Oregon February2017

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Missed OpportunitiesPatients with neuropathy

Dr. Thomas Burke Medical Director

HealthLightReno , NV

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Topics

What is neuropathy?What are common causes of neuropathy?What is the physiology behind the symptoms?(you learned this in school)What ‘neuropathy’ means to a practice?

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YOU ARE THINKING…..

• How do I assess and then present a care plan to patients with neuropathy? Not comfortable with that.

• Later this morning I will give you suggestions.

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Symptoms of Neuropathy• Burning pain, can’t sleep• Tingling• Loss of feeling (sensation), poor balance• Trouble walking (hard to lose weight)Severe neuropathy can lead to woundsThey will come to you because you treat pain and can help with weight loss.

Who has neuropathy?

• Diabetes, chemotherapy, and statins

• But wait, we can’t treat “diseases”• I agree; You CAN treat the symptoms

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DIABETES: YOU KNOW THIS• High blood glucose damages blood vessels • Diabetic patients suffer decreased blood flow to

eyes, heart, kidney and nerves in the lower legs.• Poor blood flow = ischemia• Ischemia = pain (A SYMPTOM OF NEUROPATHY)• You treat pain, correct?

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WHAT ELSE? • Serum nitric oxide was observed significantly

low in diabetic participants as compared to control…

• Nitric oxide; vasodilator; Nobel Prize 1998• Lack of nitric oxide = low blood flow. • It is one reason people with diabetes have

health problems: eyes, heart, kidney, amputations…and neuropathy

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WHAT IS NITRIC OXIDE AND WHY SHOULD YOU

CARE• Vasodilator; Nobel Prize 1998• Lack of nitric oxide = low blood flow. • It is one reason people with diabetes

have health problems: eyes, heart, kidney, amputations…and neuropathy

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NITRIC OXIDE• written as NO• Where is NO found? • On hemoglobin, inside red blood cells, just as

oxygen is…and in most other cells• Nobel Prize 1998

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So what?• Nitric oxide is what keeps our arteries open

so blood can flow to organs. Dilates all vessels: arteries, veins and lymphatics.

• Good blood flow reverses ischemic pain.

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Painful diabetic neuropathy

• is due to reduced blood flow….think about the patient’s symptoms.

• Eye problems, heart disease, kidney failure!

Is it any wonder blood flow to feet and their nerves progressively decreases?

REMEMBER PAIN ?

• Nitric oxide dilates vessels and increases blood flow and

oxygen delivery to nerves. Decreases edema

• Think of grandma’s heart pain (angina). Treatment was (is) nitroglycerin. Nitroglycerin is converted to nitric oxide.

• Increased flow to coronary arteries = more oxygen = less pain.

• Inflammation, swelling, edema also reduce blood flow.• Better venous and lymphatic flow removes edema.

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WHY DOES LIGHT THERAPY DECREASE PAIN?

Two reasons

1). Better blood flow = less pain(think of a rubber band around your finger)

2). Direct inhibition of pain signals…exactly the same way that narcotics decrease pain

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LIGHT THERAPYJournal of Molecular and Cellular Cardiology 2009; 47: 256–263

Enhancement of nitric oxide release from nitrosyl hemoglobin and nitrosyl myoglobin by red/near infrared light: Potential role in cardioprotection.

Red/infrared “Light therapy” = increased nitric oxide LOCALLY which then increases circulation.

1998 Nobel Prize.

WHY DOES LIGHT THERAPY DECREASE PAIN?

Two reasons

1). Better blood flow = less pain(think of a rubber band around your finger)

2). Direct inhibition of pain signals…exactly the same way that narcotics decrease pain

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NITRIC OXIDE AND PAIN RELIEFThe molecular mechanism of action of peripheral morphine analgesia: stimulation of the cGMP system vianitric oxide release.

Eur J Pharmacol 1991; 201:121-122

Morphine + receptor = nitric oxide release = pain relief

Human Plasma Response to Light(dose dependent;

more diodes = better response)

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10

20

30

120 diodes 60 diodes

PercentIncrease

Nitric oxide metabolites

Impressive, rapid changes in vessel diameter

Oregon February2017

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Ease of use for neuropathyThis is one configuration

Ease of use

Foot Bed

Newest technology

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Where can lights be used to reduce pain?

Anywhere there is a need to increase circulation or reduce pain.

FDA• Lasers and LED devices are FDA cleared

for increasing circulation and reducing pain.

• As long as you say your goal is to do either, or both, for a patient, you are safe

• You don’t claim to treat a disease; just its symptoms

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Pain (chemotherapy)

• “Chemo-induced peripheral neuropathy (pain, tingling, numbness)is caused by the chemotherapy drugs used in cancer treatment.”

• per American Cancer Society

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American Journal of Neuroradiology2005; 26: 205-206

“The pathophysiological mechanisms ofchemotherapeutic agents are not well understood, but several have been hypothesized, including demyelination, secondary inflammatory response, and microvascular injury.”

Again…..Infrared increases nitric oxide which grows new vessels!!!!....and this reverses microvascular injury.

Angiogenesis

Circulation. 2002; 105: 2133-5.

• Nitric oxide and angiogenesisCooke JP, Losordo DW

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How Lights (red and infrared) change circulation and pain

Nitric Oxide (NO)↓

Guanylate cyclase + NO↓

GTP → cGMP↓(PKG)

Phosphorylation↓

1) vasodilation2) analgesia

3) angiogenesis

LightPasses through

Skin

RBC

Vascular EndothelialCells

ASPIRIN FOR PAIN!

Aspirin induces nitric oxide releasefrom vascular endothelium: a novelmechanism of action

British Journal of Pharmacology 2004; 143: 159-165.

Aspirin = nitric oxide = pain reliefConsider aspirin side effects

FIBROMYALGIA PAIN

Abnormal microcirculation and temperature in skin above tender points in patients with fibromyalgia.

Rheumatology (Oxford). 2000; 39:917-921.

If light therapy improves abnormal circulation, would it help clients with fibromyalgia???

ARTHRITIS PAIN

Modulation of pain in osteoarthritis: the role of nitric oxide.

Clin J Pain 2008; 24: 353-65.

Conclusion of authorsNitric Oxide, produced transiently in small amounts, can

bring dramatic relief to people with painful OA.

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RAYNAUD’S PAIN

Effect of nitric-oxide-generating system on microcirculatory blood flow in skin of patients with severe Raynaud's syndrome: a randomised trial.

Lancet. 1999; 354(9191): 1670-1675

Painful, Scleroderma Ulcer with Raynauds

June 27, 2005 July 11, 2005• Treatments tried over 6 months

• Vicodin, Percocet, Methadone for pain• Viagra, Procardia, Prednisone, Carpal

Tunnel Release; Radial & Ulnar Artery Sympathectomies; Debridement to increase circulation

• 19 Physician office visits in 6 months

• 2 Weeks of infrared Therapy• 3 x per week• 25 minutes per treatment• Results:

• Pain significantly reduced• Range of motion improved

with occupational therapy

Painful, Scleroderma Ulcer with Raynauds

• 7 weeks of infrared Therapy• Results:

• Off all narcotics• Able to button clothing, write,

do needlework• Patient discharged with home system

• Final photo

August 10, 2005

September 22, 2005

So what?

• Nitric oxide is what keeps our arteries open so blood can flow to organs.

• Good blood flow heals wounds

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Before(4 months after ceasing daily

treatments)

40 year venous ulcerHealed in 5 Months

QuickTime™ and aCinepak decompressor

are needed to see this picture.

ON A PREVIOUS SLIDE I SAID….• Poor blood flow to the skin can lead to

wounds that are difficult to heal.

• If the wound gets infected, it may require an amputation.

• Who wants to have only one foot or one leg?

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88 yr old Diabetic Female treated 3X/week

February 5, 1999 March 5, 1999 March 31, 1999January 8, 1999

Resolved 81 daysAmputation avoided

WHO SAYS NITRIC OXIDE MAY BE IMPORTANT IN

WOUND HEALING?

Nitric oxide regulates wound healing.

J Surg Res. 1996; 63: 237-240é

Faster wound healing

• Horwitz L, Burke T, Carnegie D: Augmentation of wound healing using monochromatic infrared energy.

• Adv. Wound Care 1999, 12:35-40

WHAT ELSE? SENIOR CITIZENS Diabetes mellitus is associated with an increased risk of falls in elderly residents of a long-term care facility.Gerontol A Biol Sci Med Sci 2005; 60: 1157-62

Therefore, if red/infrared diodes increase nitric oxide in diabetic patients, will the absolute number of falls (and broken bones) decrease?Millions of diabetic patients out there.

INFRARED + Physical Therapy REDUCES FALLS IN ELDERLY DIABETIC

PATIENTSKochman J. Geriatric Physical Therapy 27: 2004

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1 4 7 10 13 16 19 22 25 28 31 34 37

Patient No.

Num

ber o

f Fa

lls

98 Total Falls 3 Months Pre TREATMENT4 Total Falls 3 Months Post TREATMENT

P < 0.0001 vs. Pre TX

Falls and fear of falling• Powell MW, Carnegie, DH, Burke TJ.

• Reversal of diabetic peripheral neuropathy with photo therapy (mire) decreases falls and the fear of falling, and improves activities of daily living in seniors.

• Over 1000 patients! Sensation increased.• Age and Aging 2006; 35: 11-16.• Think of the number of seniors in the US.

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Why use vibration?(because it increases nitric oxide)

Maloney-Hinds C, Petrofsky JS, Zimmerman G, Hessinger DA

The Role of Nitric Oxide in Skin Blood Flow Increases Due to Vibration in Healthy Adults

and Adults with Type 2 DiabetesDiabetes Technology & Therapeutics. 2009, 11: 39-43.

Acupuncture• Anesth Analg. 2007; 104: 301-7.

• Acupuncture enhances generation of nitric oxide and increases local circulation.

• Tsuchiya M1, Sato EF, Inoue M, Asada A.

REHABILITATION

Nitric oxide modulates fracture healing. J Bone Miner Res. 2000; 15: 342-51.

Modulation of tendon healing by nitric oxide.Inflamm Res. 1997; 46: 19-27.

MAJOR EFFECT OF LIGHT• First and foremost = vasodilation• Vasodilation means blood vessels get “bigger”

allowing more blood to flow freely to tissues• More blood flow = more oxygen and nutrients

• What causes vasodilation? • IT’S THE RELEASE OF NITRIC OXIDE• Although nitric oxide is a natural body

substance….often, we don’t make enough nitric oxide…….or disease(s) destroys it

• Where you treat is where vasodilation occurs

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VAS Pain Scale Pre and Post Treatment

0100200300400500600700800

0 1 2 3 4 5 6 7 8 9 10

VAS Pain Scale

Num

ber o

f Pat

ient

s

Pre-TreatmentPost-Treatment

2239 diabetic patients; half with DIABETIC neuropathy

Worse pain 8, 9 and 10 before light therapy

J Diabetes Complications. 2006; 20: 81-87

Microcirculation Changes

Heel

20 minute Treatment (near infrared) =

Vasodilation; increased blood flow

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Microcirculation Changes

Medial Knee over MCL

20 minute Treatment (near infrared) =

Increased blood flow

STATINS

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Statin Drugs May Increase Risk of Peripheral Neuropathy

St. Paul, Minn. – Statin drugs can increase the risk of developing peripheral neuropathy, according to a study published in the May 14 issue of Neurology, the scientific journal of the American Academy of Neurology.

STATINS: WHY?

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Statins lead to dose-dependent reductions in coenzyme Q10, a key mitochondrial antioxidant and electron transport carrier.

ATP IS REDUCED

ONE MORE

• Concussions and traumatic brain injury• Sports, military vets, IEDs

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SPECT imaging of brain

• “TBI patients demonstrated regions of hypoperfusion in frontal, pre-frontal and temporal cortices, and sub-cortical structures. Hypoperfusion in ‘frontal’, ‘left posterior’ and to a lesser extent ‘sub-cortical’ sub-groups was concordant with neuropsychological localization.”

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Soldiers/Sports

• Suffer concussions (TBI). Auto accidents too.• Symptoms are chronic and DEVASTATING• Documented blood flow decrements in

brain• NIR restores blood flow in brain…• Most Symptoms resolve. QOL improves. • TBI “SYMPTOMS”: another opportunity for you. • Be a hero 54

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Michael Hamblin, PhD Harvard University

• “The fact that near-infrared light can penetrate into the brain would allow non-invasive treatment to be carried out with a low likelihood of treatment-related adverse events.”

• SPECT shows low blood flow; treat with NIR. Does circulation improve?

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TO INCREASE CIRCULATION IN TBI

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Confidential

Preliminary Results Images: Pre v. Post Treatment

Treatment

Confidential

Preliminary Results Images: Pre v. Post Treatment

Treatment

CONCERNS WITH NO PRODUCTION IN THE BODY?

• Only if a person is ALSO taking nitrates such as nitroglycerin• Only if someone is using drugs (“blood thinners”) to prevent

blood clots (such as coumadin, waren)• Be careful in people with chronic low blood pressure• We don’t know about pregnancy • Don’t treat skin over a malignancy• There may be others; don’t assume anything!• Don’t make any claims about healing; SYMPTOMS, YES!• Have the person consult with a physician

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Can you “get” too much nitric oxide production (from light

therapy?)• No! You cannot over treat.• Any extra, unused nitric oxide is

converted to nitrates (NO3) and nitrites (NO2).

• Excess NO3 and NO2 are excreted in the urine

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TAKE AWAY MESSAGE

Why is Red/NIR Light Therapy Effective?

Non-invasive, local, drug-free release of Nitric Oxide from hemoglobin and endothelial cells.

Light therapy and Chiropractors:why use it?

Because it can be part of your overall efforts to reduce painful

conditions in your patients

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OPPORTUNITY FOR PRACTICE

• Acute revenue from new patients in your clinic• Tests for sensory integrity• Tests for balance, walking distance/speed

Suggest 20 treatments over 6 weeks (3X/week); cease if no progress after 6-8 treatments. Don’t be greedy or over promise

• We can offer possible reasons for failure• Consider offering home units for chronic

disease patients (eg. Diabetes)d 63

Neuropathy papers• Improved foot sensitivity and pain reduction in patients with

peripheral neuropathy after treatment with monochromatic infrared photo energy--MIRE.

• Harkless LB, DeLellis S, Carnegie DH, Burke TJ.• J Diabetes Complications. 2006 Mar-Apr;20(2):81-7.

• Reversal of diabetic peripheral neuropathy with phototherapy (MIRE) decreases falls and the fear of falling and improves activities of daily living in seniors.

• Powell MW, Carnegie DH, Burke TJ.• Age Ageing. 2006 Jan;35(1):11-6. Epub 2005 Nov 22. Erratum

in: Age Ageing. 2006 Jul;35(4):454.

Neuropathy papers.

• Improved sensitiv ity in patients with peripheral neuropathy: effects of monochromatic infrared photo energy.

• DeLellis SL, Carnegie DH, Burke TJ.• J Am Podiatr Med Assoc . 2005 Mar-Apr;95(2):143-7.

• Reversal of diabetic peripheral neuropathy and new wound incidence: the role of MIRE.

• Powell MW, Carnegie DE, Burke TJ.• Adv Skin Wound Care. 2004 Jul-Aug;17(6):295-300.

• Symptomatic reversal of peripheral neuropathy in patients with diabetes.• Kochman AB, Carnegie DH, Burke TJ.• J Am Podiatr Med Assoc . 2002 Mar;92(3):125-30.

Better use of drugs

• Laser Therapy: Infrared Photo Energy May Reduce Neuropathic Pain

• Thomas J. Burke, PhD• Practical Pain Management 2007; 7: 57-63• In this paper we showed a decrease in the

consumption of pain drugs; and an increased quality of life.

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BENEFITS

Increases Nitric oxide…at the site of treatmentNitric oxide has many effects

1. Increase blood flow wherever you treat2. Reduce pain and restore sensation3. Improve gait and balance, reduce falls4. Help with wound healing; prevent

amputation5. May decrease number of drugs

Remember, light therapy does one thing and only one thing!

Tests

• Good history. CBC; A1c• Monofilamen: can they feel it? where?• Skin temperature.

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Show in your office?

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THANK YOU

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