A Call to Reflect on the Wellness and Medical Indications of Photobiomodulation: What Challenges Lie Ahead?

Can we distinguish between wellness and medical indications of PBM?

The boundary between indications for using PBM for wellness purposes and those for medical purposes is quite blurred. According to the World Health Organization definition of health, “health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.” This definition clearly highlights the complexity of the concept of health and, at the same time, the complexity of the concept of wellness. Wellness is a very broad concept that encompasses several dimensions, such as physical, social, occupational, emotional, intellectual, environmental, and spiritual aspects. In this respect, the term “wellness” does not strictly overlap with the term “health,” which is intuitively understood in a more limited way.

The indications for PBM in the context of wellness may contribute to emotional or social well-being through, for example, an appearance that is more in line with how a person wishes to present themselves (skin rejuvenation, hair regrowth, etc.). In aesthetic medicine, PBM helps reduce atrophic acne scars, acne, and wrinkles.^5–7 PBM is also commonly used in sports medicine, both to optimize preparation and to promote recovery in athletes, whether amateur or professional. ³ All these preoccupations deserve to be respected and can contribute to the person’s well-being in one way or another. ⁵ However, they do not necessarily constitute a medical indication. Indeed, a medical indication would rather stem from the major consequences of an unmet need (e.g., a deterioration of mental health to the point of developing a psychiatric disorder) or from the origin of that need (when it is linked to a pathology). In wellness indications, PBM is used as a first-line option or as a complementary approach alongside other well-being treatments, such as cosmetic or aesthetic care. Conversely, when used in the context of a medical indication, PBM constitutes a therapeutic modality in its own right, integrated into a broader pathway of medical care. ⁸ In dermatology, for example, this could involve reducing lesions secondary to radiodermatitis or keloid scars. ⁹ A parallel can be drawn with sports practice. Physical activity is an integral part of well-being and contributes to maintaining good health. In its regular, everyday practice, it belongs to the domain of wellness. However, following certain diseases (diabetes, cardiovascular disease, cancer, etc.), it becomes part of a dedicated care plan and, as such, may be medically supervised—for example, through adapted physical activity programs. In some ′ systems, such as the French system, adapted physical activity may be reimbursed, which encourages patient adherence. The same question could be raised for PBM depending on the main objective pursued.

Ensuring accessibility according to the indication: An economic challenge

There is a real economic cost associated with high-quality PBM practice. High-quality PBM devices are expensive, with prices varying depending on the type of device, its versatility, and whether consumables are required. Device maintenance must also be taken into account. To ensure proper technical performance (the wavelengths delivered and their degree of purity, irradiance, safety of use, etc.), maintenance must be carried out by trained professionals. These precautions also apply to home PBM devices. At present, reimbursement for PBM sessions is limited and, in countries where it exists, generally restricted to health care institutions and in strictly defined medical indications. As a result, the cost is mostly borne by the user. In the context of wellness indications, it is reasonable to expect the user to bear this cost, and this is reflected in the price of sessions at a PBM center or with a professional or in the price of a device purchased for home use. However, in the case of a medical indication, the situation is more complex. It depends first and foremost on the health care system, and therefore on the country, but also on whether or not the choice has been made to reimburse PBM treatments in the health care system. In general, the decision by a health care system to fully or partially reimburse a treatment is based on its demonstrated performance (medical benefit) in treating or improving a health condition that is considered a priority and/or costly for society. In this regard, PBM has been favorably evaluated in several cost-effectiveness studies in various domains,^10,11 although the robustness of the data could be further consolidated. ¹² Expanding reimbursement for PBM would improve patient access, as more medical centers would be willing to acquire equipment and provide PBM sessions. However, this would require clear regulation of the reimbursed indications. Indeed, from the perspective of containing collective health care costs, it would be necessary to make a clear distinction between wellness and medical indications to ensure the financial sustainability of reimbursement by public or private payers, as is already the case for other treatment modalities.

Establishing the conditions necessary for effective PBM: An efficiency challenge

The rapid expansion of PBM should not make us lose sight of the conditions required for its effectiveness and the essential safety standards that must be applied in practice.

The globalization of markets now provides almost unlimited access to devices manufactured around the world. Compliance of equipment is normally governed by national or international standards. However, the current global market makes it easy to sell noncompliant equipment. It is therefore the responsibility of manufacturers, but also of each private purchaser and each health care provider, to ensure that devices comply with applicable standards to guarantee safe use. It is important that every purchaser be informed about the risks associated with device wear and tear, particularly concerning LEDs, the wavelengths emitted, and the power levels delivered. For example, failure to respect emitted wavelengths close to 500 nm could expose users to ultraviolet radiation and increase their risk of skin cancer in case of excessive exposure. Regular spectrometric and dosimetric monitoring is also essential to good PBM practices.

The issue of appropriate indications for PBM use is also crucial. The current expansion of indications tends to portray PBM as the next “miracle treatment,” ² particularly since some of its indications concern common diseases and conditions ¹³ for which no satisfactory solutions currently exist, such as certain neurodegenerative disorders.^14–16 Its lack of major adverse effects (as far as we currently know) also contributes to this enthusiasm. ¹⁷ However, a well-defined indication is the cornerstone of successful PBM treatment. With regard to medical indications, it is essential not only to have a specific diagnosis but also to integrate PBM into existing therapeutic guidelines. The prescription of PBM for medical indications should be carried out by health care professionals trained both in the specific condition being treated and in the practice of PBM itself.

Beyond the indication itself, the effectiveness of PBM treatment depends on strict compliance with the technical characteristics specific to this therapeutic modality. Delivery parameters (dose, session frequency, device ergonomics in relation to the treated area, etc.) must be carefully controlled to ensure treatment performance.^18,19 In the case of wellness indications, the user is the primary decision-maker regarding their care and the level of investment it entails (financial cost, time commitment, etc.). However, in medical indications, PBM must meet additional performance requirements, especially if it involves collective investment through partial or full reimbursement. Moreover, medicine operates within a framework of evidence-based practice. Accordingly, each treatment must be regularly evaluated to determine its appropriate place within the available therapeutic arsenal for the benefit of patients. PBM can only be meaningfully assessed in real-life settings if it is delivered for clearly defined indications and under standardized conditions.

Distinguishing between wellness and medical indications of PBM is not merely a matter of semantics. Reflecting on the respective scope of wellness and medical indications is an essential step toward the reasoned integration of PBM into the arsenal of medical therapies and care strategies. This approach aims, on the one hand, to ensure broad accessibility to the technique (according to the effect each individual seeks) and, on the other hand, to strengthen the scientific evidence supporting the efficacy and safety of PBM. Such clarification would help refine its role within individual care pathways across many medical specialties and encourage further investment in PBM by other stakeholders.