Efficacy of super-pulsed 905 nm Low Level Laser Therapy (LLLT) in the management of Traumatic Brain Injury

World Journal of Neuroscience, 2012, 2, ***-*** WJNS
Published Online November 2012 (http://www.SciRP.org/journal/wjns/)
Efficacy of super-pulsed 905 nm Low Level Laser Therapy (LLLT) in the management of Traumatic Brain Injury (TBI): A case study
William Stephan1, Louis J. Banas1, Matthew Bennett2, Huseyin Tunceroglu3
1William Stephan M.D., Limited Liability Company (LLC), New York, USA
2Bennett Health and Wellness, New York, USA
3University of Buffalo School of Medicine and Biomedical Sciences, New York, USA
Email: huseyint@buffalo.edu

ABSTRACT
Traumatic brain injury is a major health concern worldwide with massive financial and social impact. Conventional treatments primarily focus on the pre- vention of further damage to the brain parenchyma, while failing to address the already existent symptoms. Previous clinical studies have shown that Low Level Laser Therapy (LLLT) can significantly reduce pain and induce temporary vasodilation in capillaries, which the authors hypothesize can be used to improve the quality of life in TBI patients by treating their current symptoms, which are predominately migraine- like headaches. This case report illustrates the use of LLLT in the treatment of a patient with a TBI and the great clinical success achieved in the reduction of pain, as measured by VAS—achievable within five treatments of 10 minutes in duration.
Keywords: Traumatic Brain Injury; Low Level Laser Therapy; LLLT; Chronic Migraines; Headaches
1. INTRODUCTION
Traumatic brain injury (TBI) typically occurs when there is any sudden trauma to the skull that induces damage to the brain. There are many causes of TBIs, but unfortu- nately no documented cures. According to Faul et al., the annual incidence of TBI in the United States is approxi- mately 1.7 million incidents, which account for 30.5% of injury related deaths [1]. The direct and indirect costs of TBI totaled an estimated 76.5 billion dollars in the United States in 2000 [2]. Traumatic brain injuries play a major role in the health care of our nation, especially in our armed forces, where the men and women serving our country are at a higher risk to suffer a TBI.
Treatment is centered on preventing future insult to the brain, but very little can be done to treat the already ex- isting symptoms. These symptoms, as described by the National Institutes of Health, range from mild to severe and include: headaches, nausea, vomiting, confusion, and blurry vision. Current theory on alleviating the symp- toms of TBIs is based on reducing inflammatory and oxi- dative stress and increasing perfusion to support meta- bolic needs [3]. A study by Naeser et al. looked at the use of Near Infra Red (NIR) light for the treatment of TBI, stroke, and neurodegenerative disease. Their results were very promising, showing that nightly treatments with NIR LED over a period of months to years improved cognitive abilities [4]. Furthermore, they showed that the use of NIR light increased ATP production, caused vaso- dilation, and improved perfusion. We believe that the superpulsed 905 nm LLLT system employed in this case study operates through similar mechanisms of action and to support our hypothesis we present a case report of a patient with a traumatic brain injury that was treated with the superpulsed 905 nm LLLT system two years after the injury occurred.
2. CASE REPORT
A 25-year-old man with no pertinent past medical history presented as a new patient. His only complaint was chronic debilitating migraines since a traumatic brain injury which occurred in May of 2010. He was attacked and repeatedly hit over the head with a lead pipe, cons- quently requiring many sutures and leaving a scar on the brain as evidenced by the MRI performed subsequent to the incident. Since the attack, he has been experiencing excruciating migraines daily which he rates at ranging from 7/10 to 10/10 using a Visual Analog Scale (VAS) reference and physically describes them as: throbbing, squeezing sensations located primarily to the occipital region of his skull. He complains of being unable to have a peaceful night of sleep or to participate in play with his four children, the oldest being 9, due to the constant pain Published Online November 2012 in SciRes. http://www.scirp.org/journal/wjns
2 W. Stephan et al. / World Journal of Neuroscience 2 (2012) **-**
and agony he experiences.
After undergoing multiple previous treatment modali- ties, which included: medications, vitamin supplements, and chiropractic massage therapies, all of which were unsuccessful at alleviating his symptoms, he had all but given up hope. Willing to try anything to rid himself of the chronic pain, he agreed to undergo LLLT treatment. Using a Theralase® superpulsed LLLT medical laser sys- tem equipped with a multiple probe handpiece (5 × 905 nm wavelength @ 0 to 100 mW average power per laser diode + 4 × 660 nm wavelength @ 25 mW average power per laser diode), he was given a total of five treat- ments delivered over a two week period, with the 905 nm laser diodes set to 50 mW average power. The LLLT was targeted to a total of four areas on the scalp for two and a half minutes each: midline occipital region just below the lamboidal suture, superior aspect of the nape to target the Circle of Willis and over the mastoid processes bilate- rally. We selected 905 nm wavelength based on a previ- ous scientific study that demonstrated that the 905 nm superpulsed wavelength employed by the system was able to increase inducible Nitric Oxide Synthase (iNOS) expression by 700%, as compared to numerous other wave-lengths that showed little or no effect [5]. iNOS has been well documented in numerous clinical studies to cause temporary vasodilation by signaling endothelial cells located in capillary walls to become flaccid and relax. Additional studies have shown that 810 nm and 665 nm wavelengths may also be effective, but those specific wavelengths are not able to produce as much iNOS expression, when compared to 905 nm superpulsed technology [6]. An average power for the superpulsed 905 nm laser diodes was initially chosen to be 50 mW based on personal experience, but further clinical inves- tigations may uncover more clinically effective average power settings.
Immediately after the first treatment of only ten min- utes in duration, the patient reported a 43% reduction in pain, reporting a VAS of 4/10 from a pre-treatment score of 7/10. He stated the throbbing and squeezing nature of his pain had immediately subsided and that all that was left was more of a dull achy pain. He continued with the treatments over the next week and with each new treat- ment his pain was further reduced. By the end of the course of 5 treatments, his pain had reduced by over 90% and all that remained was a minor ache that was barely even noticeable. Furthermore, he reported no side effects from the treatment except for a slight sensation of warmth over the area where the laser was placed. He was no longer experiencing constant pain; even his children no- ticed the difference saying that he looked happier. After two years, he was finally able to achieve a good night’s rest.
3. DISCUSSION
Low Level Laser Therapy (LLLT) has been used in many acute and chronic conditions, but its effectiveness is yet to be fully documented by human clinical trials for mi- graine, stroke or TBI. Currently Dr. Michael Whalen, working at Massachusetts General Hospital, is conduct- ing controlled studies using a low level laser with the hopes of bringing this new technology into the forefront of neuroscience and medicine. This case study gives one example of how LLLT can be used to treat chronic mi- graines, specifically those that are a result of traumatic brain injuries. LLLT has been shown to reduce pain and inflammation, create a state of vasodilation by activating the nitric oxide pathway and further even promote an- giogenesis. The present theory is that by increasing blood flow to the brain, and subsequently, increasing oxygen delivery to the brain, the symptoms of a migraine can be mitigated. This case differs from previous studies per- formed using laser therapy to help patients with TBIs in that the type of laser and the settings used were unique. Specifically, unlike the LED light used by Naeser et al., the therapeutic laser we utilized only required five treat- ments over two weeks to be effective with immediate re- sults after the first treatment.
It is currently unclear whether or not our patient will need maintenance therapy. He was interviewed at two weeks and two months post treatment and remains sym- ptom free. He is deeply appreciative of the care he was given and continues to enjoy family life which was impossible before LLLT. More research needs to be done, especially controlled double blind studies to further eva- luate the full effectiveness and possible side effects of using LLLT in the treatment of TBIs and migraines, but the latest research has shown that LLLT is an extremely safe and effective technology for a wide range of neural and muscular skeletal conditions.
REFERENCES
[1]
Faul, M.X.L., Wald, M.M. and Coronado, V.G. (2010) Traumatic brain injury in the United States: Emergency department visits, hospitalizations, and deaths. *, **-**.
[2]
Finkelstein E, C.P., Miller T and associates, The Inci-dence and Economic Burden of Injuries in the United States. Oxford University Press, 2006. doi:10.1093/acprof:oso/9780195179484.001.0001
[3]
Sahni, T., et al., (2012) Use of hyperbaric oxygen in traumatic brain injury: retrospective analysis of data of 20 patients treated at a tertiary care centre. British Journal of Neurosurgery, 26, 202-207. doi:10.3109/02688697.2011.626879
[4]
Naeser, M.A. and Hamblin, M.R. (2011) Potential for transcranial laser or LED therapy to treat stroke, trau- matic brain injury, and neurodegenerative disease. Pho- Copyright © 2012 SciRes. WJNS
W. Stephan et al. / World Journal of Neuroscience 2 (2012) **-**
Copyright © 2012 SciRes. WJNS
3
tomedicine and Laser Surgery, 29, 443-446. doi:10.1089/pho.2011.9908
[5]
Moriyama, Y., et al. (2009) In vivo effects of low level laser therapy on inducible nitric oxide synthase. Lasers in Surgery and Medicine, 41, 227-231. doi:10.1002/lsm.20745

The laser used in this study was the TLC-1000, super-pulsed multi-probe laser
For more information please call 1-866-843-5273 or visit www.theralase.com

Modern pharmaceuticals becoming part of the culture in the NHL

Globe and Mail

You’re the average NHL player, which means you stand a shade over six feet tall, you weigh just over 204 pounds, and you’re about 27 years old.
Between October and April of any given year, you will drop your battered self into an airplane seat on 80 or so occasions and rack up between 50,000 and 90,000 air miles.

You play an average of three games a week, and most of the time you’re suffering from a sprain, a strain, a tear or a break of one type or another.
So what do you do to withstand the maelstrom? In many cases the answer lies in the miracle of modern pharmaceuticals.
“You’ve just played a game, you have to travel, you’re up early the next day for a practice, maybe you’ve slept badly, maybe you’ve got other things going on at home or wherever, so for sure, pills can become a popular option for some guys,” the Vancouver Canucks’ Alex Burrows, whose team has one of the most demanding travel schedules in the NHL, said earlier this season.
In speaking to more than a dozen current NHL players and to several agents and hockey executives over the past five months, it is apparent the nexus of scheduling, player safety and travel is forming a little-noticed backdrop to the coming collective bargaining between the league and its players.
The life of the modern NHL player is not all first-class charters and swank hotels, there is also an eye-glazing amount of drudgery and crippling late-night flights and early morning practices, all of it seasoned with a generous pinch of fear – of injury, of unemployment, of failing on the ice.
As grinds go it’s fun, and handsomely remunerated; players happily embark, but even the fittest risk becoming tenderized by the end.
One Western Conference star described the perilous cycle thusly: industrial quantities of caffeine or over-the-counter decongestants (or both) to get up for games, alcohol and/or sleeping pills to tamp down post-game adrenalin, get up early for video and practice, rinse, repeat.
Since the death of former New York Rangers enforcer Derek Boogaard, who accidentally overdosed on a cocktail of pain medication and booze last year, and the subsequent deaths of NHL tough guys Rick Rypien and Wade Belak, the league and its teams have followed up on a public pledge by commissioner Gary Bettman to amend the NHL’s substance-abuse and behavioural policy, and have quietly tightened the rules concerning the way medication is dispensed in dressing rooms.
Sources also said the two physicians who oversee the NHL/NHLPA substance-abuse and behavioural-health program, Brian Shaw and David Lewis, made a point during their annual tour of the league’s dressing rooms of stressing the perils of sharing pills, whether they are for pain or sleep. According to multiple sources, the NHL Players’ Association and the NHL had discussions before this past season to find ways to control the availability of drugs – some teams apparently now keep a detailed log of their players’ prescriptions and refills.
“They’re trying to do it in order to make steps in the right direction so that what happened [last] summer doesn’t happen again in the near future,” the Boston Bruins’ Milan Lucic said in an interview in the early stages of the season.
But as with most other aspects of the league, policies vary from team to team, and no system is perfect.
Conversations with players and other officials throughout the league reveal that while the prevalence of opiates such as Oxycodone in NHL dressing rooms has been well-documented, the same is true of sleeping aids such as the prescription drug Ambien, which many players privately claim are popular among NHLers.
Generally speaking, there’s a ready supply of whatever a player needs to dull the pain or find sleep – all it takes is a teammate with an extra tablet or two in his shaving kit.
“It still goes on and it always will, guys pass pills around,” said a recently retired NHLer who played the bulk of his career in the Western Conference, where travel schedules are the most punishing.
And despite all the good will and best intentions of the league and the players’ union – and there is plenty of evidence of both from both – the central problem is intractable.
Because of the complexities of schedule-making and the financial situation of teams and the multipurpose buildings they play in, the simplest solution for improving the players’ lot – spreading out the games or playing fewer of them – isn’t practical.
So the specific demands in the eventual contract negotiations will likely have to do with details such as minimizing the number of back-to-back games.
But some players are beginning to advocate for more sweeping change.
Though the NHLPA has yet to pick its bargaining committee for the contract negotiations – an announcement is said to be imminent – there is talk it may seek to address some of the nuts and bolts regarding the league schedule and associated logistical issues at the negotiating table.
The other main barrier is a cultural one – professional hockey does all sorts of things that make little or no sense from a high-performance training standpoint.
Reams of studies have concluded it’s best for athletes to train around the same time they compete and that rest is as important as effort.
And yet hockey teams, which invariably play in the evening, universally practise in the morning. Game-day skates, pioneered in the NHL by former Chicago Blackhawks coach Rudy Pilous to keep his players from carousing too late, are another tradition that runs counter to the science.
“Their main usefulness is as mental preparation, routine, there’s no discernible physical benefit. In my view they should only ever be optional, to have everyone skate is an aberration. Everyone recovers differently, everyone needs different levels of rest,” said Georges Larivière, an emeritus professor of kinesiology at the Université de Montreal who has long studied hockey players. “And everyone knows that no practice is truly optional if you’re a rookie or a fourth-line player.”
For all that, many players are comfortable with the ritual – beyond the patchwork of practices among NHL teams, there is a range of opinion expressed by those in uniform.
“I think you at least have to give guys the option, I know I like to feel the ice and get my legs going,” said 23-year-old Montreal Canadiens defenceman P.K. Subban.
Among other players, the complaints are legion: coaches who insist players be at the rink for team meetings barely six hours after their charter has flown in; practice ice that is dangerously rutted and chippy because of the number of concerts and other events held in a typical NHL arena.
Larivière said teams typically don’t pay as much attention as they should to rest and recovery or to individual training and that the NHL routine becomes “a vicious circle.”
Other professional sports leagues, such as the NFL, have clauses in their collective agreements that limit the amount of time players can spend at the team facility and stipulate things such as the length of practices.
The NHL has no such strictures. The closest thing is Article 16.6 of the CBA, which reads: “practice sessions shall be scheduled at reasonable times in accordance with the general practice of clubs in the league.”
Some players see that as an area for improvement.
“The more guys are tired, the more likely they are to get hurt. This is going to be an issue [in the negotiations], maybe not the biggest issue, but it’s something a lot of guys are talking about,” said a player representative from an Eastern Conference team. Though the NHLPA has yet to set its negotiating positions, an official with the union said the player’s characterization “is accurate as far as we’re concerned.”
It’s not as though teams are completely insensitive to the concerns.
Many coaches only hold optional game-day skates and limit full-fledged practices to once or twice a week – and league-wide there is unprecedented emphasis on nutrition, preventive therapy and hockey-specific fitness training.
More and more teams are altering their travel policies and plumping for an extra night’s stay in a hotel after road games in faraway cities.
Several teams on the cutting edge, the Canucks and Calgary Flames chief among them, have done things such as consulting sleep doctors and arranging their practice and travel schedules in such a way as to minimize the physical demands on players.
“The games are so close, rest becomes a big factor,” Burrows said. “They’ve given us tricks to control our breathing, methods to help us sleep, whether it’s iPhone apps or other things to lower your heart rate and allow you to get better sleep. It works.”
But evidently not for everyone.

Chronic Pain and Depression

American Chiropractic Association:

Pain serves an important function in our lives. When you suffer an acute injury, pain warns you to stop the activity that is causing the injury and tells you to take care of the affected body part.

Chronic pain, on the other hand, persists for weeks, months, or even years. Some people, often older adults, suffer from chronic pain without any definable past injury or signs of body damage. Common chronic pain can be caused by headaches, the low back, and arthritis. Unfortunately, there is scant objective evidence or physical findings to explain such pain.

Until recently, some doctors who could not find a physical cause for a person’s pain simply suggested that it was imaginary— “all in your head.” This is unfortunate because we know that all pain is real and not imagined, except in the most extreme cases of psychosis. Emerging scientific evidence is demonstrating that the nerves in the spinal cord of patients with chronic pain undergo structural changes.

Psychological and social issues often amplify the effects of chronic pain. For example, people with chronic pain frequently report a wide range of limitations in family and social roles, such as the inability to perform household or workplace chores, take care of children, or engage in leisure activities. In turn, spouses, children, and co-workers often have to take over these responsibilities. Such changes often lead to depression, agitation, resentment, and anger for the pain patient and to stress and strain in family and other social relationships.

How is depression involved with chronic pain?

Depression is the most common emotion associated with chronic pain. It is thought to be 3 to 4 times more common in people with chronic pain than in the general population. In addition, 30 to 80% of people with chronic pain will have some type of depression. The combination of chronic pain and depression is often associated with greater disability than either depression or chronic pain alone.

People with chronic pain and depression suffer dramatic changes in their physical, mental, and social well-being—and in their quality of life. Such people often find it difficult to sleep, are easily agitated, cannot perform their normal activities of daily living, cannot concentrate, and are often unable to perform their duties at work. This constellation of disabilities starts a vicious cycle—pain leads to more depression, which leads to more chronic pain. In some cases, the depression occurs before the pain.

Until recently, we believed that bed rest after an injury was important for recovery. This has likely resulted in many chronic pain syndromes. Avoiding performing activities that a person believes will cause pain only makes his or her condition worse in many cases.

Signs and Symptoms

Some of the common signs and symptoms of chronic pain include:

• Pain beyond 6 months after an injury
• Allodynia—pain from stimuli which are not normally painful and/or pain that occurs other than in the stimulated area
• Hyperpathia—increased pain from stimuli that are normally painful
• Hypersensation—being overly sensitive to pain

Signs of major clinical depression will occur daily for 2 weeks or more, and often include many of the following:

• A predominant feeling of sadness; feeling blue, hopeless, or irritable, often with crying spells
• Changes in appetite or weight (loss or gain) and/or sleep (too much or too little
• Poor concentration or memory
• Feeling restless or fatigued
• Loss of interest or pleasure in usual activities, including sex
• Feeling of worthlessness and/or guilt

What is the treatment for chronic pain and depression?

The first step in coping with chronic pain is to determine its cause, if possible. Addressing the problem will help the pain subside. In other cases, especially when the pain is chronic, you should try to keep the chronic pain from being the entire focus of your life.

• Stay active and do not avoid activities that cause pain simply because they cause pain. The amount and type of activity should be directed by your doctor, so that activities that might actually cause more harm are avoided.
• Relaxation training, hypnosis, biofeedback, and guided imagery, can help you cope with chronic pain. Cognitive therapy can also help patients recognize destructive patterns of emotion and behavior and help them modify or replace such behaviors and thoughts with more reasonable or supportive ones.
• Distraction (redirecting your attention away from chronic pain), imagery (going to your “happy place”), and dissociation (detaching yourself from the chronic pain) can be useful.
• Involving your family with your recovery may be quite helpful, according to recent scientific evidence.
• Drug free Cold Laser Therapy has been found to relieve pain symptoms and offer relief.

Feel free to discuss these or other techniques with your doctor of chiropractic. He or she may suggest some simple techniques that may work for you or may refer you to another health care provider for more in-depth training in these techniques.

For information about Cold Laser Therapy please call 1-866-843-5273 or visit www.theralase.com