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

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.

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

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

What Defines Laser Light?

• Light Amplification by Stimulated Emission of Radiation

• Monochromic - the color of light/wavelength• Coherent—laser light sticks together/amplifies

Coherency is Special

• Waves have the same frequency and phase• Polarized light—light moves together• Almost parallel beam—Moves together

without spread (collimating)

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

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)

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

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

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

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

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

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

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

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

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!

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

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

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

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

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

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

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

More Power is Not Better

• More Power means shorter treatment time• More Power is more cost!• More Power is more dangerous!

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

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

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

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?

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

Indications

• Arthritis• Tendonitis• Wounds• Edema• Contractures/scar tissue• Increase circulation• Pain• Muscle spasms

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

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

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 spasm• Springy block—soft tissue approximation

Front Limb

• Leg should fold into an accordion• Teres Major—limits forward extension• Biceps—commonly inflammed from overuse

or elbow joint problems

Biceps

• Will palpate hard/painful/difficult to differentiate from the bone!

Thoracolumbar Spine• Vertebrae should have movement• Twitch can indicate problem• Palpate paraspinals for inflammation/pain• VERY GENTLE—not spinal manipulation!!

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 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

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 prevent fibrous tissue needed!

• Treat compensatory concerns• Proven to help bone healing!

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”• VOSM

Roo• Severe hip and stifle arthritis• Chronic renal failure• Had severe hematuria and inappropriate urination• Doing great with once weekly laser!!

Zoe• Unknown neurologic vs. vestibular disease• Treat compensatory trigger points• Treat presumptive hip arthritis• MUCH improved quality of life

Spike• Weakness in rear end• Shoulder arthritis mild• Mild hip arthritis• Treat spinal muscle spasms• Targeted exercise

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 other exercises?• Combine with other modalities/medications

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

Questions?