Photobiomodulation Therapy (PBMT): Laser Therapy for Pain Management – A New Paradigm Dr. Roberta Chow Quantum Pain Management – Sydney, Australia August 9, 2017 1 Roberta Chow, Disclosures • I have no disclosures to report. The contents of this activity may include discussion of off label or investigative drug uses. The faculty is aware that is their responsibility to disclose this information. 2 Planning Committee, Disclosures AAAP aims to provide educational information that is balanced, independent, objective and free of bias and based on evidence. In order to resolve any identified Conflicts of Interest, disclosure information from all planners, faculty and anyone in the position to control content is provided during the planning process to ensure resolution of any identified conflicts. This disclosure information is listed below: The following developers and planning committee members have reported that they have no commercial relationships relevant to the content of this webinar to disclose: AAAP CME/CPD Committee Members Dean Krahn, MD, Kevin Sevarino, MD, PhD, Tim Fong, MD, Tom Kosten, MD, Joji Suzuki, MD; and AAAP Staff Kathryn Cates-Wessel, Miriam Giles, Carol Johnson, and Justina Pereira. All faculty have been advised that any recommendations involving clinical medicine must be based on evidence that is accepted within the profession of medicine as adequate justification for their indications and contraindications in the care of patients. All scientific research referred to, reported, or used in the presentation must conform to the generally accepted standards of experimental design, data collection, and analysis. The content of this CME activity has been reviewed and the committee determined the presentation is balanced, independent, and free of any commercial bias. Speakers must inform the learners if their presentation will include discussion of unlabeled/investigational use of commercial products. 3 Target Audience • The overarching goal of PCSS-O is to offer evidence-based trainings on the safe and effective prescribing of opioid medications in the treatment of pain and/or opioid addiction. • Our focus is to reach providers and/or providers-in-training from diverse healthcare professions including physicians, nurses, dentists, physician assistants, pharmacists, and program administrators. 4 Educational Objectives • At the conclusion of this activity participants should be able to: . Describe the most important characteristics of light as medicine . Summarize the effect of light in the somatosensory nervous system most relevant to pain relief . Describe the broad range of tissue effects initiated by light which modulate pain . Evaluate the experimental and clinical evidence base for application in clinical practice . Identify patients most likely to respond to PBMT 5 Photobiomodulation Therapy (PBMT) – MESH definition NLM “A form of light therapy that utilizes non-ionizing forms of light sources, including LASERS, LEDS and BROAD- BAND LIGHT in the visible and infrared spectrum. It is a non-thermal process involving endogenous chromophores eliciting photophysical (i.e. linear and non-linear) and photochemical events at various biological scales. This process results in beneficial therapeutic outcomes including but not limited to the alleviation of pain or inflammation, immunomodulation and promotion of wound healing and tissue regeneration.” 6 Synonyms • Low level laser therapy • Photobiostimulation • Low reactive-level laser therapy • Biomodulation • Low intensity laser therapy • Biostimulation • Low level light therapy • Cold laser • Low energy laser irradiation • Soft laser • Low power laser • Laser therapy It is called “LOW” because of the comparison with surgical “HIGH” power lasers, but it does not really describe the true nature of the lasers. 7 Case Study • Major SO 39 year Female Afghan Veteran . Nurse 17 years in military (special ops) . Severe widespread pain 24/7 for 1 yr − Hypermobile − Knee pain +++ (bilat tib osteotomy), − L5/S1 back injury − Thoracic pain - myofascial − Rt ulnar nerve neuropathy − etc. PTSD (2009) 8 Treatment at presentation (09/2016) Non-drug therapies Drug Therapies • Exercise physiology • Buprenorphine sublingual tabs (exercises made knee pain • Morphine sulphate Pregabalin worse) 150mg bd • Chiropractic – helped with mobility • Venlafaxine 225mg daily • Pain psychologist • Quetiapine 75mg at night • Pain specialist • Ketamine infusions • Pain physiotherapist • Naprosyn 500mg daily (PRN) • Psychiatrist • Celecoxib 200mg daily • Diazepam 5-10mg prn …..in hospital at the time she came to me (unable to cope at Despite all these therapies she home) was not getting any better 9 PBMT Where do we start with a patient like this? • Establish a “hierachy” of the pain problems …. ….what is the most troublesome area? • Look for nociceptive pain generators in the areas of pain – such as painful entheses or trigger points • Is there a neuropathic component? • Explain the “hardware” vs software nature of pain.. diagnostic imaging findings do not necessarily reflect clinical “pain” experiences . PBMT treats “software” – nerves, muscles, tendons etc. which cannot easily be imaged – “reprogramming software” • Importantly – she wanted to get better 10 Light Based Therapies • Greeks and Egyptians worshipped light • Neils Finsen - Nobel Prize 1903 • Blue light for neonatal jaundice • Red light for blindness of prematurity • Light for depression (SAD) • Vitamin D is synthesized in the skin by UV light • UV for psoriasis Nobel Prize Medicine 1903 Synthesis of Vit D in skin 11 Clinical Application of Photobiomodulation Therapy 12 Principles of Treatment • Apply the laser/light to tender areas in the region of clinical interest • Treat the lymphatics pertaining to the area • Treat associated tender points in the associated dermatomes and/or myotomes • Treat the spine overlying the nerve roots • +/- treat the tibia or sternum for stem cell stimulation • +/- treat “brain” 13 Q: What is the “medicine”? – A: photons A Photon is: • a discrete bundle (or quantum) of electro- magnetic (or light) energy. • always in motion at the constant speed of light • can have particle-like interactions (i.e. collisions) with electrons and other particles • both a wave and a particle all the time 14 Einstein 1916 Light Amplification by Stimulated Emission of Radiation 15 Laser Characteristics • Monochromatic i.e. single wavelength • Coherence . the basis of speckle formation) • Lack of divergence (original lasers) . diode lasers do have divergent beams 16 Laser Therapy - Tunér and Hode 2002 Laser Parameters • Wavelength (nm) from 400 to 1064 nm (red 650, 670 nm and infrared 810, 904 nm most commonly used) • Power (W or mW) 1 mW to 500 mW • Mode (pulsed or continuous) • Time applied (seconds to minutes) • Site applied (anatomical location) • Area (localised or scanning) From these we can calculate the dose of light delivered – in Joules 17 Primary effects of light in cells The First Law of Photochemistry states that “for light to exert an effect it must be absorbed” …and something must absorb it Smith KC. The Photobiological Basis of Low Level Laser 18 Radiation Therapy. Laser Therapy. 1991; 3(1): 19-24. How does it work? Chromophores are molecules which are “light absorbers” in membranes and the respiratory chain, which absorb photons After absorption electromagnetic energy is transduced to electrophysical and/or electrochemical energy. Not heat!! Cytochrome C oxidase* Porphyrins and Flavins Adenine Nucleotides (NADH) 19 Cytochrome C oxidase in Mitochondrial Membrane • ATP synthesis/inhibition • Induction of NF-κB • Gene transcription • Expression of growth factors • bFGF, VEGF, TGF • Increased inducible nitric oxide synthase • Production of reactive oxygen species 20 Secondary cellular effects of light absorption • Reduces action potentials in nerves • Reduces inflammation • Reduces muscle spasm • Reduces swelling/oedema • Stimulates tissue repair/wound healing • Modulates CNS neurotransmitter production • Initiates systemic effects (abscopal effect) 21 Laser effects in the somato- sensory nervous system HUMAN STUDIES ANIMAL STUDIES 18 human studies 25 animal studies Established the Established the principle principle that laser that transcutaneous selectively suppresses laser can inhibit action nociceptor (A and C potentials(block nerve fibre) action potentials conduction) in underlying nerves Has specific anti- inflammatory activities Chow R, Armati P, Laakso EL, Bjordal JM, Baxter GD. Inhibitory effects of laser irradiation on peripheral mammalian nerves and relevance to analgesic effects: a systematic review. Photomed 22 Laser Surg. 2011; 29 (6): 365-81. Studies showing inhibition of neural stimuli following noxious stimuli Tsuchiya D, Kawatani M, Takeshige C. Laser irradiation abates neuronal responses to nociceptive stimulation of rat-paw skin. Brain Res Bull. 1994; 34(4): 369-74. ……………………….. Kasai S, Kono T, Sakamoto T, Mito M. Effects of low-power laser irradiation on multiple unit discharges induced by noxious stimuli in the anesthetized rabbit. J Clin Laser Med Surg. 1994; 12(4): 221-4. 23 Neural blockade by direct application of light to nerve following pro-inflammatory stimulus Sato T, Kawatani M, Takeshige C, Matsumoto I . Ga-Al-As laser irradiation inhibits neuronal activity associated with inflammation. Acupunct Electrother Res 1994 Jun-Sep 19(2-3) 141-51 24 Microtuble Polymerisation and Transport Function Microtubule Associated Proteins (MAPS) are ATPases Images of microtubule arrays (Alberts