03/07/2018
From LLLT to HILT – A Tissue Response Analysis
by Paul Schwen
• LLLT – Low Level Laser Therapy, a.k.a. class III and class IIIB, cold laser, weak laser energy, SLD (superluminous diode, or bright LED), or simply LED
• HILT High Intensity Laser Therapy, a.k.a. class IV, HDLT (High Dose Laser Therapy)
Studies citing LLLT benefits use dosages far too low to produce anything more than temporary, transient stimulation of surface and shallow tissues unless performed IN-VITRO.
Why then do proponents of LLLT continue to tout its benefits, when overwhelming evidence suggests HILT is far superior? Why do clinical researchers continue to suppress contradictory data and support older, entrenched practices when newer, more effective modalities need to be established? For the following two reasons:
1. Vested Interests - medical studies citing the benefits of LLLT devices are sponsored by manufacturers and resellers (as is the case with Michael Hamblin, PhD, perhaps LLLT’s best-known LLLT proponent for 12+ years and compensated by Thor™ lasers);
2. Medical Hubris – see below A Decade of Reversal: An Analysis of Contradicted Medical Practices. Low-value practices and patterns of medical research are clung to, despite reversal of established medical practice common and occurring across all other types and classes of medical practice.
Why Is This Relevant?
1. The relative principles of NIR light energy as beneficial in the treatment of a wide range of human disease and injury still applies, despite dosage differences;
2. There is no ceiling dose in laser therapy! when exposed to sunlight, the human body absorbs a wide range of photonic energy across the entire energy spectrum, far more that is absorbed from one wavelength of therapeutic laser energy in a clinical environment. Just as the chloroplasts in plants act as sugar factories for the supply of ordered molecules to the plant, the mitochondria in humans, animals, and plants, act to produce the ordered ATP molecules as the energy supply for the processes of life. In addition, human mitochondria maintain a mammalian memory from the distant past, when absorption of light energy was necessary for survival. For plants, this means photosynthesis - the conversion of sunlight into food energy loads for cells; for humans, this translates into ATP synthase - similar conversion of sunlight into cellular energy (ATP, or Adenosine Triphosphate).
Use the following formula to calculate treatment dosage: Treatment Time (S) = Total Energy Delivered (J)/Average Output Power (W)
• Treatment Time with a 30Watt Laser (HILT)
30 seconds = 1,000 J/10W
• Treatment Time with a 10Watt Laser (HILT)
100 seconds (1 minute and 40 seconds) = 1,000 J/10W
• Treatment Time with a 5Watt Laser (HILT)
200 seconds (3 minutes and 20 seconds) = 1,000 J/5W
• Treatment Time with a 500milliWatt Laser (LLLT)
2,000 seconds (33 minutes and 20 seconds) = 1,000 J/0.5W
• Treatment Time with a 5milliWatt Laser (LLLT)
200,000 seconds (55 hours 33 minutes and 20 seconds) = 1,000 J/0.005 W
• Summary:
Clinical outcomes due to relevant treatment parameters means HILT is the proven in-vivo effective modality in NIR energy treatments (LLLT, or low energy means minimal tissue response, HILT, or high energy means maximal tissue response).
• The Bunsen-Roscoe Law of Reciprocity
The Bunsen-Roscoe law (BRL) of reciprocity states that a certain biological effect is directly proportional to the total energy dose irrespective of the administered regime.
(For more information, see ‘The Reciprocity Rule in Photobiology - a Review’, on page 8 of this document).
A survey of the available literature on dose-time relationships in photobiology strengthen the view that the Bunsen-Roscoe law seems to be restricted to rather narrow limits for most photobiological reactions. With this knowledge it is surprising that the available information on the influence of radiation intensity is poor and that in most experimental and clinical studies variations in radiation intensity are not included in the experimental setup (or simpler: are not studied). In photomedicine where endpoints such as therapeutic efficacy, carcinogenesis, immunosuppression and photoaging are of major importance, validity and failure of the BRL are either completely unknown, suppressed, or subject to speculation based on experience from animal models and comparison of historical data.
Beyond phototherapy, investigations into the molecular events underlying the differential effects of equal doses and varying intensities are necessary for a comprehensive understanding of the way living tissues responds to NIR radiation. In this regard to date, most information comes from basic research into the effects of low level laser therapy (LLLT), which is unfortunately skewed by LLLT device manufacturers and resellers sponsoring most LLLT clinical studies, clinical researchers having a personal stake in research study outcomes, and personal bias due to medical hubris.
Systematic clinical research into carefully designed studies will result in optimized higher- energy phototherapeutic regimens and dosages, with an improved therapeutic index, i.e. a maximized therapeutic benefit with minimized adverse reactions.
Until that time, while researching the data below, it is important to understand basic scientific principles that govern NIR energy and its effects on human tissues, and not be misled by researchers with a personal stake in clinical outcomes, or clinical bias due to medical hubris.
Relevant Clinical Research Studies on the Internet
How Flashing Lights and Pink Noise Might Manish Alzheimer’s, Improve memory and More…
https://www.nature.com/articles/d41586-018-02391-6
Revolution in Blood Medicine – Intranasal Laser Therapy
http://drsircus.com/general/revolution-blood-medicine-intranasal-laser-therapy/
Lasers for Thyroid Tissue Regeneration
https://thyroidpharmacist.com/articles/lasers-thyroid-tissue-regeneration/
Effects of High Intensity Laser Therapy on Pain and Function of Patients with Chronic Back Pain
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5468204/
Clinical Trial for High Intensity Laser Therapy (HILT) for Elbow Epicondylitis (HILT)
https://clinicaltrials.gov/ct2/show/NCT01992627
Cognito Therapeutics Is Focused on Discovering and Developing New Treatments and Preventive Therapies for Neurodegenerative Diseases -
https://www.cognitotx.com/
The End of Alzheimer’s?
https://www.bostonmagazine.com/health/2017/11/27/li-huei-tsai-alzheimers-treatment/
Laser Therapy Facilitates Superficial Wound Healing in Humans: A Triple-Blind, Sham-Controlled Study
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC522143/
Aetna, Blue Cross, Blue Shield - Recent Well-Designed, Controlled Studies Have Found No Benefit from Low- Energy Lasers in Relieving Pain in Rheumatoid Arthritis or Other Musculoskeletal Conditions
http://www.aetna.com/cpb/medical/data/300_399/0363.html
Laser Therapy, Technology Assessment
http://www.lni.wa.gov/claimsins/files/omd/lllttechassessmay032004.pdf
Review of Transcranial Photobiomodulation For Major Depressive Disorder: Targeting Brain Metabolism, Inflammation, Oxidative Stress, And Neurogenesis
https://www.spiedigitallibrary.org/journals/Neurophotonics/volume-3/issue-03/031404/Review-of-transcranial-photobiomodulation-for-major-depressive-disorder--targeting/10.1117/1.NPh.3.3.031404.full?SSO=1
Shining Light on The Head: Photobiomodulation For Brain Disorders
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5066074/pdf/main.pdf
Can NIR (Near Infra-Red Energy Reach the Brain in Treatment of TBI?
http://www.laser-therapy.us/research/index.cfm?researchinput=bestwavelength
https://www.youtube.com/watch?v=iZbP2IVekh0
Effects of Pulsing in Low Level Light Therapy
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2933784/
The Effect of Laser Radiation on Spermatogenesis in Men
https://www.ncbi.nlm.nih.gov/pubmed/2281618
Laser Therapy for Male Infertility. Part 1. Etiology and Pathogenesis. Experimental Studies
https://www.ncbi.nlm.nih.gov/pubmed/29135155
Secret to Renewed Teeth? Lasers Show Gleam of Hope
https://www.usatoday.com/story/news/nation/2014/05/28/lasers-regrow-teeth/9608231/
Laser Therapy (Photobiomodulation Therapy) For Breast Cancer-related Lymphedema
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5719569/pdf/12885_2017_Article_3852.pdf
High-Intensity Laser Therapy Versus Pulsed Electromagnetic Field in The Treatment of Primary Dysmenorrhea (Painful Menstrual Cramps)
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5684002/
Effects of High-Intensity Laser Photobiomodulation On Equine Bone Marrow-Derived Mesenchymal Stem Cell Viability and Cytokine Expression
https://www.ncbi.nlm.nih.gov/pubmed/29131717
Effects of Photobiomodulation Therapy in Patients with Chronic Non-Specific Low Back Pain: Protocol for A Randomized Placebo-Controlled Trial
http://bmjopen.bmj.com/content/bmjopen/7/10/e017202.full.pdf
Efficacy of High Intensity Laser Therapy in The Treatment of Male with Osteopenia or Osteoporosis: A Randomized Placebo-Controlled Trial
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5599844/
Efficacy of High Intensity Laser Therapy in Treatment of Patients with Lumbar Disc Protrusion: A Randomized Controlled Trial
https://www.ncbi.nlm.nih.gov/pubmed/28854500
Lipogels Responsive to Near-Infrared Light for The Triggered Release of Therapeutic Agents
https://www.ncbi.nlm.nih.gov/pubmed/28801266
Near-Infrared Light-Sensitive Liposomes for The Enhanced Photothermal Tumor Treatment by The Combination with Chemotherapy
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4126419/
Effect of Diode Laser in The Treatment of Patients with Nonspecific Chronic Low Back Pain: A Randomized Controlled Trial
in https://www.ncbi.nlm.nih.gov/pubmed/25141218
The Effects of Two Different Laser Therapies in The Treatment of Patients with Chronic Low Back Pain: A Double-Blinded Randomized Clinical Trial
https://www.ncbi.nlm.nih.gov/pubmed/27472858
Is Laser Therapy Effective in Acute or Chronic Low Back Pain?
https://www.ncbi.nlm.nih.gov/pubmed/20414695
results: There were no differences between laser and placebo laser treatments on pain severity and functional capacity in patients with acute and chronic low back pain caused by LDH – LLLT is ineffective (more power is needed!)
Meta-Analysis of Pain Relief Effects by Laser Irradiation on Joint Areas
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3412059/pdf/pho.2012.3240.pdf
(suggesting HILT is a superior modality)
Laser Therapy (Classes I, II And III) For Treating Osteoarthritis
https://www.ncbi.nlm.nih.gov/pubmed/12804422
Despite some positive findings, this meta-analysis lacked data on how LLLT effectiveness is affected by four crucial factors: wavelength, treatment duration of LLLT, dosage and site of application over nerves instead of joints. There is clearly a need to investigate the effects of these factors on LLLT effectiveness for OA in randomized controlled clinical trials.
The Efficacy of Laser Therapy for Shoulder Tendinopathy: A Systematic Review and Meta-Analysis of Randomized Controlled Trials
https://www.ncbi.nlm.nih.gov/pubmed/25450903
A systematic review with procedural assessments and meta-analysis of Laser Therapy in lateral elbow tendinopathy (tennis elbow)
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2442599/
Transcranial Laser Therapy (810 Nm) Temporarily Inhibits Peripheral Nociception: Photoneuromodulation Of Glutamate Receptors, Prostatic Acid Phophatase, And Adenosine Triphosphate
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4725212/
(Effects are more profound and long-lasting with HILT)
A Systematic Review of Laser Therapy with Location-Specific Doses for Pain From
Chronic Joint Disorders
https://ac.els-cdn.com/S0004951414601276/1-s2.0-S0004951414601276-main.pdf?_tid=f5330ac5-3a13-4a7a-9e14-7ab2699aa940&acdnat=1520308167_424a8c842bafd2c0803bfd6a03ac532a
Effect of Low Level Laser Therapy on Neurovascular Function of Diabetic Peripheral Neuropathy
https://ac.els-cdn.com/S2090123211000361/1-s2.0-S2090123211000361-main.pdf?_tid=7c55a66f-0199-4ebc-a6c8-d0b3a3f7ea1e&acdnat=1520308378_6ea0d1ae6bd231f8f9e4943aad845919
Comparative Study on The Efficacy of Pulsed Electromagnetic Field And
Laser Therapy on Mitogen-Activated Protein Kinases
https://ac.els-cdn.com/S2405580816303065/1-s2.0-S2405580816303065-main.pdf?_tid=1caf25a6-4982-45e6-a0d2-c836edfebe58&acdnat=1520308539_e81ffe1d7d7da3926b6c9a38a2b17ec8
Case Study: Use of Vibration Therapy in The Treatment of Diabetic Peripheral Small Fiber Neuropathy
(NOTE: high-speed vibration therapy is indicated as an effective adjunct to HI LT)
https://ac.els-cdn.com/S1877593411000117/1-s2.0-S1877593411000117-main.pdf?_tid=d9ef0879-09cc-41ec-bf0f-b420c5773d2a&acdnat=1520308904_9b38385c4c28aa9c764ce68ac6b409c7
Laser Acupuncture for Treating Musculoskeletal Pain: A Systematic Review
with Meta-analysis
https://ac.els-cdn.com/S2005290114001149/1-s2.0-S2005290114001149-main.pdf?_tid=677e59d3-24bf-45a4-8a8c-8de08583eba3&acdnat=1520311372_02eda913861706497804baff8f4b6aef
Laser Therapy Efficacy Evaluation in Mice Subjected to Acute Arthritis Condition
https://www.ncbi.nlm.nih.gov/pubmed/28772237
Comparison of Effects of Laser Therapy and LIPUS On Fracture Healing in Animal Models and Patients: A Systematic Review
https://www.ncbi.nlm.nih.gov/pubmed/28688752
Effects of High Intensity Laser Therapy on Pain and Function of Patients with Chronic Back Pain
recently small seekers https://www.ncbi.nlm.nih.gov/pubmed/28626329
Effect courses was 1 of the founders of High-Intensity Laser Therapy in The Management of Myofascial Pain Syndrome of The Trapezius: A Double-Blind, Placebo-Controlled Study
https://www.ncbi.nlm.nih.gov/pubmed/25274197
Effectiveness of High-Intensity Laser Therapy and Splinting in Lateral Epicondylitis; A Prospective, Randomized, Controlled Study
Https://www.Ncbi.Nlm.Nih.gov/Pubmed/25614134
Long Term Effects of High Intensity Laser Therapy in Lateral Epicondylitis Patients
https://www.ncbi.nlm.nih.gov/pubmed/26714978
Investigation of The Effect of GaAs Laser Therapy on Lateral Epicondylitis
https://www.ncbi.nlm.nih.gov/pubmed/19877824
Efficacy of High-Intensity Laser Therapy in The Treatment of Chronic Neck Pain: A Randomized Double-Blind Placebo-Control Trial
https://www.ncbi.nlm.nih.gov/pubmed/26914684
Long-Term Effect of High-Intensity Laser Therapy in The Treatment of Patients with Chronic Low Back Pain: A Randomized Blinded Placebo-Controlled Trial
https://www.ncbi.nlm.nih.gov/pubmed/24178907
Use of Electroanalgesia And Laser Therapies as Alternatives to Opioids for Acute and Chronic Pain Management
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5749131/
Treatment of Drug-Resistant Fibromyalgia Symptoms Using High-Intensity Laser Therapy: A Case-based Review
https://www.ncbi.nlm.nih.gov/pubmed/29080932
Laser Therapy to Treat Fibromyalgia
https://www.ncbi.nlm.nih.gov/pubmed/24801056
Effect of Laser Therapy on Pain, Quality of Life and Sleep in Patients with Fibromyalgia: Study Protocol for A Double-Blinded Randomized Controlled Trial
https://www.ncbi.nlm.nih.gov/pubmed/23171567
Effect of Low-Level Laser Therapy on The Post-Surgical Inflammatory Process After Third Molar Removal: Study Protocol for A Double-Blind Randomized Controlled Trial
https://www.ncbi.nlm.nih.gov/pubmed/24195796
Effects of laser therapy and low dose amitriptyline therapy on clinical symptoms and quality of life in fibromyalgia: a single-blind, placebo-controlled trial
https://www.ncbi.nlm.nih.gov/pubmed/12215864
High Intensity Laser Therapy (HILT): state of the art in sporting traumatology and pain therapy
https://pdfs.semanticscholar.org/b27b/7acb8a74c20e37e3e98b510ba96ac467ae8b.pdf?_ga=2.77412309.1972336951.1520312887-1354315015.1520312887
Photodynamic Therapy in the Treatment of Cancer
https://pdfs.semanticscholar.org/e4bc/dc667d764fefc11022e925e306337c5c4c8e.pdf?_ga=2.121042120.1972336951.1520312887-1354315015.1520312887
Radial Pressure Waves vs High Intensity Laser Treatments in Acute Ankle Sprains
https://www.high-intensity-laser.com/study-4
Surgical versus nonsurgical treatment of chronic low back pain: A meta-analysis based on current evidence
https://www.ncbi.nlm.nih.gov/pubmed/26406211
Low-Intensity Red and Infrared Laser Effects at High Fluences On Escherichia Coli Cultures
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4617122/
The Reciprocity Rule in Photobiology - A Review
http://www.photobiology.com/reviews/bunsen/index.htm
The Bunsen-Roscoe law (BRL) of reciprocity states that a certain biological effect is directly proportional to the total energy dose irrespective of the administered regime. Dose is the product of intensity and the duration of exposure and thus the time needed to deliver a certain dose is influenced by the intensity of the source and whether the exposure is continuous or fractionated. This law has been given the name of R. Bunsen and H. E. Roscoe who by their classic work in the 19th century opened a new field of research entitled by them "photochemistry". For photochemical reactions it can be assumed that this law is valid only, at least within a certain dose range which must be individually defined for each reaction. However, responses of cells and tissues to electromagnetic radiation usually involve a sequence of interacting biological reactions making a linear dose-time relationship less likely. Additionally, photosensitizing molecules might induce different cellular and molecular responses than does radiation alone. In photomedicine knowledge of the validity and the limits of the BRL is crucial for the understanding of the pathophysiology of photodamage and of the mechanisms of phototherapy. To date only few data on the role of the BRL in photomedicine are available. In this review we summarize the pertinent literature regarding the effects of dose-time relationship in experimental and clinical photodermatology.
A Decade of Reversal: An Analysis of 146 Contradicted Medical Practices (Medical Hubris)
http://www.mayoclinicproceedings.org/article/S0025-6196(13)00405-9/pdf
Objective: To identify medical practices that offer no net benefits. Methods: We reviewed all original articles published in 10 years (2001-2010) in one high-impact journal. Articles were classified based on whether they addressed a medical practice, whether they tested a new or existing therapy, and whether results were positive or negative. Articles were then classified as 1 of 4 types: replacement, when a new practice surpasses standard of care; back to the drawing board, when a new practice is no better than current practice; reaffirmation, when an existing practice is found to be better than a lesser standard; and reversal, when an existing practice is found to be no better than a lesser therapy. This study was conducted from August 1, 2011, through October 31, 2012.
Results:
2044 original articles were reviewed, 1344 of which concerned a medical practice. Of these, 981 articles (73.0%) examined a new medical practice, while 363 (27.0%) tested an established practice. A total of 947 studies (70.5%) had positive findings, while 397 (29.5%) reached a negative conclusion. A total of 756 articles addressing a medical practice constituted replacement, 165 were back to the drawing board, 146 were medical reversals, 138 were reaffirmations, and 139 were inconclusive. Of the 363 articles
testing standard of care, 146 (40.2%) reversed that practice, whereas 138 (38.0%) reaffirmed it.
Conclusion:
The reversal of established medical practice is common and occurs across all classes of medical practice, shedding light on low-value practices and patterns of medical research. With therapeutic laser applications, a reversal of established medical practice is taking place, albeit very slowly because of suppression of clinical evidence by established researchers and practitioners. Efforts to increase momentum in reversal of established practice from LLLT to HILT will be of great benefit to both patients and practitioners worldwide.
For more information, please contact the author, Paul Schwen, at 1.801.473.7885 or via e-mail at pauls@advanmed.com.
Neuroscientists are getting excited about non-invasive procedures to tune the brain’s natural oscillations.
