Category Archives: Rheumatoid Arthritis

External Laser Therapy and Laserneedle Acupuncture for Chronic Pain

Featured Image:   Comb Jelly (Mnemiopsis sp.)

https://i.ytimg.com/vi/weeFO6kLu5o/maxresdefault.jpg

Dear Pain Matters blog readers,

External laser therapy is used to exert various biological/cellular effects in the body including:

  • Stimulation of various acupuncture points (via noninvasive, painless Laserneedle acupuncture); and
  • Treatment of local damaged areas within the tissue.  Local laser therapy may be done for pain management, rehabilitation and regeneration of damaged tissue.

External laser therapy uses various laser wavelengths (i.e. colours) to penetrate different depths and tissues beneath the skin including:

  • Infrared laser (800 – 900 nanometers, ‘nm’; 810 nm, may be used) – 5 to 7 cm depth below the skin;
  • Red laser (630 – 680 nm; 658 nm may be used) – 2 to 3 cm depth below the skin.  Red laser can increase cellular activity and blood circulation as well as stimulate immune cells, fibroblasts and mitochondria, leading to regeneration and improved healing including wound healing;
  • Green laser  (532 nm) – 0.5 to 1 cm depth beneath the skin.  Green light is largely absorbed by haemoglobin in the red blood cells; and
  • Blue laser (405 nm) – 1 to 2 mm depth only.  Blue laser light has anti-inflammatory effects.

External laser therapy can be applied via:

  • Single point lasers.  Only one point and 1 wavelength can be used in single point lasers; or
  • Laserneedles.  Up to 12 multi-channel lasers/points including different wavelengths/colours/power outputs may be used at the same time (e.g. Weberneedle system, Lasershower).

External laser therapy may treat various painful medical conditions including:

  • Spine syndromes/back pain;
  • Osteoarthritis;
  • Rheumatoid diseases;
  • Tendon inflammation;
  • Migraine/headache; and
  • Trigeminal neuralgia

(Michael Weber MD).

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Source:   http://www.webermedical.com/en/weber-medical-for-professionals/med-lasertherapy/external-laser-therapy/

Fibromyalgia:

A study involving laser acupuncture treatment for fibromyalgia patients reported an average Pain Scale of 4.4, post-laser acupuncture (compared to an average Pain Scale of 8.5, pre-laser acupuncture).

Further improvements occurred when laser acupuncture plus intravenous laser was offered to fibromyalgia patients (i.e. average Pain Scale of 2.9, post-laser acupuncture plus intravenous laser, compared to 8.9, pre-treatment).

Both:

  • Laser acupuncture; and
  • Laser acupuncture plus intravenous laser

were more effective for pain management than medication alone (6.8, post-medication, versus 8.7, pre-medication) and metal needle acupuncture (6.0, post-treatment, versus 8.5, pre-treatment) in fibromyalgia patients (Wieden).

(For more on intravenous laser, please refer to:
http://www.webermedical.com/en/weber-medical-for-professionals/med-lasertherapy/intravenous-laser-therapy/.)

Possible Mechanisms:

I urge all interested readers to read Chapter 4 called ‘Rewiring a Brain with Light’, in Norman Doidge’s 2nd book, ‘The Brain’s Way of Healing’.  This book provides an excellent introduction into phototherapy (i.e. low level laser therapy; LLLT) (Doidge, 2016).  

Scientists have recently shown that humans (including the human eye and brain) may detect and perceive a single photon (Tinsley et al, 2016).  This is very interesting as it shows the sensitivity of the human body to the biological (hence potential healing) effects of natural light including its visible wavelengths from 400 to 700 nm (blue to red) and invisible wavelengths from 800 to 900 nm (near infrared).

Summary:

Whilst relatively new (and undergoing further research), external laser therapy and Laserneedle acupuncture may be useful for reducing pain in many chronic pain conditions including fibromyalgia.

Dear Pain Matters blog readers, if you would like to get in touch with Dr Michael Weber and his team, please email Martin Junggebauer on:

junggebauer@webermedical.com

Martin is an integral member of Dr Michael Weber’s team, and he will be sure to assist you with your enquiries.

http://www.dr-weber-laser-clinic.com/en/home/

Sabina Walker

“Sedare dolorem divinum opus est”
“It is divine to alleviate pain”

Galen, 130-200 C.E.

REFERENCES

(1A) Michael Weber MD

Laser in Pain Therapy and Rehabilitation

http://www.webermedical.com/en/weber-medical-for-professionals/med-lasertherapy/pain-therapy-rehabilitation/

http://www.webermedical.com/en/the-business/dr-weber/

http://www.webermedical.com/en/weber-medical-for-professionals/the-principle/

(1B) Michael Weber MD, Robert Weber, Martin Junggebauer

Medical Low Level Laser Therapy – Foundations and Clinical Applications (2nd Edition, June 2015)

http://www.isla-laser.org/en/

(1C) Michael Weber MD, President of International Society for Medical Laser Applications (ISLA)

International Society for Medical Laser Applications (ISLA)

http://www.isla-laser.org/en/

(1D) Michael Weber MD, Thomas Fussgänger-May MD, Tillman Wolf MD

“Needles of Light”: A New Therapeutic Approach

Medical Acupuncture (2007); 19(3)

DOI: 10.1089/acu.2007.0539

http://www.my-dr.de/FG/texte/infounten/Publikationen/Medical_Acupuncture.pdf

(1E) Michael Weber MD, Zulia Frost MD

Multi-Laser Needle Acupuncture and Laser Blood Irradiation Therapy – Clinical Application of Biological Laser Therapy (Pages 1-50)

http://www.metgesacupuntors.org/resources/pdfs/congres_2009/17_30Z_Frost.pdf

Other Papers, Articles and a Blog by Fred Kahn, MD FRCS(C):

(2) Wieden, Torsten E. (MD Anaesthesiologist, Special pain therapy)

e-mail: wieden@schmerzpraxis-celle.de

Fibromyalgia in Pain Therapy – Mechanisms and Treatment Options in Laser Therapy

http://www.isla-laser.org/wp-content/uploads/Fibromyalgia-in-Pain-Therapy.pdf

(3) Pryor, Brian A

Class IV Laser Therapy – Interventional and Case Reports Confirm Positive Therapeutic Outcomes in Multiple Clinical Indications (2009)

http://www1.udel.edu/PT/PT%20Clinical%20Services/journalclub/caserounds/11-12/September/PryorLaserPromotional.pdf

(4) Class IV Laser Therapy – Case Study Reports (Pages 1-39)

http://www.madisonlasertherapy.com/uploads/6/4/3/2/6432749/class_iv_therapy_laser_case_studies_report_2013.pdf

(5) Litscher G, Rachbauer D, Ropele S, Wang L, Schikora D, Fazekas F, Ebner F.

Acupuncture Using Laser Needles Modulates Brain Function: First Evidence From Functional Transcranial Doppler Sonography and Functional Magnetic Resonance Imaging.

Lasers Med Sci. 2004;19(1):6-11.

DOI: 10.1007/s10103-004-0291-0

http://www.ncbi.nlm.nih.gov/pubmed/15316852

(6) Norman Doidge MD

The Brain’s Way of Healing – Remarkable Discoveries and Recoveries from the Frontiers of Neuroplasticity (Chapter 4 – Rewiring a Brain with Light)

Publisher: Penguin Publishing Group (26 January 2016)

ISBN: 9780143128373

http://www.normandoidge.com/?page_id=1042

(7) Blog by Fred Kahn, MD FRCS(C), LLLT Specialist

http://fredkahnmd.com/2016/07/12/current-research-on-the-management-of-pain/

(8) Tinsley JN et al

Direct detection of a single photon by humans.

Nat. Commun. 7:12172

doi: 10.1038/ncomms12172 (2016).

http://www.nature.com/articles/ncomms12172

 

 

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Can Vagus Nerve Stimulation Decrease Inflammation, Hence Reduce Inflammatory Pain in Some Chronic Pain Patients?

Dear Pain Matters blog readers,

One of the most under-appreciated nerves of our body is the vagus nerve.  In Latin, the word ‘vagus nerve’ literally means ‘wandering nerve’.  (In fact, the words vagrant, vagabond, and vague are all based on the same word, ‘vagus’.)

So what does this vagus nerve do?

Answer:  Too much to answer in a single blog post, that’s for sure!

As such, I will only focus on one function of the vagus nerve (from an ‘inflammation/pain’ perspective).

Persistent localised inflammation is a key component of, and contributes to pain in, many chronic pain conditions including CRPS, rheumatoid arthritis (joint inflammation), and inflammatory bowel disease (Crohn’s disease, ulcerative colitis).

Dr Kevin Tracey’s research –

Dr Kevin Tracey’s team found that stimulation of the efferent vagus nerve (motor branch of the vagus nerve) can significantly curtail, and even block, the release of potentially damaging pro-inflammatory cytokines.  Not only can activation of the efferent vagus nerve protect against organ and tissue damage, but it may also reduce pain caused by inflammation.

Specifically, stimulation of the ‘Cholinergic Anti-Inflammatory Pathway’ including the efferent vagus nerve leads to decreased release of pro-inflammatory mediators including tumor necrosis factor alpha (TNF), hence reduced localised inflammation.

So what??  (you may ask)

In November 2012, Dr Kevin Tracey’s lab reported the first successful clinical trial that showed that stimulation of the vagus nerve can be effective for decreasing inflammation and pain in Rheumatoid Arthritis patients.

This is very exciting news….and it raises further questions….

For example, if stimulation of the vagus nerve can be effective in Rheumatoid Arthritis patients, could stimulation of this same vagus nerve also offer certain relief from inflammatory pain to other chronic pain patients with persistent localised inflammation (including some patients with CRPS, inflammatory bowel disease, etc)?

If yes, could vagus nerve stimulation be offered in addition to, or as an alternative to, current pain treatments?

I look forward to further updates of Kevin Tracey’s clinical study involving stimulation of the vagus nerve in Rheumatoid Arthritis patients.

Any benefits to Rheumatoid Arthritis patients may offer hope and inspiration to some chronic pain patients with persistent inflammation (eg CRPS, inflammatory bowel disease, etc).

Here’s to ‘less chronic pain, more gain’.

Sabina Walker

REFERENCES

Dr Kevin Tracey

(1)  http://www.feinsteininstitute.org/faculty/kevin-j-tracey-md/

(2)  “SetPoint Medical Presents Positive Clinical Results for First Human Study of Implantable Neuromodulation Device for Rheumatoid Arthritis” (12 Nov, 2012).

http://www.businesswire.com/news/home/20121112005932/en/SetPoint-Medical-Presents-Positive-Clinical-Results-Human#.VGQLh4fN6-I

(3A) The Body Electric

http://www.huffingtonpost.com/dr-kevin-j-tracey-md/the-body-electric_b_5396922.html

(3B) …Or click here for interview with Dr Kevin Tracey (if above link does not work):

Dr. Kevin Tracey Explains How A Nerve Stimulator Could Change Arthritis Treatment

http://www.huffingtonpost.com/2014/05/30/nerve-stimulator-arthritis-treatment_n_5420248.html

(4) Can the Nervous System Be Hacked?

By Michael Behar; 23 May, 2014; The New York Times (Magazine)

http://www.nytimes.com/2014/05/25/magazine/can-the-nervous-system-be-hacked.html

(5) Fox, Douglas. The Shock Tactics Set to Shake Up Immunology. Nature (04 May 2017); 545: 20–22.

doi: 10.1038/545020a

http://www.nature.com/polopoly_fs/1.21918!/menu/main/topColumns/topLeftColumn/pdf/545020a.pdf

Academic papers by Kevin J Tracey (there are now over 315 published papers):

(6) Koopman FA, Chavan SS, Miljko S, Grazio S, Sokolovic S, Schuurman PR, Mehta AD, Levine YA, Faltys M, Zitnik R, Tracey KJ, Tak PP. Vagus Nerve Stimulation Inhibits Cytokine Production And Attenuates Disease Severity In Rheumatoid Arthritis. PNAS (2016); 113(29): 8284-8289.

doi: 10.1073/pnas.1605635113

http://www.pnas.org/content/113/29/8284.abstract

(7) http://www.researchgate.net/profile/Kevin_Tracey/publications

Other References

(8) Bonaz B, Sinniger V, Hoffmann D, Clarençon D, Mathieu N, Dantzer C, Vercueil L, Picq C, Trocmé C, Faure P, Cracowski J-L, Pellissier S. (2016), Chronic Vagus Nerve Stimulation in Crohn’s Disease: A 6-Month Follow-Up Pilot Study. Neurogastroenterol Motil (2016); 28: 948–953.

doi: 10.1111/nmo.12792

https://www.ncbi.nlm.nih.gov/pubmed/26920654

(9) Sabina Walker, Peter D. Drummond; Implications of a Local Overproduction of Tumor Necrosis Factor-α in Complex Regional Pain Syndrome [Review Paper, 24 pages]; Pain Medicine (Dec 2011), 12 (12), 1784–1807.

http://onlinelibrary.wiley.com/doi/10.1111/j.1526-4637.2011.01273.x/abstract

(Our 24-page Review Paper includes extensive discussion of Kevin Tracey’s research and whether this research may be relevant to CRPS.)  

 

Anti-TNF Drug (Infliximab) Therapy for CRPS and Other Chronic Pain Conditions

Dear Pain Matters blog readers,

Chronic Pain and Anti-TNF Drug Therapy

Infliximab and other selective anti-TNF drugs have been used to treat Lumbar Radicular Pain including severe Sciatica, Rheumatoid Arthritis, and Crohn’s disease (refer to first 8 papers in References)….and more recently, for Complex Regional Pain Syndrome (CRPS) (refer to all remaining References).

 

Complex Regional Pain Syndrome (CRPS) and Anti-TNF Drug Trial

Several European studies showed promising results following anti-TNF drug (Infliximab) trials in CRPS patients.

(1) Infliximab Treatment for 2 CRPS Patients –

In the 1st Infliximab paper, pain decreased in 2 CRPS patients.

– 1st Patient (Female, 50):  Chronic CRPS, Duration ~ 5 years

– 2nd Patient (Female, 55): Acute CRPS, Duration ~ 2 months, caused by left arm Colles’ fracture

Blister fluid from the CRPS limbs of both patients showed significant reductions in localised tumor necrosis factor-alpha (TNF) and IL-6 following Infliximab treatment.

More importantly (to the 2 patients anyway), there were:

– Reduced pain;

– Decreased vascular disturbances;

– Less swelling/edema;

– Enhanced motor function; and

– Improved symptoms (Huygen et al, 2004).

(2) Infliximab Treatment for 1 CRPS Patient –

In the 2nd Infliximab paper, pain decreased in 1 patient with acute CRPS.  Specifically, a female patient (62) with acute CRPS for 3 months, caused by left hand Colles’ fracture, showed near-complete remission following Infliximab treatment for 8 weeks (Bernateck et al, 2007).

(3) Infliximab Trial for CRPS (7 Cases, Plus Placebo Group) –

Six (6) CRPS patients were treated with Infliximab, while another 7 CRPS patients were given placebo.  There was greater reduction in TNF levels in the Infliximab-treated patients (compared to placebo).  However, for various reasons, this study was discontinued (Dirckx et al, 2013; Nederlands Trial Register 449 ISRCTN 75765780).

(4) Perispinal Etanercept (A Back Pain Patient) –

The Institute of Neurological Recovery in Florida published an 8-minute YouTube on 25/11/2009 of a female patient with constant and severe back and leg pain for 2 years. Several minutes after a single dose of perispinal Etanercept, she enjoyed pain relief and leg movement.

‘Immediate relief after 2 years of severe constant pain 480p’

https://www.youtube.com/watch?v=vP6Nw1_OGIg

 

More research into anti-TNF drug treatment for CRPS is warranted.  Such studies should confirm whether localised TNF levels are elevated in CRPS-affected limbs in the first place.  If yes, analysis is necessary whether any anti-TNF drug treatment leads to a significant reduction in these elevated localised TNF levels, and if yes, whether this is also accompanied by reduced pain (etc).  Induced skin blisters or skin biopsies may be necessary to confirm localised TNF levels in CRPS-affected limbs, both ‘before’ and ‘after’ anti-TNF drug treatment.

NOTE:  If localised TNF levels are already low to begin with (prior to anti-TNF drug treatment), anti-TNF drug treatment is (likely) not justified.

Possible adverse effects also need to be considered prior to anti-TNF drug treatment.

 

Wishing all pain patients less pain,

Sabina Walker

PS YOU DON’T HAVE TO READ THE FOLLOWING UNLESS YOU ARE VERY INTERESTED IN SCIENCE –

POSSIBLE MECHANISMS OF ANTI-TNF DRUG THERAPY IN CRPS NERVE PAIN

Anti-TNF drugs (e.g. InfliximabEtanercept) are TNF monoclonal antibodies that selectively block TNF, hence limiting the pro-inflammatory process.

The reduction of TNF and other pro-inflammatory mediators (via anti-TNF drug therapy, or otherwise) may alleviate certain painful symptoms in CRPS and other nerve pain conditions.

Ongoing trials are warranted including analysis of side effects.

For further details, please refer to 24-page Review Paper by Sabina Walker and Prof. Peter Drummond. In particular, please see pages 1790 – 1791, plus related references on page 1804 (listed below).

REFERENCES:

Anti-TNF Drug Therapy For Lumbar Radicular Pain Including Severe Sciatica, Rheumatoid Arthritis, and Crohn’s disease

(1) Karppinen et al; Tumor necrosis factor-alpha monoclonal antibody, infliximab, used to manage severe sciatica. Spine 2003;28:750–4.

(2) Manning; New and emerging pharmacological targets for neuropathic pain. Curr Pain Headache Rep 2004;8:192–8.

(3) Korhonen et al; The treatment of disc-herniation-induced sciatica with infliximab: One-year follow-up results of FIRST II, a randomized controlled trial. Spine 2006;31:2759–66.

(4) Burnett, Day; Recent advancements in the treatment of lumbar radicular pain. Curr Opin Anaesthesiol 2008;21:452–6.

(5) Cohen et al; Randomized, double-blind, placebo-controlled, dose-response, and preclinical safety study of transforaminal epidural etanercept for the treatment of sciatica. Anesthesiology 2009;110:1116–26.

(6) Lipsky et al; Infliximab and methotrexate in the treatment of rheumatoid arthritis. Anti-tumor necrosis factor trial in rheumatoid arthritis with concomitant therapy study group. N Engl J Med 2000;343:1594–602.

(7) Emery, Buch; Treating rheumatoid arthritis with tumor necrosis factor alpha blockade. BMJ 2002; 234:212–213.

(8) Blam et al; Integrating anti-tumor necrosis factor in inflammatory bowel disease: current and future perspectives. Am J Gastroenterol 2001;96:1977–1997.

Anti-TNF Drug Therapy For Complex Regional Pain Syndrome (CRPS)

(9) Huygen et al. Successful treatment of CRPS 1 with anti-TNF. J Pain Symptom Manage 2004;27:101–3.

http://www.ncbi.nlm.nih.gov/pubmed/15157033

(10) Bernateck et al. Successful intravenous regional block with low-dose tumor necrosis factor-a antibody infliximab for treatment of complex regional pain syndrome 1. Anesth Analg 2007;105:1148–51.

http://www.rsds.org/pdfsall/Bernateck_Rolke.pdf

(11A) Dirckx, Groeneweg, Wesseldijk, Stronks, Huygen; Report of a Preliminary Discontinued Double-Blind, Randomized, Placebo-Controlled Trial of the Anti-TNF-α Chimeric Monoclonal Antibody Infliximab in Complex Regional Pain Syndrome; Pain Practice (Nov 2013); 13(8):633–640.

DOI: 10.1111/papr.12078

http://onlinelibrary.wiley.com/doi/10.1111/papr.12078/abstract

(11B) Nederlands Trial Register 449 ISRCTN 75765780

http://www.controlled-trials.com/ISRCTN75765780/crps

(12) Sabina Walker, Peter D. Drummond; Implications of a Local Overproduction of Tumor Necrosis Factor-α in Complex Regional Pain Syndrome [Review Paper, 24 pages]; Pain Medicine (Dec 2011), 12 (12), 1784–1807.

In particular, please refer to pages 1790 – 1791, plus related references on page 1804 (also listed above).

http://onlinelibrary.wiley.com/doi/10.1111/j.1526-4637.2011.01273.x/abstract