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TRIGGERPOINT and CHRONIC MYOFASCIAL PAIN TREATED WITH INFRARED ENERGY EMITTED BY (LED) A PHOTON STIMULATOR FOLLOWED BY COHERENT MONOCHROMATIC LIGHT TO SPECIFIC ACUPUNCTURE POINTS - PHYSIOLOGIC AND CLINICAL OUTCOME ASSESSMENT

Jacob Green, M.D., Ph.D. , Deborah Fralicker, D.C, Richard Bowles, B.S. ,Yu-Jiun (Eugene) Shen, M.S. – University of Florida

ABSTRACT:

A new infrared LED photon-emitting device was used in the office treatment of chronic myofascial pain patients with trigger points identified by classic clinical palpation examination.  The related known regional acupuncture points were stimulated by LED to Infrared along with the trigger points.  The groups of   patients’ (one workman’s comp one not) reported overall level of pain experience was significantly reduced. The results of acupuncture treatment with soft laser in a significant number of chronic myofascial pain sufferers who’s trigger points were initially treated with Photon emitted Infrared energy (a safe and effective treatment modality) with this new device are presented in this report.   A clear correlation beween the number of joules of energy applied  and pain reduction is presented.

INTRODUCTION:

Chronic myofascial pain with associated myofascial trigger points is a condition that does not readily ameliorate with simple treatment protocols. The use of a new  Infrared device, Meditech Bioflex® infrared photon stimulator, whose Infrared low energy emissions were directed at primary known acupuncture treatment points and over the actual painful trigger point areas, was assessed.

The evaluative protocol utilized a standard patient generated visual analog pain rating scale for each treatment, a Leikert Scale for overall rating of total treatment effectiveness, and in a few select cases objective evidence of skin surface temperature measurement obtained by high-resolution digital infrared imaging (Thermogram) before and after each treatment. A generally  favorable overall outcome  of Infrared therapy  by patients of this new mode of  treatment is presented as recorded.   

Infrared Energy by LED emission has been well documented to be photo biologically active to cellular enzyme systems.  Beneficial effects on human cellular systems in a microscopic level has been well established by Dr. Karu[i].  Unfortunately, little is said in any prior scientific publications about the total number of joules of energy used.  Light therapy treatment reports with some parameters typically omit Infrared treatment factors such as wave length of that are in our opinion of great significance.  Our findings indicate overall joules of Infrared therapy as applied to the patient is directly related to change of their clinical condition.

MATERIALS AND METHODS:

This study was performed to assess the clinical utility of photon stimulation coupled with (laser)coherent and (LED) non-coherent monochromatic light at known wave lengths for chronic myofascial and trigger point pain patients. A series of consecutive patients presenting to the Southeastern Neuroscience Institute P.A., Pain Rehabilitation Clinic were clinically evaluated and given a proscribed course of  treatments  with our  Meditech LED instrument, coupled with Bioflex monochromatic coherent (laser) light emitter.  Patients were all evaluated for  clinical outcomes (pain reduction).  Myofascial trigger points were initially identified and charted both by clinical (palpatation)  means and by increased focal heat as determined by a high resolution digital infrared imaging system of skin surface temperature measurements.

Infomed consent was obtained from all subjects for this therapy.   Trial treatment outcomes were evaluated by using a standard 10-cm visual analog pain scale where all  subjects were asked to indicate the intensity of their own pain experience  before and after all therapy sessions. A standard digital high-resolution infrared imaging by Thermogram was carried out before and after treatment in a selected number of studied patients.  Upon completion of up to the ten treatment sessions, where joules of energy per session were recorded, all patients were reassessed at “end of therapy”  by self-reports using the standard pain  analog scale.  A special one-time only specific Leikert scale designed to allow the patient to assess his/her overall treatment effectiveness was also employed.  All these survey instruments were statically compared.  (See Chart A - results section).

Infrared photon stimulation via Meditech-Bioflex LED emitter was applied to the skin over the myofascial pain sites for 2 to 10  minute sessions - total joules of energy for each session at all acupuncture points and each painful area as stimulated by a device generating 660nm at 3  millijoules/second was recorded.  A total of 38 patients of various ages - 20 Males  - 18 Females completed the infrared LED treatments. Myofascial trigger points as stated were individually treated and the patient evaluated for pain relief and circulatory integrity (by Infrared Imaging).  Dolorimitry because of its subjective nature was not utilized.  Soft laser emission was also applied to each area and trigger point after each Infrared LED session was completed.   (Soft laser emission defined as treatment with coherent monochromatic light.) Laser was also applied to each specified acupuncture site area after each infrared generated by LED session was completed. The coherent monochromatic laser light characteristics was monochromatic at  GaAIA’s 830 nm = non-nanometer 75 mv, a class 3B Canadian  fully  approved laser process.

RESULTS

   A total  of 138  similar Infrared pulsed treatments were given to all 38

participants.  18  were Workman’s   Comp  complainants,  20  were   “other

Myofascial  pain problem” patients, non-workmans  compensation.  The total

number of treatments given  were 138.     Both the   Workman’s  Comp   group

and  “other  pain”   group  participants received 69  total  treatments  each.

The   overall   visual  analog   self -rating   for  pain  in  the    non-workman’s

compensation   group   prior   to  the   first   treatment   was   5.9, and  before  the   last  

treatment   was 4.9.   The patient’s who  were  Workman’s  Comp   started  at 6.7 Visual 

Analog Pain  Rating, a higher level of pain perception than overall total group average, 

And  their   rating  was reduced  it  to 5.7.   The non-Workman’s   Comp  group   started  

with    a   4.8  pain  score    average,  with   a  3.9  level  of   pain    after   treatment.   It 

appears therefore,  that   the  patient’s under  Workman’s Comp  did not do  as well pain

reduction wise and also  had a higher degree of  pain perception  scores to start with.

When  the  patients  were asked to rate  “ effectiveness  of  treatment”  with  this

Infrared   instrument, the average Leikert  scale rating  was 7.0. The  scale was set up

0-5 being either  harmful to  no  help  and  5-10  being  of   no  help  to  great help. The

entire group of 38  participants who  underwent 138 treatments gave an assessment, a

Leikert  score of 7.0, meaning it was of significant    help (5 being neutral).  Interestingly,

the workman’s comp group   had a 6.8 self rating of the value of the treatment process.   

This common sense assessment suggests it  was a help to the patients and not a

random chance event.  The  other group (non-Workman’s Comp)   was 7.2, also  a

positive response  to the question of treatment effectiveness as  judged by the

participating  patients.  Random chance would have given an effectiveness rating of a

perfect 5.0 on Liekert scale.

It    appears that    we have  avoided the  utilization of heavy  pain medication by

Applying  physical    measures   with   Infrared   treatments,  for   a short period of time.

Although the average number of patient treatments were low for both groups, and  it   is

anticipated that further  improvement could  have been obtained, sociological and other

factors  frequently   kept   th e   patients  from getting more treatment.     Dropouts were 

commonly    experienced   because  of   the  fact   that   clients   typically  expected  

immediate  improvement  and  some did  not   obtain   these  results  right   away.  They  

were   all   told  initially   that it  would    take  an average of up to  ten treatments  based

on our previously published works.[ii][1]    Only  a  few   clients  obtained   the  offered     ten 

treatments, the  Workman’s  Comp group got   eight  treatments or  beyond.   Many got

significantly better on less.  Treatment sessions less than ten.  Some stated they were 

afraid  to  get  better  because  of  loss  of  benefits, some patients dropped out because

of this concern.

RESULTS

INFRARED STUDY RESULTS

Chart A

# of patients/treatments - health / auto                        # of patients/treatments - workers comp only

6 patients          -           1 treatment                                4 patients          -           1 treatment

2 patients          -           2 treatments                              2 patients          -           2 treatments

4 patients          -           3 treatments                              3 patients          -           3 treatments

3 patients          -           4 treatments                              2 patients          -           4 treatments

2 patients          -           5 treatments                              1 patient            -           5 treatments

1 patient            -           6 treatments                              4 patients          -           6 treatments

1 patient            -           9 treatments                              1 patient            -           7 treatments

1 patient            -           10 treatments                            1 patient            -           8 treatments

Patient overall acceptance of “needle-less” acupuncture therapy with (monochromatic incoherent light) LED and soft laser (monochromatic coherent light) was good.  An overall treatment Leikert-scale rating for “improvement or worsening” where   “0”  signified harmful; a rating of “5” indicated that treatment had no significant value; and a rating of “10” indicated significant improvement on most patients.   Patients’ self-assessment of the pain, experience as measured by the standard visual analog scale, indicated a statistically significant drop in pain ratings for each individual trigger point patient in most cases  with treatment and over the course of all treatments.

DISCUSSION:

 We defined all pain as “real”.  It is a “complex” intertwined psychological and physiological experience of the individual patient.  Our physiologic objective assessment by use of  the infrared imaging (high resolution) device included observing a significant drop in the temperature of the “hot spot” in the myofascial Infrared treated areas (see Thermogram picture 4).  

All Infrared emitting devices for human use are manditoraly quantatated by our team in cooperation with the University of Florida, Dr. Zhang,  independent of those attributes claimed by any manufacturer (CTI, Bales, Anodyne, etc.) has analyzed each instrument for wavelengths and powe/unit time.  This Meditech device is exactly as manufacturer stated.

Our initial findings offer encouraging data as to  the effectiveness of the Infrared LED photon emitter followed with the soft laser at  acupuncture sites as described for use in outpatient therapy of chronic myofascial trigger point pain. 

Office based Chiropractic and Aliopathic physicians see increasingly more patients who complain of chronic (>6 months duration) muscle pain and also often have clinically palpable trigger points. Despite a myriad of scientific advances and new invasive procedures, in many cases only minimal patient pain improvement was previously afforded.  Alternative treatment modalities have been sought with greater frequency because of standard medical therapeutic failures thus far.

Initially, our group conducted Infrared explorations with a single commercially Infrared emitter lGA erase, available over the counter[iii].  This was prior to any patient treatment of chronic myofascial painful conditions.  Subsequently, we had very successfully used yet another LED, non-coherent monochromatic light device in patients with painful diabetic neuropathy[iv].  Our current findings offer ongoing and encouraging data of the effectiveness of a newer photon stimulator now coupled for the first time with the  Meditech Bioflex monochromatic coherent light device for careful and controlled use in outpatient therapy of chronic myofascial pain and trigger points.

Our group’s very first published  Infrared study for the assessment of potential physical effects alone (Ref.2) where emitted light energy photon stimulation was first applied to asymptomatic volunteer control subjects in single and repetitive sessions at our multidisciplinary neurologic/pain rehabilitation center.   No harmful events occurred.  Recordings and study of any neurovascular change, via the method of high-resolution digital infrared imaging[v] of each infrared energy application session were made in these early volunteers.  In a later study (ref. 3), (14) informed voluntary control subjects  and in a series of  (24) volunteer informed  patients with diabetic neuropathy of the lower extremities was treated. This effect lasted 12 months at last follow-up.   Dramatic  pain improvement by both visual analog scale and Leikert (overall effectiveness) scale  was noted in our original study  of painful diabetic neuropathy of the feet and legs.

Chronic pain accounts for a high percentage of health care costs. In 1994, Liberty Mutual Insurance Company received 119,000 claims for back pain alone.[vi] In a cost-benefit analysis, Conrad and Day[vii] found that treatment by health maintenance organizations (HMOs) and primary care physicians was the least expensive, while treatment by orthopedic surgeons and chiropractors was the most expensive; however, patient satisfaction was greatest when treatment was provided by chiropractors.   It was suggested that using alternative clinical treatments for patients with spinal problems could result in negative outcomes. The relative frequency of alternative treatment use  in a community setting was discussed by Shekelle.[viii]

The continued excitability of peripheral musculoskeletal tissue and central neural excitability together may contribute to the persistence of soft tissue pain (treatment failures) in cases of post-trigger point injection pain. Electrical stimulation of myofascial trigger points has been used successfully in some cases of chronic recurrent back pain.[ix] Any improvement in chronic recurrent back pain treatment is economically significant. The different photon stimulators we previously tested appear likely to be very helpful in the battle against chronic back pain.   The Meditech “Bioflex” unit, with both monochromatic coherent and non-coherent light appears now to be quite superior for myofascial pain treatment in our opinion.

A prior assessment of (monochromatic) laser therapy for musculoskeletal disorders was carried out in a meta-analysis of randomized clinical trials using various protocols and was reported by Beckerman et al.[x] There was no clear relationship at that time between laser (non-LED) energy dosage and outcome in the 36 published early clinical trials. The review involved a large number of patients in 1992.  On average, greater efficacy was afforded by laser treatment compared with placebo. The (LLLT) laser appeared to have a substantial therapeutic impact on rheumatoid arthritis, post-traumatic joint disorder, and also myofascial pain conditions.  These were similar to our findings within the presented study.

In an early 1995 study of posterior neck treatments using 100 watt laser, Wong et al concluded that there was a rapid alleviation of pain and tingling in the arms with this individual laser treatment protocol.[xi]  Miner et al reflected that the biophysical action of laser interventions are now only being partially understood.[xii] Gray et al suggested that there is a large variety of signs and symptoms in TMJ.[xiii] Their testing of soft laser therapy had similar rates of treatment success when compared with modalities, diathermy, magnapulse, and ultrasound. Hay et al undertook a detailed analysis of myofascial pain treatments, including stretch-and-spray, laser, trigger point injections, and transcutaneous electrical nerve stimulation and all of these therapies were found effective to some degree. [xiv]

Improving circulation and enhancing drug uptake were thought to be account for the good outcomes of these other reported alternative pain treatments. Yang et al successfully used an assessment of brain magnetic field changes evoked by acupuncture treatments with a super conductive quantum interference device, (a biomagnetometer).[xv] They however assessed only 12 subjects. Davis noted that nonpharmacologic techniques such as acupuncture, massage, and relaxation might all help to some degree in lessening chronic pain.[xvi]  Acupuncture, hypnosis, and herbal remedies are continually increasing in popularity.[xvii] Light emission therapy alone as previously reportedly has been used with some success in a number of chronic pain patients.

In the search for other modalities in the treatment of chronic pain, Waylonis et al reported on the clinical responses to various therapy modes, including neon laser therapy, which offered no advantage in his single early study.[xviii]  In another early study, acupuncture therapy in TMJ, myofascial pain, and occlusal splint offered decreased symptomatology.[xix] Occlusal lifting (a TMJ treatment) did elevate muscle tension in the study of silver spike joint electrotherapy and other unusual modalities.[xx]

            The use of photon therapy is a relatively new concept in the treatment of cancer. Various proton and photon high energy beams have been used for photon irradiation for cancer patients.[xxi],[xxii] Innovative considerations for photon therapy included skin contact monochromatic infrared irradiation therapy[xxiii] and “light emitted photothermal sclerosis” of leg vein problems has also been published[xxiv]. Similar diverse technical considerations of light distribution in the skin are made for therapeutic sources of infrared light emission therapy.[xxv] Acupuncture  itself seems to be a very acceptable mode of treatment,[xxvi],[xxvii] especially when done by the mode of infrared stimulation as previously described.   Whalen says Infrared is perfect for increasing energy inside cells.  Wound healing is enhanced.  Mucusitis and its treatment is seen.[xxviii]

There appears to be a progression from the use of LED alone to now include laser coherent monochromatic light treatments done of various human painful conditions. We are continuing to explore this new LED Infrared coupled together with coherent monochromatic light mode of treatment for chronic myofascial pain and trigger points and other painful ailments.

SUMMARY :

Significant Myofascial pain by patient groups  initially described in statistical purposes - one workman’s comp and one matched non-workman’s comp injury associated with myofascial pain was reported favorable assessments of this new mode of LED photon therapy (maximum 20 joules of Infrared energy per treatment session).  The Infrared  treatment was at  660 – 990 angstroms).  This photic energy was generated by a Infrared LED emitting equipment.   It was followed by low energy coherent light (laser) treatment of local trigger points and of the myofascial pain areas per se.  Using the standard visual analog scale for pain measurement, treated patients in both groups reported a significant reduction in the level of myofascial pain. Skin surface temperature measurements in the area of the myofascial trigger points were lower (moved towards normal) post treatment than those controls non-treated.

This new Infrared (LED) Photon stimulation followed by monochromatic coherent light therapy, as described, appears to be particularly useful for outpatient treatment, especially by physicians and their staffs with special interest in myofascial trigger points.

REFERENCES:

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