September 2022 is Drug-Free Pain Management Awareness Month

Opioid pain medications work in the nervous system or in specific receptors in the brain to reduce the intensity of pain. More than 191 million opioid prescriptions were dispensed to American patients in 2017, and the most common drugs involved in prescription opioid overdose deaths include Methadone, Oxycodone, and Hydrocodone[1].

Up to 25% of patients receiving long-term opioid therapy struggle with opioid addiction[2]. In 2016, more than 11.5 million Americans reported misusing prescription opioids in the previous year[3].

Prescription opioid use and abuse leading to addiction and catastrophic outcomes remains a national crisis. The leading cause of injury death in the United States is drug overdose[4], and most of the deaths from drug overdose deaths involved an opioid. From 1999 to 2020, more than 263,000 Americans have lost their lives to overdoses involving prescription opioids[5].

Because many die prematurely, surviving family members and communities lose out on benefits from an individual’s lifetime earnings. Opioid use disorder also results in costs associated with added health care expenses, criminal justice, lost productivity, and reduced quality of life. In 2017, these costs totaled an estimated $1.02 trillion—54% was attributed to overdose deaths and 46% to opioid use disorder[6].

Overdose deaths involving prescription opioids nearly increased by five times from 1999 to 2020[7]. We are losing 187 people a day from opioid overdoses and 68,630[8] people died from opioid overdoses in the U.S. in 2020 (74.8% of all drug overdose deaths).

Prescription opioids are often recommended for low back, neck, and musculoskeletal pain management, as well as for patients suffering from peripheral neuropathy. More than 100 million suffer with chronic pain and an estimated 80 percent of all Americans will experience some form of back pain during their lifetime.

On October 24, 2018, President Donald Trump signed the Opioid Crisis Response Act (OCRA) into law. OCRA received overwhelming bi-partisan support in both Chambers. HR6, which is now Public Law 115-271, broke new ground in being the first legislation to mandate aggressive development and adoption of alternative pain treatments that include “innovative medical technologies for pain management”. On October 11, Congress held its first ever briefing on ending opioid use through “innovative medical technologies for pain management”. Photobiomodulation (PBM) was the featured technology^[9].

Summus Medical Laser devices are class 4 therapeutic lasers, FDA-cleared as adjunctive devices for the temporary relief of pain^[10]. Photobiomodulation (PBM) utilizes non-ionizing red and infrared laser light and is a non-thermal process involving endogenous chromophores eliciting photochemical events at various biological scales.

PBM treatments are shown to resolve inflammation, improve peripheral circulation, modulate pain, and enhance tissue healing.^[11]

PBM treatments delivered with a class 4 therapeutic laser are shown to significantly reduce symptoms in patients with chemotherapy-induced peripheral neuropathy^[12] and significantly reduce pain and improve the quality of life of older patients with painful diabetic peripheral neuropathy^[13].

Summus Medical Laser treatments are non-invasive, pain-free, have no side effects yet are proven to be effective for both superficial wounds and deep neurological conditions.

SUMMARY

Photobiomodulation treatments delivered with a Summus Medical Laser class 4 therapeutic laser are a proven non-invasive opioid-free solution for pain management, with concomitant societal improvement and health care savings.

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[1] https://www.cdc.gov/opioids/basics/prescribed.html

[2] Banta-Green CJ, Merrill JO, Doyle SR, Boudreau DM, Calsyn DA. Opioid use behaviors, mental health and pain—development of a typology of chronic pain patients. Drug Alcohol Depend 2009;104:34–42

[3] Centers for Disease Control and Prevention. 2018 Annual Surveillance Report of Drug-Related Risks and Outcomes — United States. Surveillance Special Report 2pdf icon. Centers for Disease Control and Prevention, U.S. Department of Health and Human Services.

[4] https://health.gov/healthypeople/objectives-and-data/browse-objectives/injury-prevention

[5] https://www.cdc.gov/drugoverdose/deaths/prescription/overview.html

[6] Curtis Florence, Feijun Luo, Ketra Rice. The economic burden of opioid use disorder and fatal opioid overdose in the United States, 2017. Drug and Alcohol Dependence, 2021-01-01, Volume 218, Article 108350.

[7] https://www.cdc.gov/drugoverdose/deaths/prescription/overview.html

[8] https://www.cdc.gov/drugoverdose/deaths/index.html

[9] https://citizenoversight.blogspot.com/2018/11/ending-opioid-use.html

[10] https://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfPCD/classification.cfm?ID=ILY

[11] https://journals.sagepub.com/doi/abs/10.1258/ebm.2012.012180

[12] https://pubmed.ncbi.nlm.nih.gov/27887804/

[13] https://pubmed.ncbi.nlm.nih.gov/31405365/

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Phil Harrington, DC, CMLSO, FASMLS is a 1987 graduate of Iowa State University with a BS in Physics. He graduated from Palmer College of Chiropractic in 1996; and practiced in Iowa for ten years, using various therapeutic lasers. Dr. Phil’s passion for Class 4 therapeutic laser has led him to become a sought-after national and international lecturer on photobiomodulation science, physiology, safety, and clinical applications. Dr. Harrington currently serves as Medical Director, Clinical Manager, and Laser Safety Officer for Summus Medical Laser. Dr. Harrington lives in Scottsdale, Arizona with his wife Tami and enjoys reading, bicycling, and visiting his two daughters.

Lasers, Heat, Metal and Growth Plates

Therapy lasers have become a “go-to” modality for many chiropractors across the country. The powerful combination of clinical efficacy, lack of harmful side effects and return on investment means that therapeutic lasers will be a popular treatment modality for years to come. Not long ago, laser therapy was perceived as voodoo. But today the mechanism of action is understood; cellular targets and physiological effects identified; and a solid track record of clinical efficacy for various conditions is emerging.

Parameters such as ideal power and power density, wavelength and combinations of wavelengths, dosage at skin surface and at depth, as well as pulsed frequencies must be studied in vitro, in vivo (in both animal and human subjects), and in clinical trials. Advancing the knowledge base will optimize laser therapy treatments so we can give our patients the very best care possible.

Many of those lecturing on laser therapy in the chiropractic world claim expertise by quoting the number of years they have used lasers, touting conjured techniques, and reciting jargon largely fed to them by the marketing department of a therapy laser company. While these tactics may have served to success- fully introduce laser therapy to our health care profession, they must be set aside for a more rigorous scientific discussion.

Like it or not, a certain knowledge of basic physics is required to have a rudimentary understanding of the modality. And an advanced knowledge of physics should be required for those lecturing and writing on the topic. Full credit should be given to those with advanced degrees in orthopedics, sports injuries, etc., but this author has observed a large number of basic science mistakes in those doctors’ writing and presentations.

To advance laser therapy as a modality, as well as preserving and gaining credibility for our chiropractic profession, scientifically correct terminology and concepts must be utilized. This article will address tissue heating and laser therapy over metal implants and growth plates.

Primum non nocere — First, do no harm. The worst-case scenario must be utilized in any examination of safety. For a therapy laser, this would mean testing the highest power available in continuous wave mode (light constantly “on”). For this test, the author used a class 4 therapy laser capable of producing 15 Watts maximum power at wave- lengths (colors) of 800, 905, and 970 nanometers (nm) individually, or in any combination.

These wavelengths are in the near- infrared (NIR) region of the electromagnetic spectrum and are non-ionizing. NIR photons have much lower energy than ultraviolet or x- rays and cannot break molecular bonds nor cause genetic damage.

There is a small peak in the absorption curve for the water molecule at 970nm. When water molecules ab- sorb photons of light, the light energy is converted into heat, so using the 970nm wavelength alone will produce the most tissue heating.

As infrared therapy laser light penetrates into the skin and is absorbed, it attenuates and gets dim- mer. This means that any tissue heating will occur from the outside-in, the skin will be warmer than any tissues deep in the body. Laser therapy is not a deep heating modality.

A therapy laser producing 15 W, CW at 970nm was run for several minutes on a human forearm. The skin temperature of the treated area was measured using a Fluke 62 Max infrared thermo-meter. This test was run for four minutes, delivering 3600 Joules to an area of 200 square centimeters, a dosage of 18 J/cm2.

Human core body temperature in a normal healthy adult is 98.6˚, but ambient skin temperature is several degrees less. In our study, the starting forearm skin temperature was 95˚. During the four minutes expo- sure, the maximum measured skin temperature was 99˚. The subject’s forearm was allowed to cool, then was exposed to direct sunlight on a summer day in Franklin, TN. After four minutes exposure, the skin temperature had increased to 102˚.

Two implications of this are that even at very high-power levels, therapy laser treatments are extremely safe, warming the tissues less than during a walk on a sunny day; and that no appreciable heating is occurring deep inside the body.

Decades ago, infrared heat lamps were contraindicated for usage over open growth plates, due to concerns of early closure induced by the deep heating. After high powered therapy lasers were FDA cleared in 2003, many (including the author) cautioned against treating over open growth plates. Now that we better understand the mechanisms of action, combined with knowledge that even the highest-powered therapy lasers are not creating significant heating inside the growth plates, those cautions can now be dismissed.

A study by Cheetham examined the radiological and histological effects of high doses of NIR therapy laser on healthy growth plates in Wistar rats. It concluded the laser “had no significant effect on the healthy growth plates of the rat knee joint.” In addition, in more than ten years clinical treatment of both human and animal juvenile patients, not a single incident of early growth plate closure or any other problem has been reported.

Chiropractors wanting to use laser therapy to treat teenage patients suffering from Osgood-Schlatter’s, back pain, scoliosis or other conditions can proceed with the assurance that laser therapy will not have a harmful effect on the patient’s growth plates.

 Another frequent question is the use of therapy laser over metal implants in the body. Therapeutic laser light is reflected, not absorbed by metal surfaces, so no heat is generated when laser therapy is used over joint replacements, plates from broken bones, or even post- surgical metal clips.

Patients with metal implants frequently have a buildup of scar tissue resulting in reduced range of motion, chronic pain and reduced mobility. Therapeutic ultrasound cannot be used over the metal, but laser therapy can, and in combination with soft tis- sue mobilization the chronic scar tissue can be effectively broken up, range of motion improved and mobility restored.

Therapeutic lasers are here to stay. As further studies are conducted, equipment is refined and protocols are enhanced, clinical effectiveness will improve and return on investment will grow. Chiropractors using laser therapy can be assured the treatments can safely be used over open growth plates and metal implants.

Managing Ankle Sprains: Clinical Do's and Don'ts

Read the full article on the Dynamic Chiropractic website.

Ankle sprain is a common sports injury in physically active individuals with a large financial burden on the healthcare system. US emergency departments reported an incidence in 2010 of 3.29 per 1000 person per year. The costs resulting from ankle sprain are $6.2 billion in healthcare costs for US high-school athletes annually.[i]

Once an ankle is sprained, it predisposes the athlete to recurrent ankle sprains and residual symptoms. Some sports such as basketball and soccer see more than 50% recurrent ankle sprains, and residual symptoms such as pain, instability (actual or perceived), swelling and weakness are present in nearly three-fourths of patients.[ii]

Acute ankle sprains occur frequently across all levels of sports participation, and in other active populations such as active-duty military personnel. Interestingly, half of all ankle sprains treated in US emergency departments did not occur during sport activity.[iii]

“Chronic ankle instability, developing from ankle sprain, is one of the most common sports injuries. Besides it being an ankle issue, chronic ankle instability can also cause additional injuries.”[iv]

With the goal of providing proper treatment for acutely sprained ankles, reducing the incidence of recurrence, lowering overall health care costs, and most importantly improving the quality of life for our patients, this article focuses on two modalities used to treat ankle injuries: cryotherapy and photobiomodulation.

Consult nearly any source on the suggested treatment for acute injuries and you will find the RICE Protocol[v][vi][vii], with even Harvard Medical School on the cold bandwagon. RICE, which stands for Rest, Ice, Compression and Elevation was first introduced into the health care lexicon by Dr. Gabe Mirkin in his Sportsmedicine Book of 1978.

For years, ice has been used to treat acute injuries under the premise that it alleviates pain, reduces tissue metabolism, and reduces swelling. It has been a standard treatment for injuries and sore muscles because it helps to relieve pain caused by injured tissue. Health care providers have used and recommended the “RICE” (rest, ice, compression, elevation) guideline for decades, but now it appears that both ice and immobilization may delay healing.

But in 2015, Dr. Mirkin completely reversed course, and now strongly advocates against the use of ice on acute injuries.

Healing requires inflammation; and anything that reduces or suppresses inflammation will also delays healing. “Applying ice to injured tissue causes blood vessels near the injury to constrict and shut off the blood flow that brings in the healing cells of inflammation”, wrote Dr. Mirkin. “When you damage tissue through trauma or develop muscle soreness by exercising very intensely, you heal by using your immunity, the same biological mechanisms that you use to kill germs. This is called inflammation.”[viii]

Normal injury healing progresses sequentially through the stages of inflammation, proliferation, remodeling, and maturation. Interrupting the first stage – inflammation – will delay and reduce the effectiveness of the subsequent three stages. So, if you plunge that sprained ankle into an ice bath, and then advise him to apply ice several times a day, you are making the injury worse, not better. Icing injured tissue causes constriction of blood vessels near the injury which shuts off the blood flow that brings in the healing cells of inflammation.[ix]

Although they are often used interchangeably, “swelling” and “inflammation” are in fact two distinct terms. Inflammation is classified as a protective response from the immune system to injury, infection, or irritation; swelling is caused by the accumulation of fluid in tissues in a specific region, or throughout the body.[x] In acute ankle sprains, swelling can occur when the body has sent all of the necessary stem cells, blood, plasma, fluid, and proteins to the area to fight the invading injury and begin the healing process from within.[xi]

What is a better solution? Photobiomodulation (PBM), more commonly known as laser therapy. Therapeutic laser devices deliver red and infrared wavelengths of light to both superficial and deep tissues to enhance blood circulation, increase tissue oxygenation and improve metabolic activity.

In turn this helps the body progress through the healing stages of inflammation, proliferation, remodeling, and maturation. Treatments with a class 4 therapeutic laser are safe and non-invasive and can be applied immediately after injury.

PBM treatments have been labelled as ‘anti-inflammatory’, but this is a misnomer. PBM does not suppress or inhibit inflammation, but instead helps with resolution of the inflammatory process. “Photobiomodulation (PBM) is able to reduce or inhibit production of important inflammatory mediators such as IL-1, IL-6, PGE2, and MMPs and significantly reduce leukocyte infiltration in different inflammatory conditions.”[xii]

Laser therapy treatments should be delivered to acute injuries as soon as possible. Proper laser treatment for a sprained ankle begins proximal to the injury site to stimulate circulation, and more importantly to open venous and lymphatic return channels in the leg. Swelling in the sprained ankle is primarily due to lack of adequate fluid drainage. Then once the proximal tissues have been treated with the laser, the ankle itself can be lasered.

A proper laser protocol for the leg portion of the treatment would use power between 6 and 9 watts, treatment time of 4 to 5 minutes, with total energy delivered between 1,440 and 2,700 joules. Given that the treated surface area is about 400 square centimeters, this equates to a surface dosage of 3.6 to 6.75 J/cm2, which is appropriate for acute injuries.

For the ankle, power between 4 and 5 watts, treatment time 3 to 4 minutes with total energy of 720 to 1,200 joules for a dosage between 2 and 4 J/cm2.

Laser treatment can be delivered daily until the swelling is down, pain levels have subsided, and the patient has gained some degree of mobility. And laser treatments should continue into the rehabilitative phase, as the patient gains strength and reestablishes proprioceptive input from the injured ankle.

In conclusion, cryotherapy should not be used on acute ankle sprains; today’s practitioner will utilize photobiomodulation for pain relief and tissue healing.

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[i] https://jfootankleres.biomedcentral.com/articles/10.1186/s13047-021-00480-w

[ii] https://link.springer.com/article/10.1007%2Fs40279-014-0218-2

[iii] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6602402/

[iv] https://jfootankleres.biomedcentral.com/articles/10.1186/s13047-021-00480-w

[v] https://www.gskhealthpartner.com/en-us/pain-relief/conditions/sprains-strains/facts-stats/

[vi] https://www.childrens.com/health-wellness/treating-common-acute-sports-injuries

[vii] https://www.health.harvard.edu/newsletter_article/treating-sports-injuries

[viii] https://www.drmirkin.com/fitness/why-ice-delays-recovery.html

[ix] https://www.garyreinl.com/index.html

[x] https://www.medicalacademic.co.za/immunology/swelling-vs-inflammation/

[xi] https://albanoclinic.com/benefits-inflammation-healing-process/

[xii] https://www.liebertpub.com/doi/10.1089/photob.2020.4825

3 Surprising uses for a Class 4 therapy laser

Three surprising uses for a class 4 therapeutic laser are acute injuries, idiopathic pulmonary fibrosis, and diabetic peripheral neuropathy. Thousands of patients have already benefited from these treatments and in the future class 4 therapeutic laser treatments will be an integral modality in all fields of health care.

Class 4 therapeutic lasers first gained FDA clearance in December of 2003. Before then therapeutic lasers cleared by the FDA and most of them used in healthcare and in laser studies were class 3 devices. While the true definition of laser class is degree of hazard to the naked eye, the power cut-off between class 3 and class 4 is 500 milliwatts or half of a Watt. Early on, class 4 devices were first perceived as being too powerful.

In 1988 laser scientist Dr. R. Glen Calderhead introduced the term “low level laser therapy” to the medical scientific literature. Dr. Calderhead was very specific - he intended the term to be used in reference to the reaction at the tissues and not to the output power of the device. This is a very important distinction. Unfortunately, in the past few years many people have altered this definition and will talk about ‘low level lasers’ in reference to the output power of the device.

Class 4 therapeutic lasers are FDA cleared class 2 medical devices. They have been used safely and effectively in both human and animal medical care for more than 18 years. Scientific researchers have concluded that to deliver a therapeutic dosage to tissues deep inside of the body a higher-powered laser must be shined at the skin surface. It only makes sense. As light enters the body it will get dimmer and dimmer as it passes through the tissues. Photons get absorbed, and the light gets dimmer.

Class 4 therapeutic lasers use infrared wavelengths, ranging from 800 to 1064 nanometers. With any of the infrared wavelengths there will be a small amount of tissue heating during the treatment. The 980-nanometer wavelength is at a small peak of absorption for water molecules, so when this wavelength is used, there will be a little bit more tissue heating.

Detractors of class 4 therapeutic laser claim that they should not be used on acute injuries due to tissue heating. The amount of tissue heating during a properly delivered class four therapeutic laser treatment has been measured. It is less than two degrees Fahrenheit. And when proper settings are used for acute injuries, there is no tissue heating at all. This is very important.

Numerous studies support the benefits of applying laser therapy two acute injuries. For the athlete with the sprained ankle, the general patient in the motor vehicle accident, or for anyone who has an acute injury they can and should be getting treatment with a class 4 therapeutic laser as soon as possible.

In 2014, a chiropractor by the name of Dr. Andrew Hall was diagnosed with idiopathic pulmonary fibrosis (IPF). He was told he had an 80% chance of dying within five years. IPF is a terminal and progressive disease. The scar tissue in the lungs interferes with oxygen exchange the patient's blood oxygen levels slowly decrease. It is a long, slow and painful death.

Given this diagnosis, Dr. Hall decided to treat himself with his class 4 therapeutic laser. After a few months he had a follow up visit with his pulmonologist who expressed great surprise at finding that Dr. Hall’s pulmonary function tests and blood oxygen levels had improved! That never happens with IPF!

As time went by Dr. Hall continued to treat himself with his class 4 therapeutic laser. Since then, studies have shown that infrared therapeutic laser will help to prevent scar tissue from growing in the lungs and can also help with remodeling to healthy collagen tissues.

Dr. Hall has created a website, ipflaserstudy.com on which he gives information about therapeutic laser treatments for IPF. He continues to be active today, more than seven years after his initial diagnosis. He has shared treatment information with doctors around the world and hundreds of patients have benefited from the laser treatments.

Diabetic peripheral neuropathy is another progressive disease for which modern medicine does not have an answer. High blood sugar levels slowly degrade the lining of the arteries in the extremities. The legs, foot and toes are most affected because the effects of gravity and the length of the nerves that travel from the spinal cord to the toes. Lack of blood flow to the peripheral nerves leads to improper nerve function and the patient will experience bizarre sensations such as tingling and numbness, feeling like they are standing on marbles or in a campfire, and they may need to wake up in the middle of the night to rub their feet and stop the pain.

Class 4 therapeutic lasers help to improve peripheral circulation and improve the function of the peripheral nerves. This helps to restore proper sensation and reduce the symptoms associated with diabetic peripheral neuropathy. There are no side effects and studies have suggested a greater than 90% success rate in alleviating symptoms associated with diabetic peripheral neuropathy.

Three surprising uses for a class 4 therapeutic laser are acute injuries, idiopathic pulmonary fibrosis, and diabetic peripheral neuropathy. Thousands of patients have already benefited from these treatments and in the future class 4 therapeutic laser treatments will be an integral modality in all fields of health care.