Arguing with Lasers

When I am thinking about various pseudo-scientific treatments it frequently takes the form of a dialogue, or to be more blunt, argument in my head. Yes I talk to myself. 

So here’s a dialogue about Low Level Laser Therapy (LLLT).

But first, I work professionally as an independent physical therapist and strength coach. If you are interested in my services you can email me at: Or if you just want to support my blog you can buy me a KoFi

Actual Low Level Laser Therapy application – credit

In brief, LLLT is a passive modality used in PT that involves the therapist moving a wand over the injured area and the wand shoots a laser at your skin.

Me: The thing that strikes me about LLLT in the peer-reviewed, published literature is the fact that the articles don’t even contain a plausible hypothesis. 

Laser Enthusiast: Well, the laser delivers energy to the tissue. 

Me: Yes, but so does a hot pack. 

LE: A laser is different!

Me: Yes, and . . .

LE: It’s  a different kind of energy than a hot pack.

Me: It’s photons. The same thing as a lightbulb. Why can’t I just use a lightbulb?

LE: It’s focused.

Me: A lightbulb can have mirrors in front of it so that it’s just as focused as a laser. And not all lasers are focused. A laser is defined by being EITHER collimated or monochromatic, it doesn’t have to be both and the most widespread kinds aren’t collimated, so they have focusing lenses too. 

LE: But it’s also monochromatic, you just said that. 

Me: Sure. It’s all a narrow range of frequencies of light. What does that do?

LE: Well, the tissue reacts in a particular way, or something . . .

Me: When I point out that the published research lacks a clear hypothesis this is specifically what I am talking about. The paper will say we used such and such frequency of light but won’t explain why. 

This illustrates the importance of doing bench research before doing any animal or clinical trials. 

The first laser studies should have involved pointing lasers at petri dishes of cells and seeing what happened. Does a particular frequency stimulate a particular molecule? Does stimulating that molecule mean anything relevant? Does a specific frequency stimulate a particular cell type to do something relevant? 

And these studies needed to compare these measures to a good control condition like the same watt-minutes of a different frequency or of white light.

These are the types of questions that should have been answered first. These are the types of hypotheses that should have been tested in the research. But this is absent from the write-ups. 

LE: So what if we don’t know the mechanism of action. There are plenty of approved drugs that we don’t know the mechanism for. 

Me: Oh sure, that’s a valid point. But the standards for approving a drug require much more clear evidence of benefit than a device. I’ve talked about the low standard of evidence for medical devices before

LE: But the studies do show positive results.

Me: But are they well designed studies? And do they show clinically relevant results?

What’s the control group in these RCT’s? Usually it’s the same laser wand without the laser turned on. While the control group may not realize they are in the control group because they feel nothing, they may suspect they are in the control group because they feel nothing. But the experimental group KNOWS they are the experimental group because they feel it get hot. So hot that it can cause burns if not used properly. 

When both the control and experimental group have a pretty good idea which group they are in then the study isn’t particularly well blinded. This influences reported results. Enough to produce false positive results. 

A good control group would be standard of care. In the same way that approval for a new pain-killer would require comparison not merely to a sugar pill but also to another standard pain-killer. If a drug company wants to sell a new pain-killer and it’s not better than Tylenol but it’s also more expensive and dangerous then it doesn’t matter if it’s better than a sugar pill, it’s not getting approved. 

LE: Well, if patients think it’s working isn’t that good enough?

Me: No.

This is what’s important about the comparison to a hot pack. The hot pack can cause burns, it’s true, but preventing that is incredibly easy. Like, you let the undergrad clinic slaves apply hot packs (true story). 

They also don’t require a physical therapist to sit there and apply the treatment. You just put the hot pack on and walk away. But the LLLT requires my doctorate educated time to sit there and constantly wiggle the wand to keep it from burning the patient. My time is expensive. 

Plus, the hot pack is something the patient can do for themself. There are a wide variety of kinds they can purchase. There are long lasting ones using the same kinds of chemistry as a chemical hand warmer. There are ones that can be microwaved for instant relief. There are electric heating pads. And they are all cheaper than a PT clinic Co-Pay.

Hot packs are really convenient for the patient. They improve the patient’s sense of ability to control and manage their own condition. They improve their self-efficacy. These are all good things for the patient long-term. 

While the laser (and any other passive treatment) creates the idea that the patient needs an appointment with the therapist to feel better. It may be profitable business but it’s not in the best interests of the patient or the cost of our healthcare system. 

LE: But you haven’t really addressed whether or not the lasers work. 

Me: How well they work needs to be put in perspective. Before we can conclude that the laser is a better treatment for the patient it has to demonstrate that it is SO MUCH better than a hot pack to justify the higher cost, higher risk and patient’s loss of control. That means big effect sizes. 

Statistically significant effect sizes don’t even matter to me. As I discussed in the VR for Back Pain article what matters to a patient are clinically significant effect sizes. And these effect sizes would need to show a clinically significant difference to hot packs, not merely to an inert control. 

Any researcher can get a statistically significant result from the “gee whiz!” factor from using lasers but that doesn’t prove the effects are real. 

So, no, lasers are for tag, not physical therapy.

The good kind of arguing with lasers – credit

Why I’m a Physical Therapist

Rejected Title: Why do I do this?

I think the New Year is a good excuse to remind myself and inform my readers of why I do what I do. I also wrote about the strength coach side of this over on my other blog.

I am a physical therapist. I have a doctorate in what I do. I work in orthopedics and specialize in shoulders, knees and low back pain. I am self-employed as a PT.

Commitment to Helping Others

As cliche as it may be I feel I have a commitment to help others. Like almost all folks who work in healthcare I want to help people. 

Eagle scout

I swore my Oath as an Eagle Scout back in 1998. Part of the oath was to “country” and also, “to help others at all times”. It took me a while to figure out how to live up to those parts of the oath. But they were the parts that resonated most for me, so I felt the need to do so.

I actually tried to enlist in the Army first. But they didn’t want someone with terrible eyesight AND allergies. 

I studied criminal justice with the thought of becoming a police officer. Thankfully I was saved from that fate by my mother. While I was taking classes in community college she got me a job at the hospital where I worked. And it was there that I finally understood that I really wanted to work in medicine to help others.

Public health

Many years later I got my Exercise Science degree from UMass Boston. Unlike the other UMass campuses, the Boston campus’ exercise science program had a strong public health component. This resonated with me. 

As a physical therapist I play a small role in the greater project of improving long-term public health outcomes. Because I help people stay physically active. This reduces their likelihood of a wide variety of diseases such as cardiovascular disease and diabetes, amongst others. I’d already worked in a skilled nursing facility (what’s commonly called a nursing home) and seen first hand how much one’s life degrades from these diseases. And I also understand the tremendous burden that these diseases impose upon society. 


I like being a mechanic for people. My first healthcare job was as an orderly in the OR. And before that I had extensive first aid training, mostly thru Scouts. I enjoy the hands-on nature of this kind of work. I would never be satisfied with the more “look at test results and prescribe things” style of medicine that exists in many other specialties outside of orthopedics. 

I like basic physics and I like understanding how machines work. People’s musculoskeletal systems are weird, complex machines. It’s really neat! And fascinating. 

Puzzle solving

And I like the puzzle solving aspect of, “this machine is broken, how do I fix it”. Unlike with a car mechanic, I never just pull out a broken part and install a new one (tho that is amazing surgery and I am happy to work on those patients). I have to use what bits of the machine still work and take into account how well each part is working and develop a solution to the puzzle. 

I really appreciate the intellectual pursuit of this aspect of being a physical therapist specifically. 


I like watching my patients improve. It is really satisfying to work with a person who starts off unable to do something important to them, or unable to do it without pain, and bring them to a point where they are capable again. Watching people’s pain get better or watching them resume physical activity or sports is really a joy for me.

One of the things that was clear to me from my years of prior healthcare work that differentiated PT from other orthopedic careers was this aspect of really seeing my patients get better. 

Bringing it All Together

Physical therapy is a vocation that allows me to: 

  • Help other people
  • Help my community
  • Work hands-on with patients
  • See my patients improve
  • Solve puzzles

That’s why I do this. 

Alas, actual jobs in physical therapy are terrible and exploitative so I work on my own as an independent physical therapist. If you’d like to help support me then you can contribute thru Ko-FI. Thanks.

Strength Training for Kids

Or how the AAP article drives me nuts

I have a child! Woo hoo!
I’m a strength coach professionally. At some point I’m going to want my kid to start strength training. So, let’s mosey on over to the American Academy of Pediatrics website and see what they have to say about strength training in kids: (not on the AAP website per se but linked from the AAP as the top hit for my query)

Yikes! Looks like they forgot to talk to somebody who is familiar with the topic before putting this out.

Credit Where It Is Due

Certainly, plenty of this page is good. They recommend strength training. Usually starting around age 7 or 8. They recommend a reasonable approach: 8-15 reps, full ROM, appropriate supervision, progressive increase in resistance.

They talk about the benefits of strength training. They point out how strength training is both safer than other activities and improves the safety of other activities. 

This is all great and if the whole article didn’t also bother my professional sensibilities I could leave it at that. 

But . . .

The first paragraph has this sentence: “[strength training] is not the same as Olympic lifting, powerlifting, or body building, which requires the use of ballistic movements and maximum lifts and is not recommended for children.”

And, um, did they talk to somebody who knew about these things? Sure seems like they didn’t. They treat this trio of activities like they are all the same, which just shows a staggering lack of knowledge.

First they categorically state that this trio of activities are not strength training. Which is objectively nonsense. 

  • Powerlifting is specifically the sport of maximizing strength. 
  • Olympic lifting is specifically the sport of maximizing power – which is inseparable from strength in exercise physiology. 
  • Body building is resistance training and therefore, compared to not doing resistance training, will necessarily improve strength, even though that’s not the focus as such. 

Incorporating Olympic lifting into one’s training does not require maximum lifts. Competing in the sport does, but it is absolutely a reasonable component of strength training for athletic development. Strength training for athletic development is something I’ve done in (U.S. NCAA) division I athletes. Useful outcomes for athletic development can be done at only 5RM. And Olympic lifting based variants can be done with lower loads, such as the dumbbell snatch, that are low load on the body overall but still worthwhile.

Maximum lifts are part of the competition in powerlifting, and I wouldn’t recommend power lifting per se for children. Ballistic movements are not part of powerlifting. 

Maximum lifts are not at all a part of body building. The program actually recommended lower down in the article could function as a low-end body building program. Ballistic movements are not necessarily part of body building and are rather uncommon in that. 

Ballistic movement are not recommended

Uh, so children shouldn’t jump. Like, at all? Because seriously, the actual measured forces on the body from jumping, just on level ground, are significantly higher than the forces from Olympic lifting. 

The actual research into Olympic lifting doesn’t show any particularly higher risks for children from the activity. A significant factor in reported problems seems to be unsupervised children and home equipment. I’m totally on board with strength training being a supervised activity for kids.

The real determining factor in when to start Olympic lifting with children seems to be maturity/cognitive development. The child needs to be able and willing to follow instructions and refrain from playing with the equipment. (I’ll stress here that a kid who doesn’t want to do Olympic lifting is clearly higher risk than one who is engaged and intrinsically motivated.)


They recommend a strength training program that is only 20-30 minutes, PLUS 20-25 minutes of warm-up and cool down. That’s not good. The most efficient program I can write has six separate exercises in it. With 2 sets per exercise and appropriate rest periods, plus the reality of setting up/taking down exercises and switching time and water breaks, this program takes 24 minutes. This is the most minimal program that is still useful. 

A more reasonable program is 8 exercises and 2-3 sets – which takes 48 minutes. With acceptable warm-up and cool down this takes 60-65 minutes.

It is not always necessary to do 10-15 minutes of warm-up. Appropriate warm-up times depend on several factors. Cool down time is just overemphasized. 

Exercise Selection

This video from the AAP is their Upper Body Strength Training Recommendation. Their are just three exercises recommended: push press, biceps curl and what the presenter calls a deadlift high pull, but really ends up being more an upright row. 

The presenter just straight up acknowledges that the biceps curl is probably not the most helpful – but is still using up one of the only three exercises on it.

These three are presented as if they are a complete program for either upper-body strength training (the title) or overhead athletes (the presenters words). Neither is even close. 

I would not call complete an overhead athlete program that doesn’t include a rotator cuff oriented exercise. Even just a DB row. 

The “program” includes no conventional pulling exercises and only vertical pushing. It’s not complete. It’s just bad.

The video also specifies an intensity of 15RM or lower! The written guidance says 8-15RM. 15+RM isn’t even strength training. 

One other note about this video – the instructor to student ratio is higher than the AAP recommendation. And I agree that there are too many students.

I’m not going to spend time on how silly I think doing these exercises one-legged is, “for balance”.

Bodyweight is Better?

The accompanying general video is by the same guy, but isn’t consistent with the other video. In this video the presenter says that the exercises should be all bodyweight – in the other video the kids are using dumbbells. The presenter says, ”as long as they use their bodyweight it’s totally safe”.  This is a nonsense statement. Like, “does this person know what numbers are?” level nonsense. And what it really shows is that the person uncritically accepts “conventional wisdom” without applying any rational thought to it. 

This same presenter emphasizes the need to use light weights both in this video and the other video. But that’s not what bodyweight is. It’s actually plenty of weight for many exercises. It is perfectly normal for a person to struggle to do 8 push-ups when they start. That means that the bodyweight exercise is more intense than the AAP guidance recommends. For some children a push-up will be a maximal lift i.e. something they can only do once. That’s not safe according to them. 

The response necessarily requires some magical assertion that because it’s bodyweight it’s different without describing how. The muscles, tendons, ligament and joint surfaces can’t tell the difference between a 1RM pushup and a 1RM bench press. They are the same.

The fact is that bodyweight is frequently too low for lower body strength training and too high for safe upper body strength training. 20 air squats just isn’t strength training.


Sigh. Superficially it’s fine. And if somebody got their kid into strength training based on these pages and videos then that is great. And it is better than not doing so. Certainly.

But it really comes across as a minimal effort, barely better than nothing set of info.

Additional reading: