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Photobiomodulation with Emrys Goldsworthy

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Photobiomodulation with Emrys Goldsworthy

Imagine a simple, painless therapy that could treat conditions ranging from acute and chronic pain to wound healing and even depression!

These are but a few examples of the therapeutic potential of photobiomodulation, or low-level laser therapy.

Today Emrys Goldsworthy takes us through his clinical experience, the evidence and the outcomes of using photobiomodulation in his practice.

Covered in this episode:

[00:39] Welcoming back Emrys Goldsworthy
[02:00] What is photobiomodulation?
[03:19] The origins of photobiomodulation
[04:46] Types of photobiomodulation
[06:29] Applications for photobiomodulation
[17:03] Response to therapy
[19:26] Acute injuries
[23:15] Photobiomodulation as an analgesic alternative
[27:16] Pain, inflammation, bruising and oedema
[30:36] Objective testing
[32:15] Immunological benefits?
[33:53] How is laser administered?
[34:41] What practitioner training exists?
[37:02] Caveats, cautions and red flags?
[39:10] Ophthalmic use?
[42:00] Transcranial laser
[43:59] Final thanks to Emrys

Andrew: This is FX Medicine. I'm Andrew Whitfield Cook. Joining me on the line today from, I'm going to say it with chagrin; sunny Brisbane, because it's pouring down here in Sydney, is Emrys Goldsworthy. 

Emrys is the director of Athletica and Physical Health. He completed a Bachelor degree in Health Science Musculoskeletal Therapy which he attained at the Endeavour College of Natural Health. He's also gained a master's degree in Sports Coaching, focusing on classical ballet coaching at Griffith University. He's been a lecturer since 2008 and currently holds the position of Senior Lecturer of the department of Musculoskeletal Therapy at Endeavour College of Natural Health.

Emrys's interest in the body began while he was a professional classical ballet and contemporary dancer. He's a graduate of the Australian Conservatoire of Ballet which led to a career in the Royal New Zealand Ballet, performing several soloist roles and touring the world with the company. Emrys has a unique approach in the examination and treatment of physical impairments. And today we're talking about another one that I am totally ignorant on, and that's photobiomodulation. 

Welcome back to FX Medicine, Emrys, how are you?

Emrys: Very good, how you doing?

Andrew: I'm good. Now, I've got to say, you are expert in these topics and I go, "Huh?" So I guess...

Emrys: It’s a bit obscue.

Andrew: Yeah, let's start off; what is photobiomodulation?

Emrys: Well, it's a term that's now being used in the literature far more often and it's the most accurate term, sometimes you’ll hear it being used or you'll see other words for it, cold laser or low-level laser, but the most accurate term is photobiomodulation. And essentially what it is is light therapy that has a modulatory effect on the bodily tissues. It's either using some form of LED device or a laser device. It ranges in colours, so depending on what the aim of the treatment in the study is, it uses mainly a red or a near infrared spectrum. There are other colours that are used but they're the main ones and the lasers are normally somewhere between a hundred and five hundred milliwatts, and these are known as 3B lasers as opposed to four lasers which are used in surgery, or they're used sometimes clinically.

Andrew: Right, so four lasers...now they're the ones that burn.

Emrys: Yes, correct yeah so they're the ones used in a surgical application normally. Yeah, and then that...the wattage on those is much higher, and higher doesn't mean therapeutically, it just depends on what the aim is.

Andrew: Yeah that's right because they're used in like tattoo removal, certain scarring but also other surgeries as well, correct?

Emrys: Correct.

Andrew: Okay, so photobiomodulation using a lower level light laser. Where does it originate from? How far, like, have we come?

Emrys: Far back? Yeah.

Andrew: Yeah, how far back?

Emrys: Well, it kind of happened by mistake. So the most well-known is in 1967, a man called Endre Mester from Hungary, he was a scientist working with rats and mice on basically trying to induce cancer with lasers. So he was trying to induce cancer with lasers after their invention a few years prior. And so what he would do is he would shave the mice and then irradiate them with...he had used a ruby laser which is the red spectrum laser and kind of had a bit of surprise and that was that firstly, no cancer was...no cancer occurred, but the treatment group using a laser, their hair grew back much faster. So he noticed that there was some kind of bio-modulation effect and that's when everyone started thinking about, "I wonder if these lasers could be used therapeutically."

Andrew: So the hair grew back faster?

Emrys: Faster, yes, so the laser light induced some kind of change in the skin, inducing faster grow back, yeah. That exact mechanism has been researched as well. It's not my area of expertise, but, again, it's probably more the beauty industry.

Andrew: Yeah, okay so those are dermal applications and one would expect you know, you shine a lot on the dermis and you, depending on what's happening within the dermal layers, one might hope for a therapeutic effect but what about deeper stuff?

Emrys: Well, yes, so, I'll explain the different types of approaches. There's mainly two different ways of approaching low-level laser or photobiomodulation. 

One is more of a healing effect, okay. So that could be deeper tissues that need healing. It could be like a muscle strain, or it could be more superficial, it could be skin breakage or a wound. And that uses more of a lower dose than I would call analgesic approach, and so those are used, generally somewhere around three joules per centimetre squared. That's the term we use in laser. It generally uses a red-light spectrum that term and that effect is slightly different. I'll go through that in a sec. 

But the other one is an antinociceptive effect or more generally used, analgesic effect. And that uses a much higher dose, six plus joules per centimetre squared. It just depends on the laser that you're using, and some of them have different apertures so you just need to know the brand's methods. And that...generally we'll use a near infrared spectrum, not always but generally. 

And so if you're talking about red light you're not going to get as deep. Generally speaking, red light doesn't go as deep as near infrared, so depending on the level you're trying to treat, you'll sort of pick and choose. But they have different effects on the body, so as I've said, the red is better for healing and the near-infrared is better for analgesic, but there is a bit of a sweet spot between the two.

Andrew: Okay, so let's go into these applications because I'm just...my mind's boggling here about applications with regards to anything from a sports injury, to chronic pain to, mucosal injury? 

Take us through what the applications of photobiomodulation are. And indeed, do you call it PBM as an acronym?

Emrys: PBM, photobiomodulation is fine. Sometimes it's PBMT, just "therapy" at the end.

Andrew: PBMT, got you.

Emrys: Yeah, they're all pretty similar. 

Okay, so generally speaking, I work in a muscular skeletal realm, okay, so a lot of the conditions that I treat are in that in that bracket. So we'll talk about that. 

Firstly, the best application I find in regards to it being better than most other things, is chronic pain. So, and when I talk about chronic pain I don't just mean generalised pain anywhere, I mean fibromyalgia syndrome for example. Nonspecific lower back pain, knee or hip osteoarthritis, lower back osteoarthritis as well. Chronic neck pain, these all respond well and I find that patients that maybe they’ve had other kinds of therapies like manipulation or things that...or mobilisation or exercise that they've not responded, they respond well to this. That's very interesting to see and I think that's in part because a lot of them are guarding the way they move, and then they've got a bit of localised muscle tightening in the area of pain.

Andrew: Yep.

Emrys: And so this actually works particularly well on muscles, alright, because although a lot of these conditions aren't strictly muscle pain, and we know that there's a lot of centrally driven mechanisms that cause chronic pain. But you can respect that a lot of their pain is myofascial. So, in regards to that, a lot of my myofascial pain is actually induced by effects, ischemic effects within the muscle. So you get this buildup of Hydrogen ions, there’s an effect of reduced oxygenation of blood...oxygenation of muscle to reduced blood flow to the muscles. And that can be in part, due to the muscle being very tight and the onflow effects from that. 

So the laser itself works really well at restoring ATP levels to those myocytes and the net effect of that is of course, relaxing the muscle and returning it to normal tone. And then you improve the blood flow and things return to normal. I mean I don't...they may not stay that way because of centrally driven mechanisms. That's why you do additional points on the body and you consider other lifestyle factors within a functional medicine sort of work up. 

Andrew: Yep.

Emrys: And other things that work really well, it really works well for neuropathic pain. So, it might be something pretty simple like carpal tunnel syndrome, okay, I've had great success with that. And in the research they've had some, particularly recently, they've had some really good results with spinal cord injury.

Andrew: Ahh.

Emrys: And this is really exciting. So they're using lasers on the spinal level where the injuries occurred, and what they've found is that, just...so, below that level, in the little lower limb maybe for example, wherever the level is that's been injured, they're getting improved muscle activity. So basically, their power's getting better, their mobility is improving and there's really good signs that this could be a potential treatment in the future. There's still room to move, room to go with that in that they need to figure out the best approach, whether they need to do other areas or less intensity or more intensity, but we're finding really good results there.

Andrew: What about things like phantom limb pain?

Emrys: Phantom limb. Okay. This is a bit obscure but I will tell you that there could be potential there. So, because that is a brain related problem, there's also some things going on at the stump. So there is some changes in that actual limb.

Andrew: Yep.

Emrys: And you can laser at that point and that does help. I've used it on people with phantom limb before. It is not a common patient you see in the clinic.

Andrew: Yeah.

Emrys: But it does work quite well but because there are so many other brain related components to that condition, I've found that a therapy called trans-cranial laser is worth trailing as well and that's something we can talk about.

Andrew: Right and that would be applicable also to things like complex regional pain syndrome, would that be right?

Emrys: That's a very difficult one to treat.

Andrew: I'll bet, yeah.

Emrys: I find that trying to affect sympathetic nervous system as well, is  worth it in that, worth treating in that, and also brain as well. Yeah.

Andrew: Yeah okay, so I took you onto a tangent there. What else can we use photobiomodulation for?

Emrys: So, I'll just go through some other pain related conditions. So, osteoarthritis, I've talked about that but that's a that's a very common one we see and a very...I find it very successful. 

Meniscus damage pathologies relating to meniscus. Lower back pain as we've already mentioned, disc pathologies. The disc pathologies, a lot of people have pain and they attribute it to disc pathology, although, you know, the research shows that a lot of people already have disc pathologies with no pain. But clinically, if that's their source of pain which...we can attribute to it sometimes, it's very successful. Because we can actually get the laser to hit the disc itself.

Andrew: Oh, right, okay.

Emrys: Yeah. So, and then you have muscle strains and ligament sprains. Things like sports injuries and things like that and they're sort of approached differently because those ones are not really trying to reduce the pain per se. I'm trying to reduce the inflammation or induce healing, really. Okay, so a lot of people will say in the literature low level laser or photobiomodulation is anti-inflammatory. But what they really mean is that it sort of facilitates healing. And that's sort of what the mechanism is, it's more a facilitation of healing. We can chat about those mechanisms.

Rheumatoid arthritis. So, I use that with vagus nerve stimulation, which I talked about previously. Because TNF alpha is a real problem with rheumatoid arthritis, a systemic approach with vagus nerve stimulation is appropriate with some localised photobiomodulation of the joints affected. Very helpful there. That's a long-term treatment, we do see improvements over time and we find that because we're not trying to cure the condition per se, we're just trying to get them managed and to the point where they can do more in their life, and then we really promote that. We get them to do more and more activity as long as they're pain free and we find it gives them more confidence. 

Other ones that a lot of people don't know about is things like lymphedema. You can actually use photobiomodulation on lymph glands, improve the flow through there. And some other ones like wound healing on the skin, I do it also to skin conditions like psoriasis and I've found it to be very helpful there. Even though it's not a wound, I've found that the inflammation on the skin with psoriasis, it seems to respond quite well. And then it's a long-term treatment, it's something that you have to work on week by week for a few months, a fair few months, but definitely worth trailing if you haven't had success elsewhere.

Andrew: I've got this thing in my mind that, you know, a laser is this point of light that you direct on to one very small area but you're talking about six plus joules per centimetre squared. How broad is the spread of the laser and it...doesn't that contradict what a laser is?

Emrys: So, what a laser is, it's small so it's just how much density of power is in that spot. And that's about how long it's been placed on that spot. Okay, and so you might get a rate of flow of joules that are whatever per second. But it's because you've held it there for that long that you get that much density.

Andrew: Right

Emrys: Okay. Now other devices such as LED clusters, which you'll see a lot of, they are quite broad. They're quite big and they can cover a broader area and of course, they're more so for superficial tissues, as I've already stated. Because they don't penetrate as deep. So they're used generally more in wound healing but I do use it for lower back. I do find it helps particularly if you increase the joules per centimetre squared.

Andrew: Okay, now one of the other things that's going through my brain here is that you mentioned it's used with Rheumatoid Arthritis, Osteoarthritis. They are, not predominantly, but they, you know, mainly I'm going to say the word ‘mainly’ involve the bone as the inflamed tissue or joints as the inflamed tissue. 

But we're talking about the use of laser particularly working on the muscle. Do you see direct action on the bone itself?

Emrys: Yes, there is bone effects as well. So, subchondral bone, you can induce repair in subchondral bone. So, there's a whole raft of studies been done very recently, and in the past, but most recently showing sort of facilitation of mesenchymal stem cells.

Andrew: Wow.

Emrys: And that's...that's helpful in that...although mostly for wound and muscle repair. But you actually get a raft of different stem cells activated when you're applying it to say, a long bone where the stem cells are present. 

So let's just say you're applying it to the knee, for osteoarthritis of the knee, you can direct it towards subchondral bone and you can get a really positive effect on pain relating to that subchondral bone, but you can also induce healing effects. Now that's been controversial but you...because most people haven't heard of that, but the research is there and it's quite compelling.

Andrew: I'm amazed.

Emrys: I do that currently and I use a raft of different things to sort of induce subchondral changes and cartilage changes as well. And it takes time, you know, these aren't overnight changes they do take months. And I still think nutrition plays a big role, and activity.

Andrew: Yes sure. 

So when you're looking at these therapies, when you're looking at bang for buck and you know what you've got to do to put up with pain, and you know trying to get an effect in your patient so that they'll continue with the therapy. How do you go with motivating your patients to continue on longer term therapy, given that they're in pain now and they want relief now? Do you employ it as just part of an overall therapy approach?

Emrys: So within my own methodology, I like to look at everything. I don't want them to come back and say, "I didn't change." And part of that is understanding what the mechanisms that are bringing about their pain and sort of maintaining their pain. You know, inflammatory, systemic inflammatory factors, oxidative stress, you know, environmental factors, and there can be a lot of different things, stressors. Then you'll have patients that don't sleep properly and I know that they potentially may not get better until their sleep pattern has improved.

And so a lot of these things I now know can get in the way, and so I make sure I address them. And most of the time that leads too much better outcomes. I think that's where a lot of other clinicians, particularly in the conventional world, they don't look at how well you sleep when you're dealing with osteoarthritis. They don't see the relevance of that. Even though most of the studies will show when they look at other factors, sleep problems come up all the time. So does stress. There's going to be a reason for that, and they have systemic effects of course, as we all know. And so I tend to work on that as well. 

Now most of the time patients will respond immediately, within a day or within ten minutes, or straight away. That's always helpful to give them confidence in the therapy. I mean I always cannot believe sometimes, how fast it works, and I get shocked. I still get shocked to this day. I've been using it for years now and you know, I might want to mobilise a neck, you know, put pressure to the neck to try to get a joint to move and I'm putting a lot of force in there and I'm expecting it to change, quite a lot. But I might sort of put a laser on it for 30 seconds and it changes it more. And I go, "Oh, I just...I just can't believe it." And that's a lot of patients, it's the majority of patients that, you know, respond that quickly.

Andrew: Yeah, yeah. What about you know, common sports injuries or let's call them sports injuries you know the TFL, tensor fasciae latae and you know, bursitis issues? 

Emrys: Oh, bursitis, yeah. Okay, so we see a lot of bursitis. So the main types of bursitis we see is trochanteric, so that's on the outside of the hip. And subacromial bursitis, that's in the shoulder. Both respond very very well, particularly if they're acute bursitis. Bursal changes are actually quite common and can be very, in many, commonly, asymptomatic. Yeah so I try not to be too patho-anatomical if that makes sense. I don't want to assume it's that tissue. I go by what the patient feels and where the pain location is. The scan might show trochanteric bursitis but their pain is at their gluteus medius tendon. So I’d rather effect that. 

So, in addition to that though, we always, the protocol with low level laser and photobiomodulation is to treat the spinal levels as well. Because when you're doing analgesic laser, you're creating essentially, a neural blockade. There's a raft of effects that occur within the nociceptor and that can be done at the end organ site which is the receptor site in the skin, and in the muscle tissue or the tendon tissue or whatever. Or it can happen at the dorsal root ganglion, in the spinal cord, at the spinal level. So you do both because you can affect both sides, both ends of the neuron. 

And so yeah, so things like bursitis of the shoulder and of the hip, they're all really relevant because that I work in a manual therapy an exercise world, I need to make sure that I've addressed their movement problems as well. And many people don't move properly and it leads to pain and it leads to mechanical overload of bodily tissues and then degeneration or whatever it is. Yeah, so I do make sure that I'm not just using laser but I'm also doing a raft of other things to make sure that true causes underlying are addressed.

Andrew: I've got to say coming from a ballet background, who are notorious for damaging their bodies and continuing to exercise throughout that…have you learned hard lessons from that history to say, "I really should be looking after my body." And teaching your patients to do the same? Like, "This is what most people will do and this is what you should do."

Emrys: Yeah, so I've had so many injuries as a dancer…

Andrew: Why does that not surprise me?

Emrys: Bilateral Osgood-Schlatter disease, and that was very late, I should have had that as a teenager, but I had that in my 20's. I'm not even sure how that was possible but it was diagnosed. I had so many different things and I used pain medication to get me through and I remember that one day that I started getting stomach cramps. And I was on...I don't know, it was some kind of NSAID. And I said "Okay, I've really got to stop this." And all dancers are the same, we just rely upon pain medication. 

So, yes, I do have to really try to change the way people think about pain and remember that, you know, if you've a tendinopathy and you're taking NSAIDs, you can inhibit healing.

Andrew: Yes, this is something that most people don't know about

Emrys: Yes and I was never told that, you know I was just told, "Just take this, just get through the season” and that was it. I think people are getting a bit wiser these days because of social media and a lot of posts that people put up again. 

But I think the idea that NSAIDs inhibit collagen synthesis is not well known. Yeah. So I think I try to educate people but, yeah, sometimes their doctor tells them otherwise, so it's hard.

Andrew: I'm waiting for the day that like it really concerns me about the modern-day marketing of NSAIDs to children. And I'm waiting for the day, "Oh, lo and behold, now we're seeing ulceration in kids."

Emrys: I agree. 

I mean that's another good thing that… while we're on children, that kids respond amazingly well to low-level laser or photobiomodulation because one thing, they don't feel it it, which is great when you're a kid. One thing that the kids hate is dry needling, which I used to do a lot of and I still do for certain cases, but laser's kind of replaced the dry needling kneeling. And yeah, they bloody love it. 

Anything from an ankle sprain to a bit of bone bruising. I mean I remember I had a patients where...a few months back, where she had tibial bone bruising. We thought it was potentially a fracture or something like that but it was just bone bruising which was great. And literally she couldn't bend her knee past nine degrees inflection. And within that one session, she gained 30 degrees knee flexion.

Andrew: Wow.

Emrys: I mean I know that that's partly to do with the analgesic effects. But she retained that. So kids respond really really well and I think in part it's because they...you know, there's such a different effect for kids. You know, I find that they...the placebo effect just works differently with them. I just don't think they know what's going on. Maybe there's a bit more of a placebo effect with the laser, I'm not sure, because they think it's really cool. Sometimes I'll make the lights dimmer and they'll see the light coming out of the probe, the laser probe, and they find that pretty cool but, just a side not. 

Andrew: What you said there is that and this is very common with physical or manual therapies is that you feel great during this session. I mean, how many times have you been to a physio or a chiro and you've had this sort of thing where it feels great during the session particularly for instance while a physio might be supporting your vertebral facets while you're in rotation of your neck. Feels great, no worries. Go home. Two hours later, and there it is again. 

So when you're seeing a continued positive response from this, that's telling...that's telling a big tale that one. That's really saying this is working on a different level.

Emrys: That's right. I think you need to consider all things. 

Like I said, the way people move has a big effect on their pain levels. So, I do have a lot of...a big part of my treatment is education about how they're moving, and so if I can change that in that first session, and I can see that they're...they understand that they're guarding or they're changing the way they move, and that's negatively affecting their pain levels. Then I know that they're going to get a good result that's long term, that may even get better and better over the course of a few days, because of that change. 

Sometimes the low-level laser may work more as the doorway for that. It may not be ‘the cure’ in itself, but it may be a doorway in order for them to move better. 

Andrew: Gotcha

Emrys: Because movement really is the key in a lot of cases to improvement. But they're being told, "Oh, you're damaged. You've got the back of an eighty-year-old." Or, "You've got, you know, bone on bone." You hear that all the time. It's infuriating for me because the research doesn't add up when you put that information to a patient and say, you know, pain levels in knee osteoarthritis don't correlate with levels of damage seen on a scan and they...it doesn't relate to them because they've already been told it's bone-on-bone. You know, they need a replacement. So, it's about educating them and also changing the way they think about their pain. I think that's really important as well. I know that's not strictly laser but you have to have a multi-modal approach, I think, with pain.

Andrew: Yeah, so two questions that have sprouted in my mind. Firstly you mentioned the sprained ankle, the acute, "Oh my god this hurts." You can get resolution in healing, bruising, edema?

Emrys: Yeah, yeah. So normally what we'll see...this is...there's a lot of conjecture about how to approach some things like sprains. Because you can have an anti-inflammatory effect, you can have an analgesic effect, right, and you can try to do both and that does work. But sometimes the analgesic effect will have an effect on the levels of substance P and PGRP and these substances, are very… one is vasoactive and one is very...sort of reduces the threshold of nociceptors, so it will change the way they move, when you reduce their pain. So sometimes reducing their pain changes the way they move and making them move more normally actually helps them heal faster, so there's that. Yeah. Depends how you look at it, you know, and I do still see reduction in swelling, within the session, every time.

Andrew: Wow.

Emrys: But you see that with acupuncture as well. And you see that with dry needling and you see that with a lot of other therapies. But you definitely see it with laser as well and...if not better. So what I try to do with those is I do try to get them back as quickly as possible within that first week. Depends on how severe it is and depends on how much is going to bother them, what they do. If it's a dancer, for example, you know, and they need to get back quickly, they’re coming every day, almost.

Andrew: Gotcha.

Emrys: Every two days maybe, depends what they can do. And it's about getting them back as quickly as possible. And so we've seen, you know, a sprained ankle that might take two weeks or three weeks, they will return within a week.

Andrew: The thing that's going off in my head is, you know, your typical footballer says, "Get me back out on the field, coach." So they hit him with a steroid injection, get them out, nothing's healed. They've just got no pain and no inflammation. They then go and...you've got a worse damaged tissue there that will take so much longer to heal because you're now stressing it. This actually resolves the wound, is that right?

Emrys: Yeah, so it induces a healing effect. So the body...you know, it's all a very endogenous effect. You know, you're creating a biomodulatory effect, you know, like I said, so the body then responds to that. You know, if you put a steroid in, you know, you're basically just trying to mask it. It doesn't really...you know, as we've already, said it's going to inhibit, potentially, healing effects. 

So, yeah, great short term but what about long term? And I think that's the same as a lot of different conditions. You know, people only really concern themselves with the short term and don't really realise that long term, the research shows most of the time, these steroid injections, particularly with degenerative tendons or the like, you know, it's not a great outcome.

Andrew: No. Particularly if they've used too regularly and you know...gut problems, cardiovascular issues, all sorts of issues.

Emrys: Yeah, I know. But they don't...a lot of them aren't aware of that and I've told them the risks, and they were never told, so, or they were and they just forget. But I don't think they realise the enormity of them. 

Andrew: What about objective results, you know, when you're looking at X-rays and things like that. You know, have you ever seen things like resolution of osteophytes, in lower back pain, osteoarthritis? Have you ever seen this sort of effect occurring?

Emrys: Okay, so I'll just tell you the way I use scans. I used to use scans all the time. I really concerned myself a lot with them. But because clinical results don't generally correlate well with results seen in scans. You find it very difficult to want to use them. Partly because of that but also because it's expensive to keep scanning patients. And so let's say it's x-ray, I don't want to keep irradiating them, you know, for health reasons. MRIs are expensive as an alternative. 

If it's a soft tissue lesion, yes we have seen that. We've seen tendon healing, and tendon collagen synthesis increasing and reduced neovessels. So there's...within a lot of chronic tendinopathies you see vessel growth into the tendon and we see a retraction of those quite commonly. I don't always do that because most of the time, the treatment effect has already occurred and to go and get the scan after that seems irrelevant to the patient.

Andrew: Pointless, yeah.

Emrys: Yeah but I really, I don't use scans as much as I used to, unless it's indicated. The only time I've used it for say lower back pain is when there's gross neurological changes in the lower limb, or they're in extreme pain, or I'm suspecting a fracture. But other than that, I don't worry too much.

Andrew: Right. And you mentioned wound healing before. One of the references I found and forgive, again, my ignorance on this. It was just the title. The Effects of Photobiomodulation Therapy on Staphylococcus Aureus Infected Surgical Wounds in Diabetic Rats. Now, I know it's a rat study, I get it, but what? How is this working?

Emrys: There's meant to be some kind of bacteriocide effect of low level laser, photobiomodulation. How that works, I'm not aware, I'm not sure, and I don't think it's been well established yet. But it could be working potentially on a chromophoric cell that are within the bacteria they absorb it and it inhibits them in some way, I'm not really sure. 

But, we see that diabetic ulcers you know, wounds that just don't heal with diabetes, they start to heal when nothing else has helped. It does take, you know, weeks and months, but they're improving every time. So if we’re just talking about wounds healing, that's one thing. If we're talking about infection that's another. And I think...I don't personally use it for infection and it's a new field, I think. But the bacteriocide effect of it is potential. 

It's antiviral effect has been pretty much squashed. But there are potential other ways of modulating the immune system with low level laser and that's being explored so that might be another way of affecting viruses but when it comes to bacteria, yeah, I think it's just the bacteriocide effect, but I'm not sure how.

Andrew: And so when you're talking about directing it to the meniscal layer or something like that, how do you aim...I'm going...do I say the word probe? How do you aim the laser?

Emrys: How do you aim it? Okay, so you put the patient's leg in a particular position that allows the opening of the joint, and so if...you're talking about the meniscus of the knee, yeah? 

Andrew: Yep.

Emrys: So, the meniscus, you’re basically able access from the front and a little bit from the side. You can trial it from the back but I'm generally aiming from the front and from the side, along the joint line. So, yeah, you can penetrate to the levels of...that you need required for therapeutic effects and you'll generally find it's quite tender to touch, so that's another area you'll try to effect as well.

Andrew: Gotcha. So, I've got to ask now, you know, like you come up with these things and you blow my mind. You did this with the vagal nerve stimulation and I was like, "Oh, totally on another wavelength." Totally blew my mind as to the therapeutic effects, the therapeutic potential of using vagal nerve stimulation in so many different areas. 

How do praccies learn about photobiomodulation? And I've got to add, vagal nerve stimulation into this, because what you opened up my mind for was so broad. And there really...like I said, my mind was blown away by the evidence behind these sorts of things. So how can praccies access resources or education?

Emrys: So, let's start with...well, let's start with...I'll start with vagal nerve stimulation. I recently did a seminar in Sydney. Which run about a month ago. It was quite successful. We're doing another one in Brisbane, and I'm hoping to do another one in Melbourne and I'll place my new website on the page.

Andrew: Yeah, yeah, great.

Emrys: And you can follow that to go to those. 

Laser is done...there's a bit of a different thing with laser. So, laser is done with particular...you need particular licenses to do education in laser. So one of the best providers, the one I use, is Thor Laser, T-H-O-R Laser, and they come about twice a year to Melbourne and Sydney and do education seminars. So I can highly recommend them. There are others, but they are the only ones I have experience with and they've got fantastic resources if you are learning and need some ongoing support after the seminar.

Andrew: Beautiful and we...so as you said, we can put those resources, the links, up on the FX Medicine website.

Emrys: Yeah, there's just so many. I mean, Thor Laser has a fantastic list of them that you can access through their website. But there are just papers after papers after papers. The amount of osteoarthritis papers, you know, I was reading through probably 30 or 40 plus, you know, it was just ridiculous. 

Like, so, you know, it's hard to really take one. But there's some really good ones and I'll put them up there, you know, particularly the ones,  the studies that were done properly and with the right parameters with the lasers.

Andrew: Yes, brilliant. Okay, so I guess from a responsible point of view, cautions, red flags, when do you go, "Uh-oh." Or, when do you have to sort of be aware that there might potentially be something more serious or sinister going on?

Emrys: Okay, well usual health history is very much where you're going to pick up red flags, okay. 

But other than that, the main, the most known and most important one is to not aim that laser into the eye, okay, because lasers can affect the retina, negatively affect the retina. But that's predominantly four lasers, but the precaution is still, and the contra-indication is still with 3B lasers. 

So, we don't use lasers. There are...because you can treat retinopathy of the eye and macular degeneration of the eye with photobiomodulation, we tend to use LED cluster probes with those instead. And that's kind of strange, having a big red light over your eye but has shown very good results. 

The other ones, it's just due to a lack of research, is areas of metastasise for cancer. We don't know what it does. So there have been mixed results in research, so it's best just to err on the side of caution. 

The other one is pregnancy, so we don't laser over a developing foetus. Not because we know it does something, because we don't know what it could do. 

Sometimes immune...people on immune suppression drugs is an issue, we just take that into consideration. Photo-sensitive patients, photo-sensitive epileptic patients. Particularly around the eyes, obviously. And yeah, that's predominantly all you concern yourself. 

There was some concern with thyroid glands, but then there's some research showing potentially that thyroid responds positively to laser. So, you know like a damaged thyroid from Hashimoto's disease. So, that's potentially a therapeutic option that we’d look at. But it doesn't need to be needed.

Andrew: With ophthalmic use it rather than the laser you use an LED cluster, is that right?

Emrys: Yes, yeah, you use an LED, like a round-headed LED cluster and usually red light. Yeah.

Andrew: I'm just...I'm blown away by the sorts of therapies that you get into. How do you find this stuff?

Emrys: Oh, it’s a bit, you know, I hear from colleagues that are using it or I read about it in research, you know. The amount of papers I scour through and end up reading about other things. And you end up being with like-minded people around you and they find out things and you know, it's kind of like that, you end up going, "Oh, there's this is new treatment." I do always I start going, "No, it can't...sounds rubbish." Pretty much my starting point yeah and then I just read about it for a while and just try to build some confidence in it. And low-level laser, I was like totally on the fence. I was like, "This sounds like rubbish." But no it was...the research is pretty damn compelling.

Andrew: Wow

Emrys: Yeah, I don't feel like that anymore. I think, you know, the VAS studies on neck pain, that's where you see the big results. Neck pain is the one that really has come up trumps in the research and I think that's because it was done so well. Exactly correct parameters, sample sizes appropriate, you know. And the results were great and they've...you know, basically showing that low-level laser is equivalent to, if not better than NSAIDs for neck pain.

Andrew: Wow, yeah.

Emrys: That's a big one for us.

Andrew: Wow, that's a big one.

Emrys: And that was the starting point and then I read further and, you know, there’s a lot. Yeah.

Andrew: Are you finding that there's a growing even a groundswell of acceptance with regards to photobiomodulation?

Emrys: Oh, without a doubt. Because there's been a lot of televised low-level laser on, you know, Channel Nine, Channel Seven, things like that. And they’ve, it’s led to people really searching for it and there's not many people that do it. And..you know, there's a lot of laser out there that's kind of...you've got to be careful what you use because not all of them do what they say they do. 
I'll get a list of the different really good providers that I know, that are used in research and they're the ones you want.

Andrew: I love...I've got to say, I have so much respect for you the way you tease apart, you know, what's the BS, to the real McCoy, sort of thing. And you then start to use this in a therapeutic way, as part of a practice, no magic, for the benefit of patients. I love the way that you tease apart and you sort of start from a skeptical standpoint, and then go, "Does this really work?” You're doing a lot of work for the listeners of FX Medicine, thanks so much.

Emrys: That's all right. Oh, I haven't mentioned it yet but I'll mention it now because I've got the opportunity. My biggest excitement about laser is really, transcranial laser. So, transcranial laser is the application of the light over the cranium and you have to apply quite a lot of joules to get any really onto the cortex.

Andrew: Yeah.

Emrys: But the results for depression in the frontal lobe have been fantastic. And you know, we talked about transcutaneous ouricular vagus nerve stimulation for depression last time. Well the combination is, to me, it's breathtaking. You know, it can be really quick, and within the first day, they're getting change. It can take a couple weeks to get, you know, really big change. But I've found the combination really useful and so if anyone's in the world of depression or treating mood disorders or...they've got to get on top of these things. These are really useful techniques that can be used alongside say nutritional interventions or other lifestyle measures. 

Andrew: PTSD as well?

Emrys: Yes, well I mean, I've found a lot of patients that come to see me with depression and they really actually have PTSD. As being...you know, that's sort of the inducer. And, yeah, we've found great results. 

I do find that it's really good to use other therapies, while sometimes it might be hypnotherapy, or other types of psychological interventions but, you know, because sometimes them processing that, those memories, is really important as well. But, yes, great results, their mood improves. I find that, because the vagus nerve stimulation's improving the brain derived neurotropic factor levels. And at the same time, the ATP levels are going up in their frontal cortex due to the laser, it's just this perfect combination, you know, for neurogenesis and neuroplasticity. So that's ideal for depression.

Andrew: Emrys Goldsworthy, thank you once again for taking me and educating me, let alone our listeners, on a new therapy which just has so, so broad an effect. You can use it in so many different conditions. It's quite amazing, absolutely quite amazing. Thanks so much.

Emrys: No problem.

Andrew: This is FX Medicine. I'm Andrew Whitfield Cook.

Additional Resources

Athletica Physical Health
Prof Endre Mester: The Father of Photobiomodulation
Emrys' Practitioner Training
THOR Laser
EMS Physio Lasers
RJ Lasers

Research Explored in this Podcast

Su B, O'Connor P. NSAID therapy effects on healing of bone, tendon, and the enthesis. J Appl Physiol 2013 Sep 15;115(6):892-899

Ranjbar R, Takhtfooladi M. The effects of photobiomodulation therapy on Staphylococcus aureus infected surgical wounds in diabetic rats. A microbiological, histopathological, and biomechanical study. Acta Cir Bras 2016 Aug;31(8):498-504

Gonzalez-Lima F, Barrett D. Augmentation of cognitive brain functions with transcranial lasers. Front Syst Neurosci 2014;8:36

Anders J, Lanzafame R, Arany P. Low-Level Light/Laser Therapy Versus Photobiomodulation Therapy. Photomed Laser Surg 2015 Apr 1;33(4):183-184

Cassano P, Petrie S, Hamblin M et al. Review of transcranial photobiomodulation for major depressive disorder: targeting brain metabolism, inflammation, oxidative stress, and neurogenesis. Neurophotonics 2016 Mar 4;3(3):031414. doi:10.1117/1.NPh.3.3.031404

Other Podcasts with Emrys include:


The information provided on FX Medicine is for educational and informational purposes only. The information provided on this site is not, nor is it intended to be, a substitute for professional advice or care. Please seek the advice of a qualified health care professional in the event something you have read here raises questions or concerns regarding your health.

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