronic low back pain: A double-blinded randomized clinical trial.

Kolda? Do?an ?1, Ay S2, Evcik D3.

Author information

  • 1Department of Physical Rehabilitation and Medicine, Antalya Training and Research Hospital, Antalya, Turkey.
  • 2Department of Physical Rehabilitation and Medicine, School of Medicine, Ufuk University, Ankara, Turkey.
  • 3Department of Therapy and Rehabilitation, Haymana Vocational Health School, Ankara University, Haymana, Ankara, Turkey.



The purpose of this study was to compare the effectiveness of two different laser therapy regimens on pain, lumbar range of motions (ROM) and functional capacity in patients with chronic low back pain (CLBP).


Forty nine patients with CLBP were randomly assigned into two groups. Group 1 (n= 20) received hot-pack + laser therapy 1 (wavelength of 850 nm Gallium-Aluminum-Arsenide (Ga-Al-As) laser); group 2 (n= 29) received hot-pack + laser therapy 2 (wavelength of 650 nm Helyum-Neon (He-Ne), 785 ve 980 nm Gal-Al-As combined plaque laser) for 15 sessions. Pain severity, patient’s and physician’s global assessments were evaluated with visual analogue scale (VAS). Modified Schober test, right and left lateral flexion measurements were done. Modified Oswestry Disability Questionnaire (MODQ) was used for evaluation of functional disability. Measurements were done before and after the treatment.


After treatment there were statistically significant improvements in pain severity, patient’s and physician’s global assessment, ROM and MODQ scores in both groups (P< 0.05). After the treatment there were statistically significant differences between the groups in lateral flexion measurements and MODQ scores (P< 0.05) except in pain severity, Modified Schober test, patient’s and physician’s global assessments (P> 0.05) in favor of those patients who received combined plaque laser therapy (group 2).


Laser therapy applied with combined He-Ne and Ga-Al-As provides more improvements in lateral flexion measurements and disability of the patients, however no superiority of the two different laser devices to one another were detected on pain severity.

Arthritis Res Ther. 2015 Dec 15;17(1):360.

The effectiveness of low-level laser therapy for nonspecific chronic low back pain: a systematic review and meta-analysis.

Huang Z1,2, Ma J3, Chen J4, Shen B5, Pei F6, Kraus VB7,8.

Author information
1Department of Orthopedic Surgery, West China Hospital, West China Medical School, Sichuan University, No. 37 Wainan Guoxue Road, Chengdu, Sichuan Province, People’s Republic of China.
2Duke Molecular Physiology Institute, Duke University School of Medicine, Duke University, PO Box 104775, Room 51-205, Carmichael Building, 300 North Duke Street, Durham, 27701-2047, NC, USA.
3Department of Orthopedic Surgery, West China Hospital, West China Medical School, Sichuan University, No. 37 Wainan Guoxue Road, Chengdu, Sichuan Province, People’s Republic of China.
4West China School of Stomatology, Sichuan University, No. 14, Third Section, Renmin Road South, Chengdu, 610041, Sichuan Province, People’s Republic of China.
5Department of Orthopedic Surgery, West China Hospital, West China Medical School, Sichuan University, No. 37 Wainan Guoxue Road, Chengdu, Sichuan Province, People’s Republic of China.
6Department of Orthopedic Surgery, West China Hospital, West China Medical School, Sichuan University, No. 37 Wainan Guoxue Road, Chengdu, Sichuan Province, People’s Republic of China.
7Duke Molecular Physiology Institute, Duke University School of Medicine, Duke University, PO Box 104775, Room 51-205, Carmichael Building, 300 North Duke Street, Durham, 27701-2047, NC, USA.
8Division of Rheumatology, Department of Medicine, Duke University School of Medicine, Durham, NC, 27710, USA.
In recent decades, low-level laser therapy (LLLT) has been widely used to relieve pain caused by different musculoskeletal disorders. Though widely used, its reported therapeutic outcomes are varied and conflicting. Results similarly conflict regarding its usage in patients with nonspecific chronic low back pain (NSCLBP). This study investigated the efficacy of low-level laser therapy (LLLT) for the treatment of NSCLBP by a systematic literature search with meta-analyses on selected studies.
MEDLINE, EMBASE, ISI Web of Science and Cochrane Library were systematically searched from January 2000 to November 2014. Included studies were randomized controlled trials (RCTs) written in English that compared LLLT with placebo treatment in NSCLBP patients. The efficacy effect size was estimated by the weighted mean difference (WMD). Standard random-effects meta-analysis was used, and inconsistency was evaluated by the I-squared index (I2).
Of 221 studies, seven RCTs (one triple-blind, four double-blind, one single-blind, one not mentioning blinding, totaling 394 patients) met the criteria for inclusion. Based on five studies, the WMD in visual analog scale (VAS) pain outcome score after treatment was significantly lower in the LLLT group compared with placebo (WMD?=?-13.57 [95 % CI?=?-17.42, -9.72], I2?=?0 %). No significant treatment effect was identified for disability scores or spinal range of motion outcomes.
Our findings indicate that LLLT is an effective method for relieving pain in NSCLBP patients. However, there is still a lack of evidence supporting its effect on function.
J Lasers Med Sci. 2015 Fall;6(4):157-61. doi: 10.15171/jlms.2015.11. Epub 2015 Oct 27.

Monochromatic Infrared Photo Energy Versus Low Level Laser Therapy in Chronic Low Back Pain.

Ammar TA1.
Author information
1Department of Basic Science, Faculty of Physical Therapy, Cairo University, Cairo, Egypt.
Low back pain (LBP) is the most common musculoskeletal disease. Monochromatic infrared photo energy (MIPE) and low level laser therapy (LLLT) are light modalities used to reduce pain and increase blood flow. The aim of this study was to compare the effects of the MIPE and LLLT in reducing functional disability and pain as well as improving lumbar range of motion (ROM) in patients with chronic LBP.
Seventy participants with LBP completed the program and were randomly assigned into 2 groups. Group 1 (n = 35) received MIPE and therapeutic exercises. Group 2 (n = 35) received LLLT and therapeutic exercises. Both groups received 2 visits per week for 6 weeks. Outcome measures were functional rating index (FRI), visual analogue scale (VAS) and modified-modified Schober test at baseline and after 6 weeks.
There were statistically significant improvements in functional disability, pain and lumbar ROM (P < .05) in each group. However, no significant differences were recorded between the groups (P > .05).
Therefore, MIPE and LLLT may play a role in treating chronic LBP and there are no differences between the two modalities in improving functional disability, pain and lumbar ROM in patients with chronic LBP.
Laser Ther. 2014 Sep 30;23(3):183-90. doi: 10.5978/islsm.14-OR-14.

A new standard of Efficacy for Low Level Laser Therapy (LLLT) in Pain Attenuation in Japan (a secondary publication).

Shiroto C1, Ohshiro T2.

Author information

  • 1Shiroto Clinic.
  • 2Ohshiro Clinic ; Japan Medical Laser Laboratory.


The assessment of the efficacy of low level laser therapy (LLLT) for pain attenuation varies among institutions, all having their own method of assessment with no common standards. At the author’s institution in the beginning, the patients were asked how they assessed their pain relief immediately after the treatment. They were to choose from excellent, good, fair, no change and poor. The overall efficacy rate was calculated by the numbers of patients scoring excellent and good, expressed as a percentage of the total number of patients. However, a large number of institutions have utilized the Visual Analogue Scale (VAS) or the Pain Relief Score (PRS) for the assessment of treatment; but even then, the evaluation could not be considered uniform. Therefore, the standardization of the efficacy rate was continuously discussed among the practitioners of LLLT, dating back to the 9(th) annual meeting of the Japan Laser Therapy Association (JaLTA) in 1997. It took four years (including the 1997 meeting) until finally an agreement was reached and a new standard of efficacy was presented at the 12(th) JaLTA meeting in 2000, based on the PRS. The new standard defined excellent as pain reduction in any treatment session from 10 to 0 or 1, good as reduction from 10 to 2?5, fair as reduction from 10 to 6?8, no change as a reduction from 10 to 9?10 and poor was defined as exacerbation of pain from 10 to 11 or greater. Efficacy rate was calculated by the number of patients scoring excellent and good expressed as a percentage of the total number of patients. For the purpose of reference, the VAS was to be used for patients receiving the treatment for the first time.

J Pain Res. 2015 May 26;8:253-6. doi: 10.2147/JPR.S84458. eCollection 2015.

Can intractable discogenic back pain be managed by low-level laser therapy without recourse to operative intervention?

Ip D1, Fu NY1.

Author information

  • 1Asia Medical Pain Centre, Mong Kok, Hong Kong, People’s Republic of China.



The aim of the study reported here was to investigate the possible clinical role of low-level laser therapy (LLLT) in discogenic back pain patients who failed to respond to a conventional physical therapy program to avoid recourse to operative intervention.


The paper reports on the long-term mean 5-year prospective follow-up of a patient cohort of 50 unselected patients visiting our tertiary referral pain center for discogenic back pain who had had a single-level lesion documented by magnetic resonance imaging followed by subsequent discography to confirm the affected disc being the pain generator. All of the patients who entered the study had failed response to a combination of nonsteroidal anti-inflammatory agents and had had not less than 3 months of conventional physical therapy. LLLT, at a wavelength of 810 nm wavelength emitted from a GaAIAs semiconductor laser device with 5.4 J per point and a power density of 20 mW/cm(2), was employed. The treatment regimen consisted of three sessions of treatment per week for 12 consecutive weeks.


All but one patient had significant improvement in their Oswestry Disability Index score, from a mean of 50% score to a mean of 10% score, at the end of treatment at 12 weeks. In addition, surprisingly, the improvement was found maintained at follow-up assessments 1 year and 5 years later. The one patient among the 50 patients who failed to respond eventually required surgery, while the others did not require surgery.


We conclude that LLLT is a viable option in the conservative treatment of discogenic back pain, with a positive clinical result of more than 90% efficacy, not only in the short-term but also in the long-term, with lasting benefits.

Photomed Laser Surg. 2014 Sep;32(9):490-4. doi: 10.1089/pho.2014.3715.

Effect of diode laser in the treatment of patients with nonspecific chronic low back pain: a randomized controlled trial.

Vallone F1, Benedicenti S, Sorrenti E, Schiavetti I, Angiero F.

Author information

  • 11 Galliera Hospital , Genoa, Italy .


Abstract Background data: Low back pain is a common, highly debilitating condition, whose severity is variable. This study evaluated the efficacy of treatment with Ga-Al-As diode laser (980?nm) with a large diameter spot (32?cm(2)), in association with exercise therapy, in reducing pain.


The present study aimed to evaluate the pain reduction efficacy of treatment with the Ga-Al-As diode laser (980?nm) in combination with exercise therapy, in patients with chronic low back pain (CLBP).


This study evaluated 100 patients with CLBP (mean age 60 years) who were randomly assigned to two groups. The laser plus exercises group (Laser+EX: 50 patients) received low-level laser therapy (LLLT) with a diode laser, 980?nm, with a specific handpiece [32?cm(2) irradiation spot size, power 20?W in continuous wave (CW), fluence 37.5J/cm(2), total energy per point 1200?J] thrice weekly, and followed a daily exercise schedule for 3 weeks (5 days/week). The exercises group (EX: 50 patients) received placebo laser therapy plus daily exercises. The outcome was evaluated on the visual analogue pain scale (VAS), before and after treatment.


At the end of the 3 week period, the Laser+EX group showed a significantly greater decrease in pain than did the EX group. There was a significant difference between the two groups, with average ? VAS scores of 3.96 (Laser+EX group) and 2.23 (EX group). The Student’s t test demonstrated a statistically significant difference between the two groups, at p<0.001.


This study demonstrated that the use of diode laser (980?nm) with large diameter spot size, in association with exercise therapy, appears to be effective. Such treatment might be considered a valid therapeutic option within rehabilitation programs for nonspecific CLBP.

Lasers Med Sci. 2014 May;29(3):1065-73. doi: 10.1007/s10103-013-1472-5. Epub 2013 Nov 2.

Long-term effect of high-intensity laser therapy in the treatment of patients with chronic low back pain: a randomized blinded placebo-controlled trial.

Alayat MS1, Atya AM, Ali MM, Shosha TM.

Author information

  • 1Basic Science Department, Faculty of Physical Therapy, Cairo University, 7 Ahmed Elziat Street from Eltahrir Street, Cairo, Egypt,


The aim of this study was to compare the effect of high-intensity laser therapy (HILT), alone or combined with exercise, in the treatment of chronic lowback pain (CLBP). A total of 72 male patients participated in this study, with a mean (SD) age of 32.81 (4.48) years. Patients were randomly assigned into three groups and treated with HILT plus exercise (HILT + EX), placebo laser plus exercise (PL + EX), and HILT alone in groups 1, 2, and 3, respectively. The outcomes measured were lumbar range of motion (ROM), pain level by visual analog scale (VAS), and functional disability by both the Roland Disability Questionnaire (RDQ) and the Modified Oswestry Disability Questionnaire (MODQ). Statistical analyses were performed to compare the differences between baseline and post-treatment measurements. The level of statistical significance was set as P < 0.05. ROM significantly increased after 4 weeks of treatment in all groups, then significantly decreased after 12 weeks of follow-up, but was still significantly more than the baseline value in groups 1 and 2. VAS, RDQ, and MODQ results showed significant decrease post-treatment in all groups, although the RDQ and MODQ results were not significantly different between groups 2 and 3. HILT combined with exercise appears to be more effective in patients with CLBP than either HLLT alone or placebo laser with exercise.

Vojnosanit Pregl.  2012 Aug;69(8):656-62.

Clinical and functional evaluation of patients with acute low back pain and radiculopathy treated with different energy doses of low level laser therapy.

Jovicic M, Konstantinovic L, Lazovic M, Jovicic V.


Institute for Rehabilitation, Belgrade, Serbia.



The main clinical phenomena in acute low back pain (LBP) with radiculopathy are pain and neurological disorders. Although some studies show that low level laser therapy (LLLT) has the ability to modulate inflammatory processes and relieve acute pain condition, the laser therapy dose protocol has not been yet completely established. The aim of this study was to investigate the effects of three different energy doses of LLLT in patients with acute LBP and radiculopathy.


The study included 66 patients with acute LBP and radiculopathy who had been randomly divided into three groups (22 patients each) received three different doses of LLLT. The patients were treated 5 times weekly, for a total of 10 treatments, with the following parameters: wave length 904 nm, frequency 3,000 Hz, average diode power 25 mW; energy dose of 0.1 J per point in the first group, 1 J per point in the second and 4 J per point in the third group; daily treatment time and accumulated energy were 16 s and 0.4 J in the first group, 160 s and 4J in the second group and 640 s and 16 J in the third group, respectively. The parameters of assessment before and after the therapy were: lumbar and leg pain measured by visual analogue scale (VAS), local and general functional changes (Schober test, manual muscle test, straight leg raise test and the modified North American Spine Society-Low Back Pain Outcome Instrument-NASS LBP).


Highly significant improvements (p < 0.01) were noted in all the groups after LLLT with respect to all the investigated parameters. The VAS scores were significantly lower in all the groups without a difference between the groups (p > 0,05). Functional improvements were better in the third group treated with the dose of 4 J per point than in other two groups (p < 0.05).


Three different energy doses of LLLT were equally effective in alleviating lumbar and leg pain without side effects, but the dose of 4 J per point seemed to be more effective in improving the activities of daily living and lumbar mobility.

Vojnosanit Pregl.  2011 Jan;68(1):57-61.

Low power laser in the treatment of the acute low back pain.

[Article in Serbian]
Mandi M, Rancié N.


Klinicki centar Nis, Klinika za fizikalnu medicinu, rehabilitaciju i protetiku, Nis, Srbija.


BECKGROUND/AIM: Acute low back pain (ALBP) is one of the most frequent painful conditions in the human population. The objective of the paper was to compare the efficacy of the low power laser (LPL) in the pain and the muscular spasm reduction with conservative methods of physical medicine.

METHOD: The prospective cohort study was done. The study involved 70 patients, both men and women, from 25 to 64 years of age with the diagnosis of ALBP. Two groups were formed. There were 40 patients in the first group and they were treated with the LPL with frequency of 73 Hz. The second group was the control one and it consisted of 30 patients who were treated with conservative methods of physical medicine (electrotherapy: diadynamic currents CP +/- 3 and CP +/- 3, interferent currents–90 Hz for 15 min; electrophoresis with novocaine). The ALBP were diagnosed by clinical examination and by the nuclear magnetic resonance imaging (NMRI). The low power laser–Gallium Arsenide (GaAs) was used. The laser sonde consisted of 4 laser diodes, each powered of 15 mW, wavelength 904 nm and with frequency 73 Hz. The total period of time for each treatment was 10 minutes and the total dose per treatment was 15 J. The intensity of acute low back pain was assessed by Roland’s scale. The degree of the spasm was assessed in the relaxed position and during movements.

Results. The average score in the first group before the onset of rehabilitation was 3.3 +/- 1.1 (Me = 3.0), and in the control group was 3.43 +/- 0.89 (Me = 3.0). After five treatments in patients who were treated with LPL the average score in Roland’s scale was decreased (1.12 +/- 1.3, Me = 2.0) and in the control group there were no changes. After 10 treatments with the LPL the analgesic effect was obtained in 82.5% of patients from the first group and in 20% of patients in the control group. The analgesic effect in patients of the first group was obtained after 7.5 +/- 2.1 treatments and in the second group after 17.9 +/- 3.2 treatments. The difference was statistically significant (t = 15.652173, p < 0.001). The spasm disappeared in 92.5% of patients in the first group and in 20% of patients in the control group after 7.02 +/- 2.2 and 17.9 +/- 3.2 treatments respectively. The difference was statistically significant (t = 15.652173, p < 0.001).

CONCLUSION: The pain and spasm reduction were obtained in the greater number of patients by usage of the LPL than by usage of conservative methods of physical medicine.

Ortop Traumatol Rehabil. 2010 May-Jun;12(3):225-36.

Comparative analysis of analgesic efficacy of selected physiotherapy methods in low back pain patients.

[Article in English, Polish]

Charlusz M, Gasztych J, Irzmaski R, Kujawa J.

Department of Internal Diseases and Cardiological Rehabilitation, Physiotherapy Ward, Medical Military Faculty, Medical University, Lodz.


BACKGROUND: Low back pain syndromes are one of the most frequent causes of movement limitation in populations of highly industrialized countries. They are listed as the main cause of inability to work among people of working age. Chronic pain and the associated limitation of movement underlie the quest for effective therapies. The use of ultrasound, LLLT, vacuum therapy with Ultra Reiz current in physical therapy of these patients prompts research over their effectiveness in the therapy of patients with low-back pain. The aim of the work was to evaluate the analgesic efficacy of LLLT, ultrasound, and vacuum therapy with Ultra Reiz current in patients with low back pain.

MATERIAL AND METHODS: The study involved 94 people divided into three groups (A,B,C). Group A (n=35) received a series of 10 low energy laser therapy sessions (wave length 808 nm, surface density of radiation 510 mW/cm(2), continuous wave form, scanning mode, a dose of 12 J/cm(2) on a surface of 100 cm(2) [10x10cm]). Patients in Group B (n=27) had ultrasound sessions with a wave intensity of 1 W/cm(2) for 3 minutes. Patients in Group C (n=32) underwent vacuum therapy (8 kPa) combined with Ultra Reiz current. Subjective pain assessment was carried out using a modified Latinen questionnaire and a visual analogue scale of pain intensity. Lumbosacral spine mobility was evaluated with the Schober test and the finger-to- floor test.

RESULTS: In Group A, following low energy laser therapy, a statistically significant decrease in pain intensity was observed, together with decreased analgesic consumption compared to the other groups. In Group C, following vacuum therapy combined with Ultra Reiz currents, a significant decrease in the frequency of pain was observed together with increased physical activity compared to both Groups A and B, assessed according to a modified Laitinen pain indicator questionnaire. The biggest improvement in global spine mobility and lumbosacral flexion was observed in Group C (vacuum therapy plus Ultra Reiz current) compared to the other groups. However, the most significant improvement in lower spine extension was noted in Group B (ultrasound).

CONCLUSIONS: 1. The study showed slightly higher analgesic efficacy of laser biostimulation in comparison to vacuum therapy combined with Ultra Reiz current in patients with low back pain. 2. A more prominent increase in lumbosacral spine mobility was observed after vacuum therapy combined with Ultra Reiz current and ultrasound therapy.

Photomed Laser Surg.. [Epub ahead of print] Received via PubMed on 12-19-09

Acute Low Back Pain with Radiculopathy: A Double-Blind, Randomized, Placebo-Controlled Study.

Konstantinovic LM, Kanjuh ZM, Milovanovic AN, Cutovic MR, Djurovic AG, Savic VG, Dragin AS, Milovanovic ND.

1 Clinic for Rehabilitation, Medical School , Belgrade, Serbia.

Abstract Objective: The aim of this study was to investigate the clinical effects of low-level laser therapy (LLLT) in patients with acute low back pain (LBP) with radiculopathy.

Background Data: Acute LBP with radiculopathy is associated with pain and disability and the important pathogenic role of inflammation. LLLT has shown significant anti-inflammatory effects in many studies.

Materials and Methods: A randomized, double-blind, placebo-controlled trial was performed on 546 patients. Group A (182 patients) was treated with nimesulide 200 mg/day and additionally with active LLLT; group B (182 patients) was treated only with nimesulide; and group C (182 patients) was treated with nimesulide and placebo LLLT. LLLT was applied behind the involved spine segment using a stationary skin-contact method. Patients were treated 5 times weekly, for a total of 15 treatments, with the following parameters: wavelength 904 nm; frequency 5000 Hz; 100-mW average diode power; power density of 20 mW/cm(2) and dose of 3 J/cm(2); treatment time 150 sec at whole doses of 12 J/cm(2). The outcomes were pain intensity measured with a visual analog scale (VAS); lumbar movement, with a modified Schober test; pain disability, with Oswestry disability score; and quality of life, with a 12-item short-form health survey questionnaire (SF-12). Subjects were evaluated before and after treatment. Statistical analyses were done with SPSS 11.5.

Results: Statistically significant differences were found in all outcomes measured (p < 0.001), but were larger in group A than in B (p < 0.0005) and C (p < 0.0005). The results in group C were better than in group B (p < 0.0005).

Conclusions: The results of this study show better improvement in acute LBP treated with LLLT used as additional therapy.

J Manipulative Physiol Ther. 2008 Mar;31(3):191-8.

Comparison of 3 physical therapy modalities for acute pain in lumbar disc herniateion measured by clinical evaluation and magnetic resonance imaging.

Unlu Z<>, Tasci S<>, Tarhan S<>, Pabuscu Y<>, Islak S<>.

Department of Physical Medicine and Rehabilitation, Medical Faculty, Celal Bayar University, Manisa, Turkey.


OBJECTIVE: This study measures and compares the outcome of traction, ultrasound, and low-power laser (LPL) therapies by using magnetic resonance imaging and clinical parameters in patients presenting with acute leg pain and low back pain caused by lumbar disc herniation (LDH).

METHODS: A total of 60 patients were enrolled in this study and randomly assigned into 1 of 3 groups equally according to the therapies applied, either with traction, ultrasound, or LPL. Treatment consisted of 15 sessions over a period of 3 weeks. Magnetic resonance imaging examinations were done before and immediately after the treatment. Physical examination of the lumbar spine, severity of pain, functional disability by Roland Disability Questionnaire, and Modified Oswestry Disability Questionnaire were assessed at baseline, immediately after, and at 1 and 3 months after treatment.

RESULTS: There were significant reductions in pain and disability scores between baseline and follow-up periods, but there was not a significant difference between the 3 treatment groups at any of the 4 interview times. There were significant reductions of size of the herniated mass on magnetic resonance imaging after treatment, but no differences between groups.

CONCLUSIONS: This study showed that traction, ultrasound, and LPL therapies were all effective in the treatment of this group of patients with acute LDH. These results suggest that conservative measures such as traction, laser, and ultrasound treatments might have an important role in the treatment of acute LDH.

Aust J Physiother. 2007;53(3):155-60

In chronic low back pain, low level laser therapy combined with exercise is more beneficial than exercise alone in the long term: a randomised trial.

Djavid GE<>, Mehrdad R<>, Ghasemi M<>, Hasan-Zadeh H<>, Sotoodeh-Manesh A<>, Pouryaghoub G<>.

Academic Center for Education, Culture and Research, Iran.

QUESTION: Is low level laser therapy an effective adjuvant intervention for chronic low back pain?

DESIGN: Randomised trial with concealed allocation, blinded assessors and intention-to-treat analysis.

PARTICIPANTS: Sixty-one patients who had low back pain for at least 12 weeks.

INTERVENTION: One group received laser therapy alone, one received laser therapy and exercise, and the third group received placebo laser therapy and exercise. Laser therapy was performed twice a week for 6 weeks.

OUTCOME MEASURES: Outcomes were pain severity measured using a 10-cm visual analogue scale, lumbar range of motion measured by the Schober Test and maximum active flexion, extension and lateral flexion, and disability measured with the Oswestry Disability Index on admission to the study, after 6 weeks of intervention, and after another 6 weeks of no intervention.

RESULTS: There was no greater effect of laser therapy compared with exercise for any outcome, at either 6 or 12 weeks. There was also no greater effect of laser therapy plus exercise compared with exercise for any outcome at 6 weeks. However, in the laser therapy plus exercise group pain had reduced by 1.8 cm (95% CI 0.1 to 3.3, p = 0.03), lumbar range of movement increased by 0.9 cm (95% CI 0.2 to 1.8, p < 0.01) on the Schober Test and by 15 deg (95% CI 5 to 25, p < 0.01) of active flexion, and disability reduced by 9.4 points (95% CI 2.7 to 16.0, p = 0.03) more than in the exercise group at 12 weeks.

CONCLUSION: In chronic low back pain low level laser therapy combined with exercise is more beneficial than exercise alone in the long term.

EMLA Laser Health J 2007;2:46-67

European Medical Laser Association (EMLA)

The effect of low level laser therapy on the intensity of chronic low back pain

H. Morshedi, M. Ebthehaj, M. Noorozi, F. Riazi  University of Qazvin Medical Sciences, Iran

Low back pains cause the unpleasant memory and important effects such as: reduction of activity, disability, job changing, irregular usage of oral and injection drugs, allocatin a perceptible fund of the family income and finally changing the mental images. The study has been done to determine the effect of low level laser therapy on the intensity of low back pack pains.

This double blind clinical trial has been done in 2004 at medical laser center of pastor-no hospital in Tehran. 30 patients with chronic low back pain (because of lumbago) in the range of 30-60 years old were randomly divided to the Case and Control groups. Both of two groups went under treatment for 3 times in a week for about 4 weeks. Applied laser in Case group was continuous red light laser and pulse infrared with Mustang system with 890 nm wavelength and 4-6 J/cm dose (energy), and was irradiated on the mentioned vertebral bodies and spinous processes. The spastic points on paravertebral areas with 0.5-1 J/cm dose, was irradiated in scan form. The trigger points with 1-2 J/cm and also the nonspastic vertebral areas with 2-4 J/cm went under irradiation. The power of continuous red light was 10 mW and pulse infrared light (GaAlAs) was 80 W. Treatment in Control group was done with off laser. Efficacy of treatment were evaluated with pain questionnaire and thermography. Data was analyzed with K square statistical test.

The Case group patients has significant symptomatic relief without any side effect. Due to the pain questionnaire and thermography, in first and second week, there wasn’t any significant difference between two groups (P>0.05) and from the third week, in regard to the pain questionnaire and thermography a significant difference between two groups was found (p<0.05).

Based on the findings, if low level laser is irradiated on the mentioned are a with appropriate dose, wavelength and exposure time, it will be a suitable and less aggressive method without and side effect on the low back pains.

Photomed Laser Surg. 2007 Feb;25(1):40-4.

Percutaneous laser disc decompression for lumbar disc hernia: indications based on Lasegue’s Sign.

Iwatsuki K<>, Yoshimine T<>, Awazu K<>.

Department of Neurosurgery, Osaka University Medical School, Osaka, Japan.


OBJECTIVE: The present study was conducted to establish reasonable indications of patient neurological manifestations for use of percutaneous laser disc decompression (PLDD).

BACKGROUND DATA: PLDD is a less invasive surgical procedure for lumbar disc hernia, whose indications have been described on the basis of radiographical findings.

METHODS: Sixty-five consecutive patients (45 men and 20 women) with lumbar disc hernia were treated with PLDD by applying a diode laser (wavelength 805 nm). A total of 450-1,205 joules (average, 805.5 joules) were delivered per disc. All patients suffered from radicular pain. They were divided based on the presence of Lasegue’s sign. The post-procedure results at 1 week and 1 year were compared between the groups.

RESULTS: PLDD was effective for patients with Lasegue’s sign (80.0%), but ineffective for those without the sign.

CONCLUSION: The present study suggests that Lasegue’s sign in patients is an indication of PLDD for lumbar disc hernia.

Neurol Res. 2005 Apr;27(3):319-23.

The effect of laser irradiation for nucleus pulposus: an experimental study.

Iwatsuki K<>, Yoshimine T<>, Sasaki M<>, Yasuda K<>, Akiyama C<>, Nakahira R<>.

Department of Neurosurgery, Osaka University Medical School, 2-2 Yamadaoka, Suita, Osaka 565-0871, Japan.


BACKGROUND: The radicular pain caused by disc herniation can be explained by two mechanisms: the compression of the nerve root by the herniated disc or the irritation of the nerve root due to chemical factors. Percutaneous laser disc decompression (PLDD) was introduced for the treatment of lumbar disc hernias in the 1980s. Decompression of the nerve root is assumed to be an effective therapeutic mechanism for PLDD. However, laser irradiation might reduce the chemical factors that cause nerve root irritation by altering intra-disc proteins. We used nerve conduction velocities (NCV) and levels of two chemical factors to evaluate the differences between the two groups in this in vivo study.

METHODS: All rabbits had the nerve root in contact with the leakage from the nucleus pulposus. One group underwent laser irradiation for the leaking nucleus pulposus including the incision site of the disc and nucleus pulposus itself. The levels of two chemical factors, prostaglandin E2 and phospholipase E2, in the intervertebral disc were measured before and after laser irradiation.

RESULTS: NCV in the laser-irradiated group was significantly faster than in the non-laser-irradiated group. The levels of chemical factors were significantly reduced after laser irradiation.

CONCLUSIONS: One of the mechanisms thought to be responsible for PLDD’s effectiveness is a decrease in the chemical factors through protein alteration in the intervertebral disc by laser irradiation.

Lik Sprava. 2004 Dec;(8):57-63.

Complex treatment of elderly patients with pain reflectory manifestations of lumbosacral osteochondrosis and peripheral circulation disorder

[Article in Ukrainian]

Macheret IeL<>, Dzhuzha TV<>.

Involutional age makes difficult the treatment of pain syndromes of vertebra origin. Concomitant diseases, age stress syndrome, hormone disbalance constrain the management of the disease. Combination of laser stimulation, reflexotherapy, psychodiagnostics and psychocorrection enhances the efficiency of the treatment of pain syndromes in patients with lumbo-sacral radiculitis and peripheral circulation disorder.

Lik Sprava. 2004 Dec;(8):53-7.

Electrophysiological changes in a complex treatment of lumbosacral pain syndrome in patients of different age group

[Article in Ukrainian]

Sereda VH<>.

The influence of two methods of treatment (pharmacological and combination with infra-red laser puncture and manual therapy) on clinical picture, electromyographic indices in 165 patients of different age group with lumbosacral radiculitis has been studied by the author. The use of these methods in treatment of such patients is substantiated by the obtained data.


1999; 27(4):24.

Relief of low back pain with low-reactive laser acupuncture techniques.

Kurland H D. Aku.

12 patients who had refractory low back pain problems related to spinal arthritis and complicated by herniated discs were treated with GaAs laser acupuncture. Nogier frequencies 2.82 and 146 were mainly used. Used points not indicated in abstract. Effectiveness was observed with immediate improvement in pain and muscle spasms. Elimination of pain medication and improvement in functional activities was progressive in 10 of the 12 patients. Two patients with spinal stenosis failed to maintain improvement for more than a brief period. One had surgical relief of the stenosis and then responded with relief of post-operative symptoms.

GaAs is effective in chronic low back pain.

Two abstracxts from Lasers Surg Med. 1998; Suppl. 10, p. 6

1)Prof. Soriano in Rosario, Argentina, performed a double blind trial with elderly people suffering from chronic low back pain. After a through medical examination the patients were divided into two groups. One received GaAs 4J per point and one received sham irradiation. Ten consecutive sessions were done, one every day. Pain was evaluated through a VAS scale at the beginning and at the end of the treatment period. Treatment was effective in 71% in the laser group and 36% in the sham group. The pain disappeared completely in 45% in the laser group and 15% in the sham group. During the follow up 35% of the patients in the laser group who had relieved their pain more than 60% relapsed, compared to 70% in the control group. There were no side effects.

2)Effects of low energy laser therapy on herniated lumbar discs. Gruszka M et al. Gruszka (Buenos Aires)  treated 15 patients with one or more protruded lumbar disc herniations with GaAs 904 nm, with a dose of 9J on each point, 20 to 25 points on the lumbar spine and on referred radicular pain points, 3 to 5 times a week during 4 months. Pain was relieved in 100%, gait and neurological signs improved in all patients, EMGs improved and CAT scans


Tatsuhide Abe, Abe Orthopaedic Clinic Futuoka City Fukuoka Prefecture Japan X12′

A 40-year-old woman presented at the Abe Orthopedic Clinic with a 2-year history of lower hack pain and pain in the left hip and leg diagnosed as a ruptured disc between the 5th lumbar/lst sacral vertebrae. The condition had failed to respond to conventional treatment methods including pelvic traction, nonsteroid anti-inflammatory drugs and aural block anesthetic injections. MRI scans were made of the affected disc, showing it protruding on the left side through the aural membrane. The gallium aluminum arsenide (GaAlAs) diode laser (830 nm, 60 mW) was used in outpatient therapy. and after 7 months, the patient’s condition had dramatically improved. demonstrated by motility exercises. This improvement was confirmed by further MRI scans, which showed clearly the normal condition of the previously herniated L5/SI disc.

Treatment of Low Back Pain

Kazuyoshi Zenba, the president of
Isehara Threrapeutic Institute

PHOTO:”Treatment of Low Back Pain” 

Low back pain is said to be a characteristic illness to human beings who started to walk in the upright position. This is caused by the poor posture, the decline of muscular strength and the fatness. In case the conventional therapy such as medical treatments or physical therapies are not effective to a low back pain patient, the low power laser therapy is recomended to take up.The low power laser can penetrate deep into the human body stimulates receptors of autonomous nervous system relieving the tension of sympathetic nerve and improves the blood circulation of entire body and affected part and mitigates the pain very quickly. Compared with conventional treatments, the effect of low power laser irradiation will continue for several hours and can be accumulated.Points of irradiation are tender points or indurated parts, 20~30sec/point, 3~5 minutes in total, if possible daily irradiation is recomended or 3~4 days a week.Recently, the radicular sciatica, which is difficult to be effected by low power laser has been found to be cured by the repoetition of very short time irradiation of high power laser. Please inform me through this association for more detaile information. (An example of laser treatment) The name of a disease: Protruded lumbar disc The birth day of the patient :October 10,1953, Sex: male
Development: On the following day when the patient went to dig bamboo shoots he tried to bring up a heavy goods from the floor. At that moment, he felt a strong pain at his back and became cannot move at all. He could not sleep through the night and was carried to our hospital. Laser treatment: Lying on his side we irradiated the low power laser to tender points of his low back 10~30 seconds at each point.Result of treatment: Soon after the first treatment, he became possible to keep sitting position and turn over while sleeping. After 4 time treatments, his pain was almost eliminated and started to drive his car.

ICMART ’97 International Medical Acupuncture Symposium, Nicosia, Cyprus, March 26-29 1997:

Low energy laser in the treatment of low back pain

S. Nikolic, Z. Trojacanec, I.J.Milankovic Institute of ME Physiology, Faculty of Medicine, Skopje, F.Y.R.O.M

Low back pain is felt in the low lumbar, lumbosacral, or sacroiliac region. Most low back pain is related to acute ligamentous (sprain) or muscular(strain) problems, which tend to be self limited, or to the more chronic osteoarthritis or ankylosing spondylitis of the lumbar area. The aim of the study was to explore the pain-alleviating effect of low level laser in low back pain .Thirty-five patients with low back pain have been treated with helium-neon laser type “Bistra” with wavelength 630 nm, average output 15 mW and an irradiance of 250 mW/cm2. The laser was locally applied to 11 sites on and around the low back. After scanning each point was treated for 30 sec, five times weekly for a total of ten treatments. The statistical analysis showed that the laser treated patients had a significant faster pain-alleviating effect compared with the 30 patients treated with medicaments only. Subjective response have been achieved after first three treatments. Irradia laser treatment may be a valuable therapy in low back pain and low energy laser can be employed as a pain relieving method.

Arch Phys Med Rehabil. 1999 Jun;80(6):647-52.


Laser therapy: a randomized, controlled trial of the effects of low-intensity Nd:YAG laser irradiation on musculoskeletal back pain.

Basford JR, Sheffield CG, Harmsen WS.

Department of Physical Medicine and Rehabilitation, Mayo Clinic and Foundation, Rochester, MN 55902, USA.

OBJECTIVE: To assess the effectiveness of low-intensity laser therapy in the treatment of musculoskeletal low back pain.

DESIGN: A double-masked, placebo-controlled, randomized clinical trial.

SETTING: A physical medicine and rehabilitation clinic.

PARTICIPANTS: Sixty-three ambulatory men and women between the ages of 18 and 70yrs with symptomatic nonradiating low back pain of more than 30 days’ duration and normal neurologic examination results.

INTERVENTION: Subjects were bloc randomized into two groups with a computer-generated schedule. All underwent irradiation for 90 seconds at eight symmetric points along the lumbosacral spine three times a week for 4 weeks by a masked therapist. The sole difference between the groups was that the probes of a 1.06 microm neodymium yttrium-aluminum-garnet laser emitted 542mW/cm2 for the treated subjects and were inactive for the control subjects.

MAIN OUTCOME MEASURES: Subject’s perception of benefit, level of function as assessed by the Oswestry Disability Questionnaire, and lumbar mobility.

RESULTS: The treated group had a time-dependent improvement in two of the three outcome measures: perception of benefit and level of function. These results were most marked at the midpoint evaluation (p < .005, p < .01) and end of treatment (p < .017, p < .001) but tended to lessen at the 1-month follow-up (p < .10, p < .004). Lumbar mobility did not differ between the groups at any time. All tests were two-sample t tests with unequal variances.

CONCLUSIONS: Treatment with low-intensity 1.06 microm laser irradiation produced a moderate reduction in pain and improvement in function in patients with musculoskeletal low back pain. Benefits, however, were limited and decreased with time. Further research is warranted.