The patient was an 88 y/o male complaining of a 1-year history of low back pain radiating to the right hip area after working out on a trainer bike. The pain was described as an intermittent dull ache, 3-4/10 on a visual analogue scale and gradually worsens throughout the day. The pain was aggravated by walking and standing and eased by sitting and stretching. Radiation to the hip area was described as tingling/numbness. The patient did not report any changes in bowel or bladder function or history of weight loss.
Xrays for the Lumbosacral Spine revealed left convex 9° distal thoracolumbar scoliosis superior T12 to superior S1. Mild anterolisthesis L4 on L5 grade 1 and moderate facet osteoarthritis mostly distal, consistent with lumbar spondyloarthrosis was also noted.
The patient was previously treated by brachytherapy for prostate cancer 20 years ago. The patient was on physiotherapy exercises and Gabapentin 300 mg once a day with no relief.
He was initially treated with the standard BIOFLEX Low Back placements using the DUO 240 arrays and both red and infrared laser probes.
|Treatment Head Wavelength||Frequency (Hz 5 μs resolution)||Duty Cycle (10% steps)||Duration (sec)||Average Power Output (mW)||Power Density (mW/cm2)||Energy (J)||Energy Density (J/cm2)|
|DUO 240 Arrays|
|660 nm (100% power)||CW||7||75||750||0.525||5.25|
|825 nm (41% power)||CW||7||126||1260||0.882||8.82|
*DUO 240+Arrays: RED 240 LEDs, wavelength 660 nm. Spot size 100 cm2
IR (Infrared) 240 LEDs, wavelength 840 nm. Spot Size: 100 cm2
**Laser Probes (spot treatment 7 seconds per point across areas covered by arrays, total treatment time 10 minutes):
RED, wavelength 660 nm. Spot Size: 0.10 cm2
IR (Infrared), wavelength 825 nm. Spot Size: 0.10 cm2
***CW – Continuous Wave Mode / Unpulsed
†4 placements (6 min horizontal L1-L3/8 min horizontal L4-S1 and SI joint/7 min oblique from R SI joint across R iliac bone/5 min oblique from L SI joint across L iliac bone)
††5 placements (6 min horizontal L1-L3/8 min horizontal L4-S1 and SI joint/7 min oblique from R SI joint across R iliac bone/5 min oblique from L SI joint across L iliac bone/6 min vertical from L1-S1)
Image 1. Standard BIOFLEX lumbar spine placement.
Treatment was initiated every other day and parameters adjusted every one to two weeks. Pulse frequency, duty cycles and power output were increased as needed per patient response. The patient noted improvement after one month of treatment reported as an improvement in pain symptoms, increase in range of motion and renewed ability to pursue activities like golf. Frequency of treatment was then gradually decreased. The patient had a total of 15 treatments.
December in the northern hemisphere is the most joyous season filled with cheer and gathering. Along with cheers and gathering, it is also the season of low back pain from shovelling snow and carrying frozen turkeys. For PBMT, low back pain treatment has been an enigma, with certain groups like the North American Spine Society1 and the Centers for Disease Control2 providing some recommendation for the utility of PBMT for Low Back Pain, whereas other groups totally questioning the efficacy of it all, with one author even suggesting it’s time to move on3. The reason for the mixed messaging falls squarely with the pathology we are attempting to address. What exactly is low back pain?
Low Back Pain (LBP) is not a diagnosis. It is a symptom. Since LBP is one of the most common reasons people seek medical help or apply for disability, it is important that other potential causes be ruled out as you will not help anyone with pancreatitis or intestinal cancer resolve their low back pain by applying PBMT in their SI joint. Most cases (more than 85%) however, actually cannot be attributed to a specific disease or spinal abnormality, called nonspecific low back pain5. Just the term nonspecific already points toward the challenges that treating LBP with PBMT face. Muscle or ligament strain (or worse, a torn ligament), bulging or herniated disks (which by itself does not always cause back pain, which is a common reason why imaging modalities not recommended as bulging disks are often incidental findings on Xrays done for other reasons), arthritis and its by product spinal stenosis (plus you need to understand what type of arthritis is causing the LBP), and osteoporosis can all cause nonspecific low back pain6.
To complicate things, patients who arrive in our clinics for LBP treatment are as varied as the snowflakes that fall in this festive occasion. It is not always your obese, middle-aged couch potato smoker that appears in your clinic reception. Even well-built professional athletes and fit and slim, weekend golfers suffer from low back pain. In an interview, Sylvester Stallone, he of the Italian Stallion fame (okay, Rocky and Rambo) complained about the pain he has in his lower back caused by years of doing his own stunts for his action films. It is obvious here that the treatment you provide for your thin college kid who developed low back pain from lifting sacks of potatoes in McDonalds should be different from the obese, middle-aged couch potato binge-watching on Rocky 1-7. This is the main reason why the evidence is patchy on the efficacy of PBMT for LBP. Treatment has to be individualized. Any clinical trial that suggests a single, static, specific dose to be applied to any subject regardless of patient background (somatotype, age, sex, BMI, level of physical activity, other compounding factors) is bound to result in uneven findings. Further, these compounding factors, such as obesity or lack of exercise needs to be addressed. In as much as no specific medication, whether it be NSAIDs, steroids, opioids, antidepressants or a simple analgesic like Tylenol has been proven to solely be adequate for the treatment of LBP, involvement of other modalities, such as physical therapy, acupuncture or radiofrequency ablation should also be considered1.
We highlight this case, an elderly mesomorphic male, moderately fit with moderate physical activity who had a history of radiation therapy with some degree of sciatica on an anticonvulsant (Gabapentin) with moderately chronic (less than a year) history of low back pain, because this might be the best candidate for your standard low back pain parameters. He has managed to achieve a certain degree of resolution with his low back pain. For the treatment of other patients who might have a different presentation, it is very important to adjust parameters and not be too dependent on your standard microwave oven buttons in your unit. Success here oftentimes is not permanent, and you may need to repeat treatment along with other modalities as we cannot halt the passage of time and the consequences of wear and tear. But it is great to know that we have a modality that is non-invasive, safe and works (if you know how to use it properly).
So as I stare out in the open window, watching the snow fall, taking my eggnog, and preparing my deliveries, I am thankful that I have my elves shovelling the path and feeding Rudolph and company. Now that I thought about it, I am obese after all, so I might need adjusted parameters. That means I can quietly enjoy this red (and near infrared) and warm glow in my back and behind before I get on my sleigh to work. Actually, why don’t I just take this with me to work? Ho ho ho ho ho ho ho…