0
How Does One Get into Rehab?
• CRI (Canine Rehabilitation
Institute)
• Training started 2009
• Received certification
5/20...
How to Utilize Cold Laser Therapy in
Canine Rehabilitation Therapy
Presented by Deanna Clark
DVM, CCRT at WVTA Meeting
10/...
What is Laser Phototherapy?
• Low Level Laser Therapy
• Low light intensity influences
cell/tissue functions
• Heating is ...
Is Laser Therapy Proven?
• Mostly yes
• More than 130 double-blind
positive studies confirming clinical
effect of LLLT
• A...
What Defines Laser Light?
• Light Amplification by Stimulated Emission of
Radiation
• Monochromic - the color of light/wav...
Coherency is Special
• Waves have the same frequency and phase
• Polarized light—light moves together
• Almost parallel be...
Does it have to be Laser?
• Monochromatic (non coherent light) light
from LED's can give good effect on superficial
tissue...
The Power of Light
• Remember atoms?
• Photon energy excites an atom and electrons
change their energy level
• Electron ju...
How it Works on the Cellular Level
• Visible red light absorbed in mitochondria and
Infra red light absorbed at cellular m...
Physiologic Effects
• Increased ATP by mitochondria and increased oxygen
consumption may result in muscle relaxation
• Inc...
How Deep can Laser Penetrate?
• Long wavelength penetrates deeper than
short
• 808nm recently proven to penetrate 3.5 cm
•...
Power of Penetration
• Still a lot to learn!
• Twice the power isn’t twice as deep (5-10% )
• http://online.liebertpub.com...
What about Absorption?
• Light is weaker further from surface it penetrates
• Tissue type
(bone,fat,muscle), pigment, dirt...
What does this Imply?
• Due primarily to absorption by water in
tissue, 980 nm (class IV) penetrates less than
808 nm, and...
Does LLLT Cause Heating of Tissue?
• Yes - all light causes heating if absorbed
• GaAlAs (3B) lasers in 300-500 mW range c...
The Laser Class
• Classified by wavelength/max output power
into four classes (subclasses)
• Ability to produce damage in ...
Can Lasers Really Damage your eyes?
• Any strong light source can injure eyes
• Powerful laser (many watts) is more
hazard...
Laser Classes
• Class I 0.4 mW
• Class II 0.5-1.0 mW blink
adequate
• Class IIIa 1-5 mW eye caution
• Class IIIb 5-500 mW ...
Class 1 (less than 0.5 mW)
•
•
•
•
•

Visible and non visible
No eye or skin danger
Laser printers, car entry, CD players
...
Class 2 (less than 1 mW)
• Visible
• Safe for short periods on eyes and extended
on skin
• Safe because blink reflex limit...
Class 3 (1mW to 500 mW)
includes 3a and 3b
•
•
•
•
•

Visible and invisible
Helium neon (HeNe)
Galium Arsenide (GaAs)--inf...
Class 4 (>500 mW)
•
•
•
•
•
•

Increases tissue temperature--can burn
Dehydrates tissue
Coagulates protein
Thermolysis
CO2...
Laser Light
•
•
•
•
•
•
•

Visible: Helium Neon (HeNe) 400-700 nm
Invisible: Infrared 750nm-950nm
600-1000 nm is therapeut...
The Calculations
•
•
•
•
•
•
•
•

Energy is power over time
Energy (Joules) = Watt (W) x second
Lasers come in mW and 1000...
More Power is Not Better
• More Power means shorter treatment time
• More Power is more cost!
• More Power is more dangero...
Laser Dosing is Cumulative
• Repeated dose 1-7 day
intervals has stronger
effect then given at once
• Recent research hint...
Can you use too high of a dose?
• With Class IV it would burn
• May have bio-suppressive effect or non
optimal effect
• Th...
Dosage
•
•
•
•
•
•
•
•
•
•

Doses—Respond 904 nM, 500 mW, IIIb
1-3 j/cm(2) circulation
1-6 j/cm(2) acute pain
2-4 j/cm(2) ...
CAREFUL
•
•
•
•

Small patients
Old or very fragile patients
Stimulate too many accupuncture points?
Less than 20 pounds l...
Contraindications
•
•
•
•
•
•
•
•
•
•
•

Dr. Laurie Edge-Hughes says….
Eye (will burn retina)
On cancerous lesions
Pregnan...
Indications
•
•
•
•
•
•
•
•

Arthritis
Tendonitis
Wounds
Edema
Contractures/scar tissue
Increase circulation
Pain
Muscle s...
Actually Using Laser!
• I use a Class 3b (Chattanooga)
• 850nM, 200 mW (5 diodes); 670nM 10mW (4
diodes) LED
• I diagnose ...
What’s the Technician Role
•
•
•
•
•
•

Doses are set by Veterinarian
Pain changes on a day to day basis
Palpation is crit...
Range of Motion
• Find Restrictions
• Joints and Muscles
Start with Neck
• Best if dog checks his own range of motion
• Many limitations in C6-C7
Cookie Spinal Flexes
• Follow treat to shoulders, hip then floor
• Great meet and greet and then ask to lay
down!
Joints

•
•
•
•
•
•

“End Feel”
Empty—pain stops motion
Capsular--firm
Bony--bone-to-bone contact
Abrupt—protective muscle...
Front Limb
• Leg should fold into an accordion
• Teres Major—limits forward extension
• Biceps—commonly inflammed from ove...
Biceps
• Will palpate hard/painful/difficult to
differentiate from the bone!
Thoracolumbar Spine
•
•
•
•

Vertebrae should have movement
Twitch can indicate problem
Palpate paraspinals for inflammati...
Rear Limb
• Treat Stifle Joint in 4 quadrants
• Hip joint in 2 sites over acetabulum
Rear Limb Muscles
• Quadriceps are often over-used
Rear Limb Muscles
• Hamstrings—especially at distal medial
attachment to stifle
Rear Limb Muscles
• Pectineus
• Iliopsoas
Response
• May take a few sessions
• Laser with massage really tends to help!!
• Releases trigger points and really helps ...
Osteoarthritis
• Treat joints affected based on depth
• Treat local muscles that are affected
• Acupuncture points?
Post-operative
• Treat operated joint
• Base dose on depth of concern
• Caution lateral suture surgery as
may actually pre...
Soft Tissue Injuries
• Strains and Sprains
• Need other modalities/exercises for resolution
Athletes?
• Treat muscle trigger points
• Study that showed it can help muscle recovery
in athletes
• 4-6 week “tune-ups”
...
Roo

• Severe hip and stifle arthritis
• Chronic renal failure
• Had severe hematuria and inappropriate
urination
• Doing ...
Zoe
•
•
•
•

Unknown neurologic vs. vestibular disease
Treat compensatory trigger points
Treat presumptive hip arthritis
M...
•
•
•
•
•

Spike
Weakness in rear end
Shoulder arthritis mild
Mild hip arthritis
Treat spinal muscle spasms
Targeted exerc...
Sadie Mae
• My own girl and reason for rehab—tolerated
nothing else!
How long does it take?
• Intense osteoarthritis patient may take
upwards of 30-40 minutes for laser alone
• Combine with o...
References
• http://www.laser.nu/lllt/pdf/Confounders.pdf
• http://www.laser.nu/lllt/pdf/Penetration.pdf
• Laurie McCauley...
Questions?
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WVTA Oct/2013 How to utilize cold laser in rehabilitation therapy

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  • About yourself… How I got into rehab
  • This session will teach you what laser is, the pros and cons of Class 3B vs. Class 4 laser and how they work. We will then focus on how to utilize laser for various patients/conditions including how to palpate trigger points and deciding what areas to treat.
  • Cold laser therapy or low level laser therapy (LLLT) is a relatively new modality that is increasingly utilized for pain relief in our animal patients. Laser therapy has been well studied since the early 90’s. There are more than 130 double-blind positive studies confirming clinical effect of LLLT and about 250 papers are annually published in peer reviewed scientific papers. (www.pubmed.com; www.laser.nu.) It was FDA approved as an adjunct for pain relief between 2002 and 2004. It is becoming increasingly popular in veterinary medicine, but there are many things to know to be able to utilize this powerful modality safely and effectively
  • Cold laser therapy or low level laser therapy (LLLT) is a relatively new modality that is increasingly utilized for pain relief in our animal patients. Laser therapy has been well studied since the early 90’s. There are more than 130 double-blind positive studies confirming clinical effect of LLLT and about 250 papers are annually published in peer reviewed scientific papers. (www.pubmed.com; www.laser.nu.) It was FDA approved as an adjunct for pain relief between 2002 and 2004. It is becoming increasingly popular in veterinary medicine, but there are many things to know to be able to utilize this powerful modality safely and effectively
  • The definition of laser is Light Amplification by Stimulated Emission of Radiation. Laser light is monochromic (single color of light/wavelength) and coherent (laser light sticks together so therefore amplifies.) Coherency is part of what makes laser light so special. This means the light moves together in the same wave length and frequency without spreading. This is different from LED’s which have monochromatic light (one color) but are not coherent. Thus the light spreads apart and loses power. There actually have been some studies that support the use of LED’s for superficial wounds, but laser is proven to penetrate deeper tissue.
  • Coherency is part of what makes laser light so special. This means the light moves together in the same wave length and frequency without spreading. This is different from LED’s which have monochromatic light (one color) but are not coherent. Thus the light spreads apart and loses power. There actually have been some studies that support the use of LED’s for superficial wounds, but laser is proven to penetrate deeper tissue.
  • This is different from LED’s which have monochromatic light (one color) but are not coherent. Thus the light spreads apart and loses power. There actually have been some studies that support the use of LED’s for superficial wounds, but laser is proven to penetrate deeper tissue.
  • LLLT utilizes light energy to penetrate tissue. LLLT emits no heat, sound, or vibration. Instead of producing a thermal effect, LLLT may act via photochemical reactions in the cells, also referred to as photobiology or bio stimulation. Laboratory studies at the cellular level suggest that irradiation stimulates collagen production, alters DNA synthesis, and improves the function of damaged neurological tissue. Visible red light is absorbed in mitochondria and infra-red light absorbed at cellular membranes. This increases ATP, increases DNA production, opens Ca channels, increases cellular proliferation, increases release of growth factor, increases myofibroblast activity (helps with healing) and alters pain threshold. Several mechanisms underlying therapeutic effects in the body with LLLT have been suggested. Theories include: increased ATP production by the mitochondria and increased oxygen consumption on the cellular level may result in muscle relaxation; increased serotonin and increased endorphins; increased anti-inflammatory effects through reduced prostaglandin synthesis; improved blood circulation to the skin in cases like neuralgia and diabetes mellitus; decreased permeability of the membrane of nerve cells for Na/K causing hyperpolarization; increased lymphatic flow and decreased edema.
  • irradiation stimulates collagen production, alters DNA synthesis, and improves the function of damaged neurological tissue. Growth factor cell signaling causes cell differentiation and maturation (vessels, bone, etc)
  • decreased permeability of the membrane of nerve cells for Na/K causing hyperpolarization--It inhibits action potentials by increasing the stimulus required to move the membrane potential to the action potential threshold.--; increased lymphatic flow and decreased edema.
  • Laser light is proven to penetrate into tissue, but there are many factors at play. Long wavelengths penetrate deeper than short. It is possible that 808-904 nm is ideal. “Penetration depth, its accurate definition, its measurement, and even its importance in phototherapy, are hotly debated topics” http://www.spectramedics.com/index.php?id=105. There is still a lot to be discovered and proven when it comes to specifics. One study shows 904nm with super pulsing is best, but this isn’t just because of the wavelength. Super-pulsing can actually cause an effect known as “bleaching” which clears the tissue and allows better penetration. The photobleaching phenomenon is where the first strong pulse bleaches the opaque barrier of tissue, letting the second pulse pass through the tissue barrier with less loss of energy (Kusnetzow et al. 2001). It is notable that twice the power doesn’t result in twice as deep of penetration it only increases it by 5-10%. Primarily due to absorption by water in the tissue, 980 nm (class IV) penetrates less than 808 nm, and this is not compensated by the higher power.
  • 808nm penetrates 54% deeper than 980. One study shows 904nm with super pulsing is best, but this isn’t just because of the wavelength. Super-pulsing can actually cause an effect known as “bleaching” which clears the tissue and allows better penetration. The photobleaching phenomenon is where the first strong pulse bleaches the opaque barrier of tissue, letting the second pulse pass through the tissue barrier with less loss of energy (Kusnetzow et al. 2001). It is notable that twice the power doesn’t result in twice as deep of penetration it only increases it by 5-10%. Primarily due to absorption by water in the tissue, 980 nm (class IV) penetrates less than 808 nm, and this is not compensated by the higher power.
  • Many things influence penetration. Penetration is due to wavelength, super pulsing, power, intensity, tissue contact and compression. We know that light is weaker the further from the surface it penetrates. Tissue type (bone, fat, and muscle), pigment, dirt, hair and clothing can decrease penetration. Clothes reduce penetration between 80 and 100% http://www.youtube.com/watch?v=MkGJvvWD1vw. So what does that mean for hair? If you aren’t directly on the skin, you aren’t getting the same absorption.
  • Holding space between the laser and skin to avoid heating will further decrease penetration. Blood also will absorb energy. Proper technique means pushing lightly with the applicator to push blood away and get through the hair; however this isn’t possible with class IV lasers.
  • If lasers don’t emit thermal effects then how do they cause heat? All light causes heating if absorbed, so it revolves around the absorption. GaAlAs (3B) lasers in 300-500 mW range cause noticeable heat sensation, particularly hairy areas or tattoos. This increased circulation causes increases of 0.5-1 °C local temperature to tissue. Melanin is an important factor thus dark skin feels hotter than fair skin. This greatly impacts certain patients. My most affected patients are generally dark pigmented short-hair dogs such as brown dachshunds or GSP and some, but not all black labs. The level of dander also seems to make some dogs more reactive. You can achieve the same dose by moving the laser frequently and coming back to the same location to achieve a cumulative effect (how Class IV lasers are used.)
  • Lasers are classified by wavelength/max output power into four classes and subclasses based on their ability to produce damage in exposed people. Class 1 is no hazard during normal use and class 4 is severe hazard for eyes and skin. This classification has nothing to do with effectiveness. Class I is 0.4 mW (visible and non-visible), has no eye or skin danger, includes laser printers, car entry, CD players, has no heating/no healing and is safe in all uses unless focused through magnifier. Class II is 0.5-1.0 mW (visible), safe for short periods on eyes and extended on skin, safe because blink reflex limits retina exposure but has no healing/no heating. Class IIIa 1-5 mW has eye caution. Class IIIb 5-500 mW has eye danger (visible and invisible); maximal permissible exposure can be exceeded with limited affects (skin) and protective eye ware if direct viewing of beam is required. Class IV >500 mW has fire hazard and danger as increases in tissue temperature can burn, it can dehydrate tissue, coagulates protein, cause thermolysis and eye danger can result from indirect or reflected beam (MUST WEAR SAFETY GLASSES!!!!)
  • Obvious that a powerful laser is more hazardous to stare into than a weak laserEnergy is power multiplied by time, so exposure time is important.
  • MPE is maximal permissible exposure
  • yttrium aluminum garnet
  • Laser light is classified into visible and non-visible based on the wavelength. Visible: Helium Neon (HeNe) 400-700 nm. Invisible: Infrared 750nm-950nm. 600-1000 nm is considered the therapeutic window with < 600 nm bactericidal. 600 nm for skin repair and acupuncture point stimulation and 600-1000 nm for tissue repair. This covers the Class3 and Class 4 lasers.
  • Like other modalities lasers are utilized using a certain dosage applied. Because we are discussing a different type of energy than what we normally use, this can be quite confusing. Figuring out the dosing is what helps ensure we are comparing apples to apples when evaluating different classes of lasers. Energy is power over time which is Energy (Joules) = Watt (W) x second. Lasers come in mW and 1000 mW= 1 watt. Therefore 1 joule from 5 mW lasers requires 200 seconds of time (3.3 minutes.) Comparatively a 50 mW laser requires 20 seconds and a 500 mW laser requires 2 seconds. Remember that Class 3 is 1mW-500 mW and Class 4 is >500 mW. However more power is not necessarily better. More power is more dangerous and in the current market, significantly more expensive.
  • In my mind the Class 3B pros are as follows; though you still have to be careful, it isn’t as much of a risk to your retina; you can treat trigger points more effectively as the laser head can often remain in one spot and directly applied to the trigger point with pressure; you can use it to treat acupuncture points; there is no risk of thermal burn and the cost is significantly less than a Class 4. The biggest advantage of a Class 4 is it takes less treatment time when treating significant areas, but you can’t pin-point the area as well since the laser has to be constantly moving to avoid thermal burns. It can be an advantage since you can’t target trigger points to treat an “area” and still achieve positive results.
  • Laser dose is important and can be cumulative. Repeating a dose at 1-7 day intervals has stronger effects then given at once. Recent research hints low power and long exposure is better than high power and short time for tissue regeneration. It is also important to note that treatment times in excess of 15-20 minutes may produce systemic effects. I have had some very debilitated and tiny patients get sick from too much laser. For that reason, in cats and dogs that are very fragile or weigh less than 10 pounds I try to keep each dose point to no more than 8.2J/cm and only complete 10-12 sites of treatment. Remember each patient is different, so I will dial up and down from this. My doses come from a standard 3B laser—Chattanooga 850nM, 200 mW. Doses from Dr. Laurie Edge-Hughes are as follows: Doses—Respond 904 nM, 500 mW, IIIb; 1-3 j/cm(2) circulation; 1-6 j/cm(2) acute pain; 2-4 j/cm(2) muscle pain; 4-6 j/cm(2) neurological indications; 4-8 j/cm(2) joint pain; 5-6 j/cm(2) wounds; 8-12 j/cm(2) chronic pain and OA; Acupuncture points @ 60 mW = 33 sec = 2J. It is important to note that not all patients respond the same, solisten to feedback from the ownerwhendeciding to bump up or down the laser dosing. With Class 4 lasers too high of a dose maycreate a delayedburn. High LLLT doses may also have bio-suppressive effect or non-optimal effect, the healing of a wound may take longer and some evidence suggests that 16j/cm(2) is inhibitory to healing.
  • Laser dose is important and can be cumulative. Repeating a dose at 1-7 day intervals has stronger effects then given at once. Recent research hints low power and long exposure is better than high power and short time for tissue regeneration. It is also important to note that treatment times in excess of 15-20 minutes may produce systemic effects. I have had some very debilitated and tiny patients get sick from too much laser. For that reason, in cats and dogs that are very fragile or weigh less than 10 pounds I try to keep each dose point to no more than 8.2J/cm and only complete 10-12 sites of treatment. Remember each patient is different, so I will dial up and down from this. My doses come from a standard 3B laser—Chattanooga 850nM, 200 mW. Doses from Dr. Laurie Edge-Hughes are as follows: Doses—Respond 904 nM, 500 mW, IIIb; 1-3 j/cm(2) circulation; 1-6 j/cm(2) acute pain; 2-4 j/cm(2) muscle pain; 4-6 j/cm(2) neurological indications; 4-8 j/cm(2) joint pain; 5-6 j/cm(2) wounds; 8-12 j/cm(2) chronic pain and OA; Acupuncture points @ 60 mW = 33 sec = 2J. It is important to note that not all patients respond the same, solisten to feedback from the ownerwhendeciding to bump up or down the laser dosing. With Class 4 lasers too high of a dose maycreate a delayedburn. High LLLT doses may also have bio-suppressive effect or non-optimal effect, the healing of a wound may take longer and some evidence suggests that 16j/cm(2) is inhibitory to healing.
  • I have had some very debilitated and tiny patients get sick from too much laser. For that reason, in cats and dogs that are very fragile or weigh less than 10 pounds I try to keep each dose point to no more than 8.2J/cm and only complete 10-12 sites of treatment. Remember each patient is different, so I will dial up and down from this.
  • There are some contra-indications to lasers. First they can definitely injure your eyes. Any strong light source can injure eyes, however a powerful laser (many watts) is more hazardous. Because the light is parallel when it enters the eye the lens will further focuses the light to a concentrated spot creating a retinal burn. However, to burn the retina, certain energy or time is needed. Because with visible wavelength range we blink, the invisible light is what causes trouble. Other contra-indications are (Dr. Laurie Edge-Hughes) on cancerous lesions, pregnant abdomen (no testing), open fontanels, over vagus nerve, over sympathetic ganglia, cardiac region of heart patients, areas of hemorrhage, over thyroid/endocrine glands, areas treated with recent cortisone injection (wait 1 week as may flare site) and stem cell therapy—wait 6-8 weeks. One major website on lasers states there are no medical contra-indications (www.lasernu.com.)
  • There are many indications to laser! As stated prior the biological effects include healing skin ulcers, accelerate collagen synthesis, accelerate inflammation phase of wound healing, enhance immune cells to combat invading pathogens, increase vascularity of healing tissue, pain reduction from endorphin release, fibroblast production and cartilage stimulation. The actual indications therefore are arthritis, tendonitis, wounds, edema, contractures/scar tissue, increase circulation, pain, and muscle spasms.
  • How do we implement all of this information on the actual patient? First the patient needs a good physical exam focused on the musculoskeletal system. I had to really seek training to learn about soft tissue, the injuries it can develop and the treatment! As a technician you too can seek this training. Canine Rehabilitation Institute is the school I attended. It is imperative to be well aware of the muscles in question and to know your anatomy well. The veterinarian should be able to diagnose and set up a treatment plan, but anyone that has injuries knows that although the original problem may stay the same, the aches and pains will differ on any given day. Palpation is therefore vital to the success of therapy as our patients can’t point to the spot that hurts!
  • Start with range of motion. Range of motion is an easy and effective way to detect restrictions. Knowing normal range of motion is vital. When examining a patient I determine where the restriction is and then immediately treat that point with laser. I also palpate each individual muscle and treat muscles that are ropey, hard, calcified or painful.
  • This same exam can be applied to patients with less tolerance and one of the glories of laser is that often patients that are very hands-off will tolerate this treatment above other modalities. In general I have found laser to be a remarkable tool for many patients and it has extended the quality of life in many patients that are maxed out with medications as well as other modalities! Used properly with massage and stretching you can really target these trigger points and give your patients a tremendous amount of relief! In general, most patients that respond will be incredibly improved the next day after their treatment. I have had a few pesky tendonitis cases that take 3-4 sessions and my own personal dog was significantly improved immediately after treatment! Laser is a modality just like any other, however, so on occasion dogs don’t seem to respond. In those cases I feel like we aren’t targeting the problem appropriately or these patients may need adjunctive medications/treatments if their pain is too severe. Unfortunately true degenerative myelopathy doesn’t respond to laser therapy, but the only treatment that effectively delays and slows progression is aggressive rehabilitation therapy and often these dogs have multiple problems or other conditions that will respond to laser.
  • Transcript of "WVTA Oct/2013 How to utilize cold laser in rehabilitation therapy "

    1. 1. How Does One Get into Rehab? • CRI (Canine Rehabilitation Institute) • Training started 2009 • Received certification 5/2011 • House Call Service—On the Go Animal Rehabilitation Service (onthegoanimalrehab.com) • True Veterinary Clinic, Lake Mills Veterinary Clinic, West Towne Veterinary Center, Odyssey Veterinary Care
    2. 2. How to Utilize Cold Laser Therapy in Canine Rehabilitation Therapy Presented by Deanna Clark DVM, CCRT at WVTA Meeting 10/12/2013 This session will teach you what laser is, the pros and cons of Class 3B vs. Class 4 laser and how they work. We will then focus on how to utilize laser for various patients/conditions including how to palpate trigger points and deciding what areas to treat.
    3. 3. What is Laser Phototherapy? • Low Level Laser Therapy • Low light intensity influences cell/tissue functions • Heating is negligible (Cold Laser) • Effects due to photochemical or photobiologic reactions like effect of light in plants
    4. 4. Is Laser Therapy Proven? • Mostly yes • More than 130 double-blind positive studies confirming clinical effect of LLLT • About 250 papers annually published in peer reviewed scientific papers • www.pubmed.com • www.laser.nu • FDA approved 2002
    5. 5. What Defines Laser Light? • Light Amplification by Stimulated Emission of Radiation • Monochromic - the color of light/wavelength • Coherent—laser light sticks together/amplifies
    6. 6. Coherency is Special • Waves have the same frequency and phase • Polarized light—light moves together • Almost parallel beam—Moves together without spread (collimating)
    7. 7. Does it have to be Laser? • Monochromatic (non coherent light) light from LED's can give good effect on superficial tissues such as wounds • In comparative studies lasers have shown to be more effective especially in deep tissue
    8. 8. The Power of Light • Remember atoms? • Photon energy excites an atom and electrons change their energy level • Electron jumps from inner to outer orbit then back—gives off energy! • Energy level given off determines what kind of radiation (unstable atoms are radio-active)
    9. 9. How it Works on the Cellular Level • Visible red light absorbed in mitochondria and Infra red light absorbed at cellular membranes • This: • Increases ATP • Increases DNA production • Opens Ca channels-many functions • Increases cellular proliferation • Increase in release of growth factor (vessels/bone) • Increased myofibroblast activity • Alters pain threshold
    10. 10. Physiologic Effects • Increased ATP by mitochondria and increased oxygen consumption may result in muscle relaxation • Increased serotonin and Increased endorphins • Increased anti-inflammatory effects through reduced prostaglandin synthesis • Improved blood circulation to skin-cases with neuralgia and diabetes mellitus • Decreases permeability of membranes of nerve cells causing hyperpolarization (inhibits action potential) • Increased lymphatic flow and decreased edema
    11. 11. How Deep can Laser Penetrate? • Long wavelength penetrates deeper than short • 808nm recently proven to penetrate 3.5 cm • “Penetration depth, its accurate definition, its measurement, and even its importance in phototherapy, are hotly debated topics” http://www.spectramedics.com/index.php?id=105
    12. 12. Power of Penetration • Still a lot to learn! • Twice the power isn’t twice as deep (5-10% ) • http://online.liebertpub.com/doi/pdfplus/10. 1089/pho.2012.3284 • Wavelength, super pulsing, power, intensity, tissue contact and compression
    13. 13. What about Absorption? • Light is weaker further from surface it penetrates • Tissue type (bone,fat,muscle), pigment, dirt, hair, clothes decrease penetration • Clothes reduce penetration between 80 and 100% http://www.youtube.com/watch?v=MkGJvvWD1vw&feature=player_detailpage • Blood absorbs energy-pushing lightly pushes blood away
    14. 14. What does this Imply? • Due primarily to absorption by water in tissue, 980 nm (class IV) penetrates less than 808 nm, and this is not compensated by the higher power • Holding space between laser and skin to avoid heating will further decrease penetration
    15. 15. Does LLLT Cause Heating of Tissue? • Yes - all light causes heating if absorbed • GaAlAs (3B) lasers in 300-500 mW range cause noticeable heat sensation, particularly hairy areas, tattoo • Melanin important factor; dark skin > fair skin • Increased circulation causes increase 0.5-1 °C local • Dachshunds, GSP’s, Black Labs • Anesthetized patients
    16. 16. The Laser Class • Classified by wavelength/max output power into four classes (subclasses) • Ability to produce damage in exposed people • Class 1 (no hazard during normal use) to class 4 (severe hazard for eyes and skin) • Classification is not effectiveness
    17. 17. Can Lasers Really Damage your eyes? • Any strong light source can injure eyes • Powerful laser (many watts) is more hazardous • Parallel light enters--further focused to concentrated spot • To burn the retina, certain energy or time is needed • With visible wavelength range, we blink • Lasers in general are much less dangerous than people think--But I wouldn’t want to experiment!
    18. 18. Laser Classes • Class I 0.4 mW • Class II 0.5-1.0 mW blink adequate • Class IIIa 1-5 mW eye caution • Class IIIb 5-500 mW eye danger • Class IV >500 mW fire hazard, Danger
    19. 19. Class 1 (less than 0.5 mW) • • • • • Visible and non visible No eye or skin danger Laser printers, car entry, CD players No heating/no healing Safe in all uses unless focused through magnifier
    20. 20. Class 2 (less than 1 mW) • Visible • Safe for short periods on eyes and extended on skin • Safe because blink reflex limits retina exposure • No healing/no heating
    21. 21. Class 3 (1mW to 500 mW) includes 3a and 3b • • • • • Visible and invisible Helium neon (HeNe) Galium Arsenide (GaAs)--infrared GaAluminumAs (GaAlAs)—infrared Max Permissable Exposure can be exceeded with limited effects (skin) • Protective eye ware if direct viewing of beam
    22. 22. Class 4 (>500 mW) • • • • • • Increases tissue temperature--can burn Dehydrates tissue Coagulates protein Thermolysis CO2, Argon, YAG laser Eye danger can result from indirect or reflected beam
    23. 23. Laser Light • • • • • • • Visible: Helium Neon (HeNe) 400-700 nm Invisible: Infrared 750nm-950nm 600-1000 nm is therapeutic window < 600 nm Bactericidal 600 nm Skin repair and acupoint stim 600-1000 nm tissue repair Class 3 and 4 lasers
    24. 24. The Calculations • • • • • • • • Energy is power over time Energy (Joules) = Watt (W) x second Lasers come in mW and 1000 mW= 1 watt 1 joule from 5 mW laser requires 200 seconds of time (3.3 minutes) 50 mW laser requires 20 seconds 500 mW laser requires 2 seconds Class 3 is 1mW-500mW Class 4 is >500mW
    25. 25. More Power is Not Better • More Power means shorter treatment time • More Power is more cost! • More Power is more dangerous!
    26. 26. Laser Dosing is Cumulative • Repeated dose 1-7 day intervals has stronger effect then given at once • Recent research hints low power and long exposure -better than high power/short time for tissue regeneration • Treatment times in excess of 15-20 minutes may produce systemic effects
    27. 27. Can you use too high of a dose? • With Class IV it would burn • May have bio-suppressive effect or non optimal effect • The healing of a wound may take longer • Found evidence that 16j/cm(2) is inhibitory
    28. 28. Dosage • • • • • • • • • • Doses—Respond 904 nM, 500 mW, IIIb 1-3 j/cm(2) circulation 1-6 j/cm(2) acute pain 2-4 j/cm(2) muscle pain 4-6 j/cm(2) neurological indications 4-8 j/cm(2) joint pain 5-6 j/cm(2) wounds 8-12 j/cm(2) chronic pain and OA Acu-points @ 60 mW = 33 sec = 2J Laurie Edge-Hughes
    29. 29. CAREFUL • • • • Small patients Old or very fragile patients Stimulate too many accupuncture points? Less than 20 pounds limit to less than 8.2J/cm and 10 points?
    30. 30. Contraindications • • • • • • • • • • • Dr. Laurie Edge-Hughes says…. Eye (will burn retina) On cancerous lesions Pregnant abdomen (no testing) Unclosed fontanels Over Vagus nerve Over sympathetic ganglia Cardiac region of heart patients Areas of hemorrhage Over thyroid/endocrine glands Areas treated with recent cortisone injection (wait 1 week as may flare site) • Stem cell therapy—wait 6-8 weeks
    31. 31. Indications • • • • • • • • Arthritis Tendonitis Wounds Edema Contractures/scar tissue Increase circulation Pain Muscle spasms
    32. 32. Actually Using Laser! • I use a Class 3b (Chattanooga) • 850nM, 200 mW (5 diodes); 670nM 10mW (4 diodes) LED • I diagnose my patients and set up treatment plan
    33. 33. What’s the Technician Role • • • • • • Doses are set by Veterinarian Pain changes on a day to day basis Palpation is critical Treat painful areas CRI CCRA
    34. 34. Range of Motion • Find Restrictions • Joints and Muscles
    35. 35. Start with Neck • Best if dog checks his own range of motion • Many limitations in C6-C7
    36. 36. Cookie Spinal Flexes • Follow treat to shoulders, hip then floor • Great meet and greet and then ask to lay down!
    37. 37. Joints • • • • • • “End Feel” Empty—pain stops motion Capsular--firm Bony--bone-to-bone contact Abrupt—protective muscle spasm Springy block—soft tissue approximation
    38. 38. Front Limb • Leg should fold into an accordion • Teres Major—limits forward extension • Biceps—commonly inflammed from overuse or elbow joint problems
    39. 39. Biceps • Will palpate hard/painful/difficult to differentiate from the bone!
    40. 40. Thoracolumbar Spine • • • • Vertebrae should have movement Twitch can indicate problem Palpate paraspinals for inflammation/pain VERY GENTLE—not spinal manipulation!!
    41. 41. Rear Limb • Treat Stifle Joint in 4 quadrants • Hip joint in 2 sites over acetabulum
    42. 42. Rear Limb Muscles • Quadriceps are often over-used
    43. 43. Rear Limb Muscles • Hamstrings—especially at distal medial attachment to stifle
    44. 44. Rear Limb Muscles • Pectineus • Iliopsoas
    45. 45. Response • May take a few sessions • Laser with massage really tends to help!! • Releases trigger points and really helps with pain • Doesn’t work for everything—listen to your patients • Most feel great the next day—more relaxed, more active, better movement • If worse, usually that night or next day
    46. 46. Osteoarthritis • Treat joints affected based on depth • Treat local muscles that are affected • Acupuncture points?
    47. 47. Post-operative • Treat operated joint • Base dose on depth of concern • Caution lateral suture surgery as may actually prevent fibrous tissue needed! • Treat compensatory concerns • Proven to help bone healing!
    48. 48. Soft Tissue Injuries • Strains and Sprains • Need other modalities/exercises for resolution
    49. 49. Athletes? • Treat muscle trigger points • Study that showed it can help muscle recovery in athletes • 4-6 week “tune-ups” • VOSM
    50. 50. Roo • Severe hip and stifle arthritis • Chronic renal failure • Had severe hematuria and inappropriate urination • Doing great with once weekly laser!!
    51. 51. Zoe • • • • Unknown neurologic vs. vestibular disease Treat compensatory trigger points Treat presumptive hip arthritis MUCH improved quality of life
    52. 52. • • • • • Spike Weakness in rear end Shoulder arthritis mild Mild hip arthritis Treat spinal muscle spasms Targeted exercise
    53. 53. Sadie Mae • My own girl and reason for rehab—tolerated nothing else!
    54. 54. How long does it take? • Intense osteoarthritis patient may take upwards of 30-40 minutes for laser alone • Combine with other exercises? • Combine with other modalities/medications
    55. 55. References • http://www.laser.nu/lllt/pdf/Confounders.pdf • http://www.laser.nu/lllt/pdf/Penetration.pdf • Laurie McCauley, DVM TOPS Veterinary rehabilitation • www.laser.nu • Dr. Laurie Edge-Hughes • CRI—likes Spectra-Vet laser • Swedish Laser-Medical Society
    56. 56. Questions?
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