LASER THERAPY IN POST HERPETIC NEURALGIA
Abstract from the MALC conference Nov 96
Dr KEVIN C MOORE THE ROYAL OLDHAM HOSPITAL, OLDHAM, UK.
Presented to the British Medical Laser Association "241" Workshop
and AGM
The Royal London Hospital
April 1996
LASERS AND PAIN TREATMENT
K.MOORE Department of Anaesthesia, The Royal Oldham Hospital, Oldham, OL1
2JH, UK.
SUMMARY
The clinical application of low incident power density laser radiation for
the treatment of acute and chronic pain is now a well established procedure.
This paper reviews the currently available English speaking literature and
summarises a selection of serious scientific papers which report a beneficial
effect following the treatment of a wide variety of acute and chronic syndromes
whose main presenting symptom is pain.
INTRODUCTION
The Helium-Neon (HeNe) laser at a wavelength of 632.8nm has proved very
successful in promoting wound healing particularly in indolent ulcers resistant
to conventional methods of therapy. However its limited depth of penetration and
low power output have rendered it less effective when treating more deep seated
causes of pain. The laser most frequently used for pain therapy is the Gallium
AIuminium Arsenide (GaAlAs) diode emitting coherent light in the near infra-red
waveband, usually 820-840nm, and with a continuous wave power output of some
60mW. The optoelectronic rationale for choosing these parameters has been
discussed by Moore and Calderhead (1).
During the past 15 years experimental research has greatly added to our
knowledge of the response of tissue to laser irradiation. Figure 1 summarises
some 10 years work by Karu (2) into the cellular response to photon energy.
Additional research at the Tissue Repair Research Unit at Guy's Hospital, London
has detailed the local tissue changes followinq exposure to laser light. The
current concept is one of a dual response to laser bioactivation.
The immediate or primary effect is a local tissue response to direct
irradiation and comprises vasodilatation with increased circulatory flow:
enhanced lymphatic drainage; increased neutrophil, macrophage and fibroblast
activity; and an improved metabolic function in depressed or damaged cells. The
delayed or secondary response consists of a systemic effect caused by
circulating photoproducts of irradiation in the blood and lymphatic systems.
Increased plasma concentrations of certain types of prostaglandins, enkephalins
and endorphins have all been identified and most probably play a major role in
the mechanism of pain attenuation.
ACUTE PAIN THERAPY
Acute trauma is invariably associated with a degree of soft tissue injury
comprising swelling, haematoma, pain, reduced mobility and in the lower limbs
impaired weight bearing. Sporting injuries and domestic accidents usually
involve damage to muscles, joint ligaments and tendons. Examples include a
sprained ankle or wrist or a twisted knee. More extensive soft tissue damage
tends to result from industrial crush injuries or road traffic accidents. In the
absence of bone fracture or other injury demanding priority treatment laser
therapy should be instituted at the earliest opportunity. Kumar (3) reported a
comparative study in 50 patients with inversion injuries of the ankle. He found
that compared to conventional physiotherapy the laser treated patients showed a
more rapid resolution of symptoms and an earlier return to full weight bearing.
Patients were treated with a GaAlAs diode laser (830nm : 60mW) at 48 hour
intervals on a maximum of 3 occasions. A similar therapeutic regime has been
described for whiplash injuries of the cervical spine (4). Ben Hatit and Lammens
(5) used a defocussed co2 laser to treat a variety of acute musculoskeletal
problems. The energy density varied between 40-70J/cm2. Patients were treated
twice a week for up to 10 sessions. Pain was reduced by 70-90%.
Beneficial effects of laser therapy in acute small joint inflammation in
rheumatoid arthritis has been described by Asada et al (6). Multiple joint
irradiation using a GaAlAs diode (830nm : 60mW) was applied for 15 seconds to
each point. Pain was reduced by up to 66% together with an improvement in the
measured range of movement (ROM).
In a similar report involving 938 patients with osteoarticular pain Soriano
(7) found pain attenuation of 88% when treating a variety of acute conditions
such as tenosynovitis, lumbago and cervical pain. He used a GaAs diode (940nm .
pulsed 10,000 Hz : average power 40mW) to treat patients twice weekly for a
maximum of 10 sessions. The energy density delivered was 6-10J/cm2 per
irradiated point.
Laser therapy has also proved helpful in reducing the severity and duration
of postoperative pain. In a comparative study involving 20 patients undergoing
elective cholecystectomy Moore et al (8) reported a 50% reduction in the
postoperative pain experienced by the laser treated patients together with a
concomitant reduction in analgesie requirements.
CHRONIC PAIN SYNDROMES
Chronic painr as the name implies, may last for months or years. Pain may
arise as a result of damage caused by trauma or surgery or be manifest as a
symptom of a systemic disease process. In later life pain due to musculoskeletal
"wear and tear" is very common. Finally neuralgic pain such as
postherpetic or trigeminal neuralgia can cause prolonged problems to sufferers.
A high percentage of patients referred for laser therapy will have already shown
little or no response to conventional methods of treatment.
In rheumatoid arthritis (RA) laser therapy can benefit not only the pain of
acute small joint inflammation but also the more established chronic pain of the
disease. Gartner (9) in an excellent review article on rheumatology considered
some 18 papers published over a 10 year period. A11 involved double blind trials
of therapy with 5 having a cross-over element. In considering the effect of
laser therapy in chronic rheumatoid and associated musculoskeletal conditions
all bar one of the reports noted a significant improvement in pain. In his own
work Gartner used a 904nm infra-red laser to treat a variety of tendinopathies
with a better than 80% success rate in relieving pain. He compared this to a
similar rate of pain attenuation using anti inflammatory drugs (NSAIDs) but
noted that whilst laser therapy was free of side effects some 20% of patients
treated with NSAIDs suffered unacceptable side effects of medication. Asada and
his colleagues (10) in a further study of some 170 patients with rheumatoid
arthritis used similar laser parameters and treatment protocols to their earlier
reported work. The group achieved pain attenuation of up to 90% and improvement
in ROM of up to 56%.
In a report of some 1000 treatments using a GaAlAs diode laser (830nm : 60mw)
for a wide variety of chronic pain syndromes Moore (11) noted an overall
reduction in pain levels of some 70%. Trelles et al (12) used a similar diode
laser to treat 40 patients with degenerative joint disease of the knee. They
delivered 18J/cm2 to each of 4 points round the knee twice a week for 8 weeks
and reported a significant pain reduction in 82% with improved joint mobility.
Li (13) used a 25mW combined COa/HeNe laser to treat 90 patients with cervical
spondylosis. Laser therapy was administered to a variety of acupuncture points
for 10 minutes daily for 2 periods each of 10 days with an intervening rest
period of 10 days. 90% of patients showed symptom improvement with an excellent
result in 43%.
Fender and Diffee (14) reported an interesting trial involving patients
suffering with chronic generalised musculoskeletal pain. They irradiated the
stellate ganglion using a HeNe laser with an lnitial exposure of 6 minutes
(36J/cm2) gradually increasing over 4-6 weeks to a maximum of 15 minutes
(90J/cm2). They postulated a mechanism of reduced sympathetic irritability
causing a stabilisation of the response loop and a breaking of the pain cycle.
In resistant cases they also treated segmental dermatomes and site specific
trigger points.
Patients suffering from postherpetic neuralgia (PHN) have shown a good
response to laser therapy. In a double blind cross-over trial Moore et al (15)
reported a mean reduction in pain levels of 74%. Patients were treated with a
GaAlAs diode (830nm : 60mW) with the laser applied in contact mode to the centre
of each 2cm2 grid over the affected area giving 24-30J/cm2 to each point.
Treatment was given twice a week for 4 weeks. Using an identical treatment
protocol but an extended regime of some 12 weeks Kemmotsu et al (16) reported an
end of treatment pain attenuation of 89%. Otsuka and colleagues (17) used an
8.5mW HeNe scanner to treat the acute rash of herpes zoster. Once the skin rash
had subsided treatment was continued using a GaAlAs laser (830nm : 60mW). Within
1 month pain had been reduced by 76% with a final end treatment improvement of
97%. The early introduction of laser therapy produced a rapid resolution of
acute herpes zoster rash and a reduced incidence of PHN.
DISCUSSION
Laser therapy is effective for a wide variety of acute and chronic pain
syndromes. During the past 7 years the Laser Therapy journal has featured some
30 papers on the subject. The preferred laser i8 the GaAlAs diode emitting light
in the near infra-red usually at 830nm. The majority of reports detail a power
output of 60mW continuous wave. Recently, however, researchers have been
assessing the use of higher output powers in the range of 150 - 300mW. In a
preliminary trial Yamada and Ogawa (18) compared the results of treating PHN
with 60mW and 150mW. They found that using the higher output power reduced both
the frequency and duration of the treatment sessions and improved the pain
attenuation by some 25%. Ohshiro (19) has devised an ingenious protocol for a
computer controlled double blind comparative trial which compensates for the
placebo effect of treatment and for patient and therapist bias. In a paper
comparing the therapeutic outcomes in 2 geographically separate but otherwise
identical clinics Shiroto (20) described how a positive therapist attitude
motivated by enthusiasm and commitment can improve the results of therapy by
15-20%.
There remains a need for more scientific studies based on well constructed
double blind comparative trials. Nevertheless the bulk of published work to date
supports the use of laser therapy for the treatment of pain. In a report of the
cost-effective benefits of using laser therapy to treat PHN, Moore (21) noted
that, compared with conventional methods of treatment, the laser proved to be
not only more effective but more economical as well. The added advantages of
absence of side effects, non-invasive nature of therapy and the ease of
application ensured good patient acceptance of the treatment modality.
REFERENCES
1. MOORE & CALDERHEAD. The clinical application of low incident power
density 830nm GaAlAs diode laser radiation in the therapy of chronic intractable
pain : a historical and optoelectronic rationale and clinical review. Int.Jour
Optoelectronics 6 : 503 520 1991
2. KARU. Photobiology of low-power laser therapy. Chur, Swit2erland. Harwood
Academic Publishers 1989.
3. KUMAR et al. A comparative study of low level laser therapy and
conventional physiotherapy for the treatment of inversion injuries of the ankle.
Lasers in Medical Science. Abstract issue 298. 1988.
4. OHSHIRO. Low-reactive level laser therapy practical application 103-110,
Chichester, UK. John Wiley & Sons 1991.
5. BEN HATIT & LAMENS. Laser therapy with 10600 defocussed co2 laser.
Laser Therapy 4 : 175-178 1992.
6. ASADA et al. Diode laser therapy for rheumatoid arthritis : a clinical
evaluation of 102 joints treated with low-reactive level laser therapy (LLLT).
Laser Therapy 1 : 147-151. 1989.
7. SORIANO. The analgesic effect of 904nm gallium arsenide semiconductor low
level laser therapy (LLLT) on osteoarticular pain : a report on 938 irradiated
patients. Laser Therapy 7 : 75-80. 1995.
8. MOORE et al. The effect of infra-red diode laser irradiation on the
duration and severity of postoperative pain : a double blind trial. Laser
Therapy 4 : 145-149. 1992.
9. GARTNER. Low-reactive level laser therapy (LLLT) in rheumatoloqy : A
review of the clinical experience in the author's laboratory. Laser Therapy 4 :
107 115. 1992.
10. ASADA et al. Clinical application of GaAlAs 830nm diode laser in
treatment of rheumatoid arthritis. Laser Therapy 3 : 77-82. 1991.
11. MOORE. LLLT for the treatment of chronic pain. Frontiers in
Electro-optics (Conference proceedings) 283-290. 1990.
12. TRELLES et al. Infra-red diode laser in low reactive level laser therapy
(LLLT) for knee osteoarthrosis. Laser Therapy 3 : 149-153. 1991.
13. LI. Laser Therapy for radicular cervical spondylosis. Laser Therapy 4
151-153. 1992.
14. FENDER & DIFFEE. Physiological response in chronic pain patients to a
new LLLT protocol. Laser Therapy 4 169-173. 1992.
15. MOORE et al. A double blind cross-over trial of low level laser therapy
in the treatment of postherpetic neuralgia. Laser Therapy (pilot issue) 7-9.
1988.
16. KEMMOTSU et al. Efficacy of low-reactive level laser therapy for pain
attenuation of postherpetic neuralqia. Laser Therapy 3 : 71-75. 1991.
17. OTSUKA et al. Effects of helium-neon laser therapy on herpes zoster pain.
Laser Therapy 7 : 27-32. 1995.
18. YAMADA & OGAWA. Comparative study of 60mW diode laser therapy and
150mW diode laser therapy in the treatment of postherpetic neuralgia. Laser
Therapy 7 : 71-74. 1995.
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20. SHIROTO et al. The importance of therapist education and motivation on
diode LLLT efficacy in pain therapy : a comparative study. Laser Therapy 5 :
175-179. 1993.
21. MOORE. Cost effective benefits of the use of laser therapy in the
treatment of intractable postherpetic neuralgia. Laser Applications in Medicine
and Surqery 61-63 Bologna, Italy. Monduzzi Editore. 1992 .
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