Oregon February 2017 Missed Opportunities Topics Patients with neuropathy What is neuropathy? What are common causes of neuropathy? What is the physiology behind the symptoms? (you learned this in school) What ‘neuropathy’ means to a practice? Dr. Thomas Burke Medical Director HealthLight Reno , NV 1 2 YOU ARE THINKING….. Symptoms of Neuropathy • Burning pain, can’t sleep • How do I assess and then present a care • Tingling plan to patients with neuropathy? Not comfortable with that. • Loss of feeling (sensation), poor balance • Trouble walking (hard to lose weight) • Later this morning I will give you Severe neuropathy can lead to wounds suggestions. They will come to you because you treat pain and can help with weight loss. 3 DIABETES: YOU KNOW THIS Who has neuropathy? • High blood glucose damages blood vessels • Diabetic patients suffer decreased blood flow to • Diabetes, chemotherapy, and statins eyes, heart, kidney and nerves in the lower legs. • Poor blood flow = ischemia • But wait, we can’t treat “diseases” • Ischemia = pain (A SYMPTOM OF NEUROPATHY) • I agree; You CAN treat the symptoms • You treat pain, correct? 5 6 1
Oregon February 2017 WHAT IS NITRIC OXIDE WHAT ELSE? AND WHY SHOULD YOU • Serum nitric oxide was observed significantly low in diabetic participants as compared to CARE control… • Vasodilator; Nobel Prize 1998 • Nitric oxide; vasodilator; Nobel Prize 1998 • Lack of nitric oxide = low blood flow. • Lack of nitric oxide = low blood flow. • It is one reason people with diabetes • It is one reason people with diabetes have have health problems: eyes, heart, health problems: eyes, heart, kidney, kidney, amputations…and neuropathy amputations…and neuropathy 7 8 NITRIC OXIDE So what? • written as NO • Nitric oxide is what keeps our arteries open • Where is NO found? so blood can flow to organs. Dilates all • On hemoglobin, inside red blood cells, just as vessels: arteries, veins and lymphatics. oxygen is…and in most other cells • Nobel Prize 1998 • Good blood flow reverses ischemic pain. 9 10 REMEMBER PAIN ? Painful diabetic neuropathy • Nitric oxide dilates vessels and increases blood flow and • is due to reduced blood flow….think about oxygen delivery to nerves . Decreases edema the patient’s symptoms. • Think of grandma’s heart pain (angina). Treatment was (is) • Eye problems, heart disease, kidney failure! nitroglycerin. Nitroglycerin is converted to nitric oxide. • Increased flow to coronary arteries = more oxygen = less pain. Is it any wonder blood flow to feet and their • Inflammation, swelling, edema also reduce blood flow. nerves progressively decreases? • Better venous and lymphatic flow removes edema. 12 2
Oregon February 2017 WHY DOES LIGHT THERAPY LIGHT THERAPY DECREASE PAIN? Two reasons Journal of Molecular and Cellular Cardiology 2009 ; 47: 256–263 Enhancement of nitric oxide release from 1). Better blood flow = less pain nitrosyl hemoglobin and nitrosyl myoglobin by red/near infrared light: Potential role in (think of a rubber band around your finger) cardioprotection. 2). Direct inhibition of pain signals…exactly the Red/infrared “Light therapy” = increased nitric same way that narcotics decrease pain oxide LOCALLY which then increases circulation. 13 1998 Nobel Prize. WHY DOES LIGHT THERAPY DECREASE PAIN? NITRIC OXIDE AND PAIN RELIEF Two reasons The molecular mechanism of action of peripheral morphine analgesia: 1). Better blood flow = less pain stimulation of the cGMP system via nitric oxide release . (think of a rubber band around your finger) Eur J Pharmacol 1991; 201:121-122 2). Direct inhibition of pain signals…exactly the Morphine + receptor = nitric oxide release = pain relief same way that narcotics decrease pain 15 Human Plasma Response to Light Impressive, rapid changes in (dose dependent; vessel diameter more diodes = better response) 30 20 Percent Increase Nitric oxide metabolites 10 0 120 diodes 60 diodes 3
Oregon February 2017 Ease of use for neuropathy Ease of use This is one configuration Where can lights be used to reduce pain? Foot Bed Anywhere there is a need to increase circulation or reduce pain. Newest technology 21 FDA Pain (chemotherapy) • Lasers and LED devices are FDA cleared for increasing circulation and reducing • “Chemo-induced peripheral pain. neuropathy ( pain , tingling, numbness) is caused by the chemotherapy drugs • As long as you say your goal is to do used in cancer treatment.” either, or both, for a patient, you are safe • per American Cancer Society • You don’t claim to treat a disease; just its symptoms 23 4
Oregon February 2017 American Journal of Neuroradiology 2005; 26: 205-206 Angiogenesis “ The pathophysiological mechanisms of chemotherapeutic agents are not well Circulation. 2002; 105: 2133-5. understood, but several have been hypothesized, including demyelination, • Nitric oxide and angiogenesis secondary inflammatory response, and Cooke JP, Losordo DW microvascular injury.” Again…..Infrared increases nitric oxide which grows new vessels!!!!....and this reverses microvascular injury. 26 How Lights (red and infrared) ASPIRIN FOR PAIN! change circulation and pain Nitric Oxide Aspirin induces nitric oxide release (NO) RBC from vascular endothelium: a novel ↓ Light Guanylate cyclase + NO mechanism of action Passes ↓ GTP → cGMP through ↓ (PKG) Phosphorylation British Journal of Pharmacology 2004; 143 : 159-165. Skin ↓ 1) vasodilation Aspirin = nitric oxide = pain relief 2) analgesia Vascular Endothelial 3) angiogenesis Consider aspirin side effects Cells FIBROMYALGIA PAIN ARTHRITIS PAIN Modulation of pain in osteoarthritis: Abnormal microcirculation and temperature the role of nitric oxide. in skin above tender points in patients with fibromyalgia. Clin J Pain 2008; 24: 353-65. Rheumatology (Oxford). 2000; 39:917-921. Conclusion of authors If light therapy improves abnormal circulation, Nitric Oxide, produced transiently in small amounts, can would it help clients with fibromyalgia??? bring dramatic relief to people with painful OA. 5
Oregon February 2017 Painful, Scleroderma Ulcer with RAYNAUD’S PAIN Raynauds Effect of nitric-oxide-generating system on microcirculatory blood flow in skin of patients with severe Raynaud's syndrome: a randomised trial. June 27, 2005 July 11, 2005 • 2 Weeks of infrared Therapy • Treatments tried over 6 months Lancet . 1999; 354(9191): 1670-1675 • 3 x per week • Vicodin, Percocet, Methadone for pain • 25 minutes per treatment • Viagra, Procardia, Prednisone, Carpal • Results: Tunnel Release; Radial & Ulnar Artery • Pain significantly reduced Sympathectomies; Debridement to • Range of motion improved increase circulation with occupational therapy • 19 Physician office visits in 6 months Painful, Scleroderma Ulcer with Raynauds So what? • Nitric oxide is what keeps our arteries open so blood can flow to organs. • Good blood flow heals wounds August 10, 2005 • 7 weeks of infrared Therapy • Results: • Off all narcotics September 22, 2005 • Able to button clothing, write, • Final photo do needlework • Patient discharged with home system 34 40 year venous ulcer ON A PREVIOUS SLIDE I SAID… . Healed in 5 Months • Poor blood flow to the skin can lead to wounds that are difficult to heal. • If the wound gets infected, it may require QuickTime™ and a Cinepak decompressor Before are needed to see this picture. an amputation. (4 months after ceasing daily treatments) • Who wants to have only one foot or one leg? 36 6
Oregon February 2017 WHO SAYS NITRIC OXIDE 88 yr old Diabetic Female MAY BE IMPORTANT IN treated 3X/week WOUND HEALING? Nitric oxide regulates wound healing. J Surg Res. 1996; 63: 237-240 é January 8, 1999 February 5, 1999 March 5, 1999 March 31, 1999 Resolved 81 days Amputation avoided WHAT ELSE? SENIOR CITIZENS Faster wound healing Diabetes mellitus is associated with an increased risk of falls in elderly residents of a long-term care facility. • Horwitz L, Burke T, Carnegie D: Augmentation of wound healing Gerontol A Biol Sci Med Sci 2005; 60: 1157-62 using monochromatic infrared energy. Therefore, if red/infrared diodes increase • Adv. Wound Care 1999, 12: 35-40 nitric oxide in diabetic patients, will the absolute number of falls (and broken bones) decrease ? Mi Millions of diabetic patients out there. INFRARED + Physical Therapy REDUCES F ALLS IN ELDERL Y DIABETIC Falls and fear of falling PA TIENTS 7 Number of Kochman J. Geriatric Physical Therapy 27: 2004 6 • Powell MW, Carnegie, DH, Burke TJ. Falls 5 4 • Reversal of diabetic peripheral neuropathy with photo therapy (mire) decreases falls and the 3 fear of falling , and improves activities of daily 2 living in seniors. 1 0 1 4 7 10 13 16 19 22 25 28 31 34 37 • Over 1000 patients! Sensation increased. Patient No. • Age and Aging 2006; 35: 11-16. • Think of the number of seniors in the US. P < 0.0001 98 Total Falls 3 Months Pre TREATMENT vs. Pre TX 4 Total Falls 3 Months Post TREATMENT 7
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