Given the new information on the benefits of transcranial photobiostimulation, doctors of chiropractic have an opportunity to deliver cutting edge treatment for post-concussion syndromes, mild traumatic brain injury (mTBI) treatment, and potentially many other brain disorders.
However, there are several questions that must be answered regarding the knowledge base, steps, and preparation doctors should undertake to become competent in transcranial photobiostimulation therapy.
Many DCs use lasers for neuromusculoskeletal (NMS) biostimulation, but be aware that there are differences between transcranial and NMS applications. The brain is a sensitive organ and frightfully unforgiving of mistakes. Different light modalities have different capabilities, limitations, and potential for CNS injury. The selection of treatment parameters and choosing between the different light delivery equipment available is of paramount importance to prevent injury and maximize outcomes.
Near-infrared LEDs, Class 1, Class 3B, and certain Class 4 lasers are the most common types of photobiostimulation equipment available to chiropractic physicians. Lasers differ from LED light in that the emitted photons are coherent, directional, higher power density or intensity, in a tighter wavelength spectrum and are divided into classes based on power and risk of injury. (See Table 1)
The various light emitting devices offer different wavelengths and photon sources. These characteristics affect penetration and absorption. Penetration depth can also be influenced by power density (watts/ cm2), monochromaticity, coherence, pulsing, delivery, and obstructions.
Photons are absorbed in the region of a molecule called a chromophore, and different chromophores will only absorb a certain photon wavelength and are sensitive to too little or too much light stimulation. An important rule to remember is that sufficient light of the correct wavelength must be absorbed in the intended tissue to have the desired effect.
Considerations for selection
If you are planning to use LEDs or one of the lower-powered Class 3B lasers, early intervention in personal injury cases frequently involves the frontal lobe, and light pulsed at 10 Hz poses minimal risk to most patients.
Almost any biophotostimulation device of the proper wavelength in the hands of a knowledgeable clinician can produce a therapeutic benefit. But you will only achieve optimal in-office therapy outcomes and realize the full potential of transcranial photobiostimulation with the skillful and precise application of considerably more powerful lasers.
LEDs should probably be restricted to home therapy programs, but they can be an effective adjunct to in-office care. If you treat personal injury patients and are not interested in taking time to develop expertise in transcranial laser therapy, then consider home-based LED photobiostimulation.
Inexpensive LED units and some low power diode (Class 1 and 2 lasers) are available for home therapy prescription including intranasal applications. These units can be safely used unsupervised by patients with minimal instruction, although treatment times can be long.
Safety concerns
The individual doctor’s practice style, office structure, and commitment to this area of patient care and how transcranial laser therapy will be employed should be taken into consideration before choosing a laser system.
Also, the application of Class 3B and Class 4 transcranial laser therapy should only be performed by a certified or trained doctor and never as unattended or performed by a CA who does not also meet the same certification and training as the doctor. Remember, even some Class 3B low-power lasers have the potential to cause injury to sensitive tissues.
When transcranial photobiostimulation is deemed to be clinically necessary, the application of transcranial laser should be as precise as possible in the delivery of therapeutic photobiostimulation to injured and stressed areas of the brain.
An EEG and patient assessment with cognitive tests and other metrics are necessary (but lie beyond the scope of this article). If you are not skilled in these areas, then establish a relationship with a chiropractic (functional) neurologist or medical neurologist for patient care.
Transcranial photobiostimulation is a new application of laser therapy.
There is a greater potential for serious and permanent consequences if used improperly. Individual state law notwithstanding, if you have an interest in adding transcranial photobiostimulation with laser to your practice, take the following steps before providing patient care. (No one wants to risk a poorly trained or untrained DC causing a transcranial laser horror story and media frenzy.)
Education basics
First, complete a laser safety certification course, as should any staff who will be delivering laser treatments, and designate an office laser safety officer. In most practices, that will be the DC.
Second, register your laser and verify it meets the regulations of your board of medicine on medical lasers (if applicable). Third, it is strongly recommended that you obtain formal transcranial laser photobiostimulation training and certification.
The level of instruction should meet CEU standards for your state board. Many DCs already possess a laser but practical knowledge in laser physics and photobiostimulation is necessary to set treatment parameters such as pulse width, Hz, and peak and average power to safely achieve clinical results. A less obvious but still important consideration is that you want to competently sort through all the manufacturers’ claims to decide which laser system is best for your needs.
Fortunately, classes in transcranial laser photobiostimulation are in the works. Although many doctors are focused on posttraumatic transcranial care, it is just the tip of the iceberg in brain photobiostimulation. A quick literature search will reveal the potential of transcranial photobiostimulation, and it is a hot topic of interest in medicine.
There is a tremendous amount of evidence of its effectiveness across a wide spectrum of brain disorders, including PTSD, neurodegeneration and dementias, cognitive disorders and functional impairment. Transcranial photobiostimulation has even been shown to be a performance-enhancing cognitive therapy and some top CEOs are using it to maintain their individual peak performance.
Only the beginning
The chiropractic profession should be at the forefront of this new modality. Hopefully, laser photobiostimulation research, including transcranial photobiostimulation, will be aggressively pursued in both chiropractic college undergrad and postgraduate research programs. Doctors of chiropractic are certainly capable of producing solid research and should contribute to the knowledge base.
At present, standards of care and definitive transcranial protocols are in need of further study and there is a lot of work yet to be done. Expect to see some solid interdisciplinary clinical studies across the spectrum of brain disorders in the not-so-distant future that will clarify and validate your therapy choices.
D
aniel J. Bourassa, DC, graduated summa cum laude from Life College in 1989 and is currently in the medical studies program at USAT. He is a past expert medical advisor for the Florida Division of Worker Compensation. He was a member of the editorial review board of the Journal of Sports, Chiropractic and Rehabilitation and has authored several articles on nutrition, rehabilitation, and low level laser therapy. He can be contacted at drfwb@watersidemed.com.
References:
1 Donovan et al. Summary of the findings of the International Collaboration on Mild Traumatic Brain Injury Prognosis. Chiropr Man Therap. 2014;22:38.
2 Dean P, et al. Long-term effects of mild traumatic brain injury on cognitive performance. Front Hum Neurosci. 2013;7:30.
3 Gavett B, et al. Mild traumatic brain injury: a risk factor for neurodegeneration. Alzheimers Res Ther. 2010;2(3):18.
4 Roozenbeek B, et al. Changing patterns in the epidemiology of traumatic brain injury. Nature Reviews Neurology. 2013;9:231-236.
5 Tuan V-D. Karu T. (2003). Low-Power Laser Therapy. Biomedical Photonics Handbook. Chapter 48. Boca Raton, FL: CRS Press.
6 Karu T. Molecular Mechanism of the Therapeutic Effect of Low-Intensity Laser Radiation. Dokl Akad Nauk SSSR. 1986;291(5):1245-9.
7 Xuan W, et al. Low-level laser therapy for traumatic brain injury in mice increases brain derived neurotrophic
