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Laser therapy presentation dr. clark
1. Cold Laser Therapy And Applications
in Canine Rehabilitation Therapy
Presented by Deanna Clark
DVM, CCRT of 4 Paws Swim and
Fitness
10/26/2011
2. What is Laser Phototherapy?
• Low Level Laser Therapy
• Low light intensity influences
cell/tissue functions
• Heating is negligible
• Effects due to photochemical
or photobiologic reactions like
effect of light in plants
3. 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!
4. Physiological Effects
• Visible red light absorbed in mitochondria
• Infra red light absorbed at cellular membranes
• Increases ATP
• DNA production
• Opens Ca channels
• Increases cellular proliferation
• Increase in release of growth factor
• Increased myofibroblast activity
• Alters pain threshold
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. Coherency is Special
• Waves have the same frequency and phase
• Polarized light—light moves together
• Almost parallel beam—Moves together
without spread (collimating)
8. 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
9. How Deep can Laser Penetrate?
• Long wavelength penetrates deeper than
short
• 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
10. Power of Penetration
• Still a lot to learn!
• One study shows 904nm with super pulsing is
best
• Twice the power isn’t twice as deep (5-10% )
• Wavelength, super pulsing, power, intensity,
tissue contact and compression
11. 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
• Blood absorbs energy-pushing lightly pushes
blood away
12. 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
13. 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
14. 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
15. 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
16. 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
17. 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
18. Class 3 (1mW to 500 mW)
includes 3a and 3b
• Visible and invisible
• Helium neon (HeNe)
• Galium Arsenide (GaAs)--infrared
• GaAluminumAs (GaAlAs)—infrared
• MPE can be exceeded with limited
effects (skin)
• Protective eye ware if direct viewing of
beam
19. 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
20. 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
21. More Power is Not Better
• More Power means shorter treatment time
• More Power is more cost!
• More Power is more dangerous!
22. It Comes Down to Dose
• Class 3 and 4 can deliver same dose
• http://www.laser.nu/lllt/pdf/theimpossibledose.pdf
25. 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
26. 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
27. Can Laser Light Cause Cancer?
• No mutational effects with wavelengths in red or
infra-red range
• No mutational effects with doses used within LLLT
• Cancer cells in vitro have shown stimulation
• Rat studies shown small tumors can recede or
completely disappear
• Rat studies shown no effect on tumors over a
certain size
• Probably local immune system is stimulated more
than the tumor
28. What about Bacteria
• The situation is the same for bacteria and
virus in culture--stimulated by laser light in
certain doses
• Bacterial or viral infection is cured much
quicker after treatment with LLLT
• Study on MRSA-one positive and other refuted
http://www.stanford.edu/~kendric/PDF/B57.pdf
29. 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!
• Japanese researcher treated calves with KCS with
excellent results (HeNe)
30. 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
31. And the Flip Side
• Many studies prove it doesn’t work
• Closer look reveals serious study flaws
• Don’t clearly indicate dose or are
under-dosed
• LLLT will not work on everything
• Matter of dosage, diagnosis, treatment
technique, individual reaction for any
modality
32. Biological Effects
• Heals leg ulcers
• Accelerates collagen synthesis
• Accelerates inflammation phase of wound
healing
• Enhances immune cells to combat invading
pathogens
• Increases vascularity of healing tissue
• Pain reduction from endorphin release
• Fibroblast production
• Cartilage stimulation
34. Contraindications
• Dr. Laurie Edge-Hughes says….
• Eye
• 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
35. Contraindications?
• www.lasernu.com says….
• None medical
• In most countries-legal, i.e. you should not treat
cancer or some other serious diseases
• Pregnancy is not-if treatment done with common
sense
• Pacemakers are electronic -not influenced by light
• Most valid contraindication is possible lack of
adequate medical treatment
36. Actually Using Laser!
• We use a Class 3b (Chattanooga)
• I diagnose my patients and set up treatment
plan
• My technicians or myself carry out plan
37. What Dose Do We Use?
• Changed dose for each indication- depth etc.
• Generally 8 J/cm(2) routine
• 10 J/cm(2) for spine
• Long treatment duration
• Recently changed to 5 J/cm(2)
• Changing back?
38. 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
41. Maddie
• Bilateral cruciate tears—no surgery—recent
concern for meniscus, bilateral severe hip DJD
• Does great with just recent once monthly visit!
42. Muscle injuries
• Laser really seems to heal muscle strains
• Great success with iliopsoas in 4-6 weeks
• Combined with other physical therapy
modalities of course!
• Treat compensatory concerns
44. Myofascial pain/trigger points
• Complete “trigger point massage”
• Laser affected areas
• Complete gentle range of motion and
stretching at same time
• Acupuncture points?
45. Sadie Mae
• My own girl and reason for rehab—tolerated
nothing else!
46. Tendonitis
• Laser can be used similar to ultrasound
• Supraspinatus/Biceps
• Diagnose specific area of discomfort-anatomy
• True P.T. Exam crucial to diagnosis
48. Performance Athletes
• Laser over trigger points and sore muscles
• Stretch and assess at same time
• Baltimore VOSM
49. Helmet
• Does one time laser session work?
• Study suggests endurance training
program combined with LLLT lead
to greater reduction in fatigue
http://www.ncbi.nlm.nih.gov/pubmed/21870127
50. How long does it take?
• Intense osteoarthritis patient may take
upwards of 30-40 minutes for laser alone
• Combine with other exercises?
• Combine with underwater Treadmill?
51. How to charge?
• Some charge per time
• Some charge per modality
• At 4 Paws we designate Level which is
basically time and includes more modalities
Introduction and certification….. My name is Dr. Deanna Clark I graduated from UW vet school in 2004 as a large animal practitioner. My journey evolved to a mixed animal and now small animal only practitioner. I became interested in Canine Rehab about 2 ½ years ago due to my own interest in Canine sports medicine. I then began the journey through CRI to become certified in March. I have been working at 4 Paws with somewhat limited hours for the last 1 ½ years
Cold laser therapy
Lots of debate on what coherence is!! Like an onion—source comes from center and moves out where as other light is similar—but comes from multiple atoms and is like looking through a frosted pain of glass—image becomes distorted
A laser designed for the treatment of humans is rarely suitable for treating animals with fur. There are, in fact, lasers specially made for this purpose. The special design feature here is that the laser diode(s) obtrude from the treatment probe rather like the teeth on a comb. By delving between the animal's hair, the laser diode's glass surface comes in contact with the skin and all the light from the laser is "forced" into the tissue. increasing power only increases the depth of penetration marginally. With the higher superficial absorbance of the 980 nm laser there will be considerable heating, and, while heat is finefor many conditions, it is not of what photomedicine
The most surprising part of this is that the GaAs differs so much from the other. What is so special with that wavelength – 904 nm? It is not the wavelength, it is the extreme pulsing (super pulsing). Today it is possible to find GaAlAs-lasers with the 904 nm wavelength and then the energy loss due to the skin barrier is about 80%. Bjordal states further: “In vivo trials with 904 nm pulse lasers, have demonstrated that these lasers achieve similar effects on collagen production with far lower doses on the animal´s skin than lasers with continuous output (Enwemeka 1991a; van der Veen and Lievens 2000).This effect can be attributed to the photobleaching phenomenon, 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), (Fig. 7).”This has further been studied by Jon Joensen and presented by himself at the WALT meeting, September, 2010in Bergen, Norway. Figure 3 and 4. Surprisingly, the penetration of the super pulsed laser light is markedlyincreasing by the time, while the 810nm laser light transmission remained constant. The very high power peaksof the GaAs laser “bleaches” the collagen and thus gradually creates a more transparent tissue. This gradually increasing transmission supports the theory of bleaching
limit at which intensity is so low no biological effect
Classification has nothing to do with effectiveness
MPE is maximal permissibleexposure
yttrium aluminum garnet
Energy is measurement of power over time
Remember that Class 3 is 1mW-500 mW and Class 4 is >500 mW
Use in our patients?
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.