Nuts and Bolts. The How-to s of Laser Therapy

Transcription

1 Nuts and Bolts The How-to s of Laser Therapy

2 Discussant 2016 Laser Therapy U. All rights reserved. Douglas Johnson, ATC, EES, CLS Senior Vice President, Clinical and Scientific Affairs Multi Radiance Medical LaserTherapyU Douglas Johnson, ATC, EES, CLS, is a certified athletic trainer with over 20 years of clinical/industrial experience. He attended Wayne State University and The University of Detroit-Mercy where he earned a Summa Cum Laude Bachelors of Science degree in Sports Medicine in He is the Senior Vice President, Clinical and Scientific Affairs at Multi Radiance Medical and is involved in numerous research studies involving super pulsed laser. Recently he was named as a clinical advisor to Laser Therapy U, invited to speak at the Annual 2014 NATA Symposium and Euroscience 2015 London, England about Laser Therapy. He served as a member of the NAALT/WALT Scientific Education Committee for the 2014 Program and currently serving as a member of the NAALT Board of Directors. He studied the effect of super-pulsed laser and light emitting diodes phototherapy on non-specific knee pain which was published in Lasers in Medical Science, May 2014 and part of a study to determine the thermal impact on combined pulsed wavelengths on human skin, June, Currently, he is a reviewer for the Journal of Athletic Training and an advisor for EuroSciCon Organizational Committee for the 2017 London Conference and session chair for PBM at ASLMS in Currently his area of research involves the precondition of athletes with photobiomodulation to improve athletic performance, accelerate recovery and reduce fatigue and injuries.

3 Notice of Copyright Low Level Laser Therapy and Sports Performance By Douglas Johnson, ATC, EES, CLS Copyright 2016, Multi Radiance Medical and Laser Therapy U All Right Reserved Version 1.0, February, 2016 Without limiting the rights under copyright reserved above, no part of this publication may be reproduced, stored in or introduced into a retrieval system, or transmitted, in any form or by any mean (electronic, mechanical, photocopying, recording or otherwise) without the prior written permission of the above author. The scanning, uploading and distribution of this book via the Internet or via any other means without the permission of the author is illegal and punishable by law. Please purchase only authorized electronic or physical copies of this manual. The Multi Radiance Medical logo, brand and product names referenced herein in this text are registered trademark(s), service mark(s) or trademarks of Multi Radiance Medical. All other brand and product names mentioned herein are trademarks of their respective owners. All trademark(s) or service mark(s) used or referred to in this text are the property of their respective owners Laser Therapy U. All rights reserved.

4 Learning Techniques and Methods 2015 Laser Therapy U. All rights reserved.

5 2015 Laser Therapy U. All rights reserved. Photobiomodulation noun 1. A form of light therapy that utilizes non-ionizing forms of light sources, including lasers, LEDs, and broadband light, in the visible and infrared spectrum. It is a non-thermal process involving endogenous chromophores eliciting photophysical (i.e., linear and nonlinear) and photochemical events at various biological scales. This process results in beneficial therapeutic outcomes including but not limited to the alleviation of pain or inflammation, immunomodulation, and promotion of wound healing and tissue regeneration.

6 What is in a Name? Laser milliwats coherence frequency NAALT Infrared Super Pulsing Power Inhibition Any modality that utilizes photons wavelength of light (typically red and/or infrared chronic Low Level Laser light) for the relief of pain, to Red accelerate healing and pain decrease inflammation treatment dose stimulation acute Laser Therapy mw joules photons LEDs Blue Light LLLT 2015 Laser Therapy U. All rights reserved.

7 Photobiomodulation Photon absorption Cytochrome C Oxidase 2016 Laser Therapy U. All rights reserved.

8 Role of Nitric Oxide NO has both a direct and indirect impact on pain sensation. Directly, acting as a neurotransmitter it is essential for normal nerve cell action potential in impulse transmission activity Indirectly, the vasodilation effect of NO can Enhance nerve cell perfusion and oxygenation Inhibit the release of histamine and other inflammatory mediators from mast cells Inhibition of prostaglandin synthesis L.I. Filippin et al., Nitric oxide and repair of skeletal muscle injury, Nitric Oxide (2009), doi: /j.niox

9 Increases in Microcirculation and Tissue Oxygenation The increase of blood flow after laser therapy is an important factor in pain relief 1 : Molecular oxygen is generated due to laser-induced photodissociation of HbO 2 in blood vessels 2 Increases lymphatic drainage, the activity of neutrophils, macrophages, fibroblasts, and the metabolism of damaged or defective cells 1 Maegawa Y, Itoh T, Hosokawa T, Yaegashi K, Nishi M. Effects of near-infrared low-level laser irradiation on microcirculation. Lasers Surg Med. 2000;27(5): The Physics of Biomedical Effect of Blood Oxyhemoglobin Photodissociation M. M. Asimov, R. M. Asimov, A. N. Rubinov, A. I. Gisbrecht, pp.33-38, Pub. Date: Vasodilation Normal

10 Stabilization Influencesof Cutaneous cellular membrane Receptors Activation of Enhancement protein synthesis of ATP (RNA,DNA) synthesis Stimulated vasodilation via Improvement increased of cellular Histamine, NO potential and Serotonin Temperature Decrease in Peroxidation modulation of lipids Low Level Laser Therapy Increase in adenosine Beneficial triphosphate acceleration of leukocytic ATP) activity formation 2015 Laser Therapy U. All rights reserved. Normalization Enhanced and lymphocyte synthesis of response Prostaglandin Normalization of specific Reduction in and nonspecific Interleukin-1 immune factors Converting Increase prostaglandin enzymatic formation into and prostacyclin activation

11 Influences Improved Cutaneous blood circulation Receptors Activation of protein Anti- Inflammatory synthesis (RNA,DNA) Improvement Anti- Edematous of cellular potential Decrease Improved in Peroxidation Immune Response of lipids Low Level Laser Therapy Increase in Improvement adenosine triphosphate of ATP) formation Microcirculation 2016 Laser Therapy U. All rights reserved. Normalization Analgesic and synthesis Effect of Prostaglandin Normalization of specific Enhances and nonspecific wound repair immune factors Increase in Regenerates enzymatic Damaged formation and Tissue activation

12 Monochromatic Lasers and General Uses Infrared Red Musculoskeletal Disorder and Pain Relief Wound healing and Pain Relief Green Blue Violet Laser Puncture Dermatology and Antibacterial Anti-viral 2016 Laser Therapy U. All rights reserved.

13 Mechanisms Increase in ATP synthesis Enhancement of ATP synthesis Inflammation LLLT Creation of ROS Increase in NO Dissociation 2016 Laser Therapy U. All rights reserved.

14 Priority Principle TM Technique + = Dose Priority Principle Method Sequencing 2015 Laser Therapy U. All rights reserved.

15 Effects of Dose: Low level laser can perform two very different biological processes: Tissue Repair Pain Relief

16 Toxicity Stimulation vs. Inhibition Inhibition Stimulation Dose Optimization 80s 240s 400s TTP 2015 Laser Therapy U. All rights reserved.

17 Technique: Contact vs. Non-Contact Contact The most common technique is static contact mode with a mild over pressure. This results in a higher local pressure, creating an ischemic area under the laser aperture and 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. (Bjordal et al) This ischemia will increase the penetration of laser into the tissue up to 40 times for 630 nm (red) and 3 times for 830 nm (infrared) as compared to noncontact. (Tuner and Hode) Non- Contact Contact Toshio Ohshiro, MD, PhD, The Proximal Priority Technique: How to Maximize The Efficacy of Laser Therapy, Laser Therapy 14.3: Japan Medical Laser Laboratory LTD, Laser Therapy U. All rights reserved.

18 Scanning Method: Contact and Non-Contact Scanning/Contact: Used for large area treatment Emitter is moved in the appropriate direction at a speed of 0.5 to 1.5 cm per second (forward - backwards, to the left to the right, upward - downward) However, due to an increase of surface area, treatment times may need to be increased to deliver a uniform dose to the entire area Scanning/Non-Contact: Used when surface pressure is contraindicated (i.e. infections, shingles, anti-coagulate therapy) Or to diminish the power or absorption of light (i.e. of pediatrics, wounds, or elderly) 2015 Laser Therapy U. All rights reserved.

19 Woodpecker Technique for Edema / Swelling Must be performed in a gravity independent position (patient positioning) Must be done prior to start of other priorities Begin at the most proximal drainage site of the affected extremity and precede distally, Oshiro s Principle Alternately compressed and released may assist with the mechanical increase of venous and lymphatic flow Note: there is no linear movement of the emitter. * Example of Woodpecker Technique Toshio Ohshiro, MD, PhD, The Proximal Priority Technique: How to Maximize The Efficacy of Laser Therapy, Laser Therapy 14.3: Japan Medical Laser Laboratory LTD, 2005

20 Trigger Points and Spasms 2015 Laser Therapy U. All rights reserved.

21 Injuries and Insults Tissue healing (or tissue repair) refers to the body's replacement of destroyed tissue by living tissue and comprises two essential components - Regeneration and Repair The differentiation between the two is based on the resultant tissue In Regeneration, specialized tissues is replaced by the proliferation of surrounding undamaged specialized cells In Repair, lost tissue is replaced by granulation tissue which matures to form scar tissue Bleeding Inflammation Proliferation Remodeling Hours Days Weeks Months

22 Injuries and Insults A gross representation of the key phases of the tissue repair process The phases identified are shown as separate entities, though in reality, they are interlinked in a very deliberate way There are events associated with one phase that act as stimulants for the following phase Bleeding Inflammation Proliferation Remodeling Hours Days Weeks Months

23 Priority Principle TM A dynamic methodology used for integrating photobiomodulation methods (dose/rate and techniques) into clinical practice by prioritizing the current physiological and functional needs of the patient and then applying the appropriate sequence of treatment methods to maximize the phototherapeutic responses and patient outcomes

24 11 Basic Methods 1. Minimizing Acute Injury 2. Chronic Injury 3. Reduce Swelling/Edema 4. Resolve Inflammation/Infection 5. Spasm 6. Controlling Pain via Systemic Methods 7. Controlling Pain via Local Methods 8. Tissue Repair Local 9. Tissue Repair Systemic 10. Increase Range of Motion 11. Functional Strength: Prepare, Performance and Recovery

25 Priority Principle TM Acute Chronic Swelling Inflammation Spasm Pain Tissue Repair ROM Functional Strength Time Phase Pain/Spasm Tissue Repair Function Acute Chronic Swelling/Edema Inflammation Spasm Pain Local Systemic ROM Strength

26 Priority Principle TM Acute Chronic Swelling Inflammation Spasm Pain Tissue Repair ROM Functional Strength Time Phase Pain/Spasm Tissue Repair Function Acute Chronic Swelling/Edema Inflammation Spasm Pain Local Systemic ROM Strength

27 Priority Principle TM : Acute Chronic Swelling Inflammation Spasm Pain Tissue Repair ROM Functional Strength Method Dose Notes

28 Acute Injury Inhibitory Rescue Protocol Local treatment Scanning 2015 Laser Therapy U. All rights reserved.

29 Priority Principle TM : Acute Injury Acute Chronic Swelling Inflammation Spasm Pain Tissue Repair ROM Functional Strength Method Dose Notes Hz x 3 minutes Rescue for injuries <48 hours Supraspinatus Rotator Cuff Epicondylitis Medial Epicondylitis Lateral Extensor Pollicis Longus Hip Flexor Adductor Hamstring Trigger Finger Patellar Achilles Plantar Fascia Acute Acute 1000 Hz Hz for 1 minute each OR Rescue for injuries <48 hours The First Priority is to prevent the further progression of inflammation, edema and swelling Smaller, more frequent, and localized doses are generally more advantageous than larger, systemic dose

30 General Stimulation Stimulatory Photohemotherapy or PHT Static Proximal arterial pulsation 2015 Laser Therapy U. All rights reserved.

31 Priority Principle TM : Photohemotherapy Acute Chronic Swelling Inflammation Spasm Pain Tissue Repair ROM Functional Strength Method Dose Notes Tissue Repair 50 Hz x 5 minutes 1) Carotid Artery 2) Subclavian Artery 3) Brachial Artery 4) Radial Artery 5) Apex Beat (5 Hz Only) 6) Femoral 7) Tibial Artery 8) Dorsalis Pedis 9) Popliteal Artery (from behind) 10) Aorta 11) Renal 12) Aorta

32 Other Methods 2015 Laser Therapy U. All rights reserved. Universal Rehabilitation Program (URP) General Somatic Biostimulation (GSB) Ohshiro s Chronic Pain Principle (OCPP) Stellate Ganglion Laser Nerve Block (SGLNG) Laserpuncture (LAcP)

33 Priority Principle TM : Oshiro s Chronic Pain Principle Acute Chronic Swelling Inflammation Spasm Pain Tissue Repair ROM Functional Strength Method Dose Notes Chronic 1000 Hertz for 30 seconds each location 3000 Hz for 10 seconds per location Bilaterally on the sides of the neck, about 2 cm below the ears. The spinal aspect of the base of the skull is next targeted, at the Atlas/Axis (C1/C2) junction. Used as a primer for the treatment of chronic pain Targets the blood supply to the brain to increase cerebral blood supply and oxygenation Stimulate the CNS to wake the master computer

34 Priority Principle TM : Stellate Ganglion Laser Nerve Block Acute Chronic Swelling Inflammation Spasm Pain Tissue Repair ROM Functional Strength Method Dose Notes Chronic 3000 Hz x 9 min (21.48 J/cm 2 ) 5000 Hz x 7 min (21.48 J/cm 2 ) Stellate ganglion is located at the level of C7 (7th cervical vertebrae), anterior to the transverse process of C7, anterior to the neck of the first rib, and just below the subclavian artery, treat bilaterally R vertebral artery Stellate Ganglion R subclavian artery L vertebral artery 1 st Rib C-7

35 Priority Principle TM : Laserpuncture Acute Chronic Swelling Inflammation Spasm Pain Tissue Repair ROM Functional Strength Corporal Probe: Corporal acupuncture is done on points on the body. This probe can also be used for muscle trigger and motor points. Name LI-4 LI-11 St-12 Location This is in the soft, fleshy web between your thumb and forefinger (headache, general pain relief) With the elbow flexed, the point is on the lateral end of the transverse cubital crease, at midpoint between LI 5 and the lateral epicondyle of the humerus. In the midpoint of the supraclavicular fossa, 4 cm lateral to the anterior midline.

36 Priority Principle TM : Laserpuncture Acute Chronic Swelling Inflammation Spasm Pain Tissue Repair ROM Functional Strength Corporal Probe: Corporal acupuncture is done on points on the body. This probe can also be used for muscle trigger and motor points Laser Therapy U. All rights reserved Laser Therapy U. All rights reserved.

37 Technique Review Review Contact Non-Contact Scanning Woodpecker Trigger Point TARGET/DOSE

38 Elimination of Swelling/Edema Inhibitory Woodpecker Treat Proximal Distal Ohshiro s Proximal Priority 2015 Laser Therapy U. All rights reserved. Scan each distal lymph node from Distal Proximal

39 Priority Principle TM : Swelling/Edema Acute Chronic Swelling Inflammation Spasm Pain Tissue Repair ROM Functional Strength Treatment Move the emitter must always from distal begin to at the most proximal proximal with slight drainage over site pressure of the affected Cold compress extremity or ice and in precede axilla area distally, if Oshiro s toleratedprinciple Woodpecker Technique: The repeated light percussive strokes may well help in the mechanical increase of venous and lymphatic flow as the vessels are alternately compressed and released. Note there is no linear movement of the diode. Method Dose Notes Swelling Inflammation Spasm Hz 1-2 minutes each area 50 Hz x 2 minutes or TARGET/DOSE 1000 Hz x 2 minutes per spasm Hz for 3 minutes Ohshiro s Proximal Priority Pontinen s Principle Systemic target (NRT) Pain or 1000 Hz x 2-5 minutes or Local targets

40 Elimination of Swelling/Edema Upper Extremity Laser Therapy U. All rights reserved. No. Primary Treatment area 1 Axilla 2 Medial anterior forearm 3 Dorsal radial aspect of the wrist

41 Elimination of Swelling/Edema Lower Extremity No. Primary Treatment area 1 Inguinal 2 Popliteal fossa 3 Lateral posterior malleolus 2015 Laser Therapy U. All rights reserved.

42 Inflammation Stimulatory Inflammation Local treatment 2015 Laser Therapy U. All rights reserved.

43 Inflammation TARGET TM or Treatment Area Recognition and Guidance Enhanced Technology LaserStim employs a unique biphasic form of electrical stimulation that continually monitors changes in electrical impedance of the skin and underlying tissue It enables users to locate asymmetries or active sites through bio-impedance deviations ie: highly-probable laser therapy targets 2015 Laser Therapy U. All rights reserved. The identification of decreased resistance (increased impedance), signals the location of inflammation, edema, spasms, etc

44 Priority Principle TM : Inflammation Acute Chronic Swelling Inflammation Spasm Pain Tissue Repair ROM Functional Strength Method Dose Notes Swelling Inflammation Spasm Pain Hz 1-2 minutes each area 50 Hz x 2 minutes or TARGET/DOSE 1000 Hz x 2 minutes per spasm 1000 Hz for 2-4 minutes Ohshiro s Proximal Priority Pontinen s Principle: Spasms: at palpable spasms in affected area, active and latent Systemic target (NRT) scanning affected level, above and below, bilaterally with majority of the time on affected side keeping to the no more than 3 levels

45 Muscle Spasms and Trigger Points Inhibitory Adapted Pöntinen s Principle PhotoProbe Reassess and repeat PRN 2015 Laser Therapy U. All rights reserved.

46 The Probes Wound/Cosmetic: This lens will protect the laser and light emitting diodes from dirt and debris when applying the emitter directly on the skin. Auricular Probe: Auricular acupuncture can be done on the ears, hands or feet to treat conditions that are present anywhere in the body. Corporal Probe: Corporal acupuncture is done on points on the body. This probe can also be used for muscle trigger and motor points Laser Therapy U. All rights reserved. Utility Probe: This is an inter cavity probe designed for treatment of the mouth, nostrils and ears. It may additionally be used as a point probe for patients that may find the corporal probe uncomfortable.

47 Priority Principle TM : Pöntinen s Principle Acute Chronic Swelling Inflammation Spasm Pain Tissue Repair ROM Functional Strength Method Dose Notes Swelling Inflammation Spasm Pain Hz 1-2 minutes each area 50 Hz x 2 minutes or TARGET/DOSE 1000 Hz x 3-4 minutes per spasm 1000 Hz for 2-4 minutes Ohshiro s Proximal Priority Pontinen s Principle: Spasms: at palpable spasms in affected area, active and latent Systemic target (NRT) scanning affected level, above and below, bilaterally with majority of the time on affected side keeping to the no more than 3 levels Corporal Probe: Corporal acupuncture is done on points on the body. This probe can also be used for muscle trigger and motor points. Utility Probe: This is an inter cavity probe designed for treatment of the mouth and ears. It may additionally be used as a point probe for patients that may find the corporal probe uncomfortable.

48 Adapted Pöntinen Principle (Multi Radiance Medical) UPDATED!!!: 1) Select [1000], [3000] or [ Hertz] 2) Identify trigger point (TP) utilizing the LaserStim TARGET feature or palpate suspected trigger points, be sure to document pain threshold, pain level ( on a scale of 1 to 10, 10 being the worst) and texture of the TP 3) Attach PhotoProbes (corporal, auricular or utility) if desired 4) Lase the TP, static method, 2-5 minutes, with mild overpressure 5) Re-evaluate the TP and record any changes in pain threshold, pain level ( on a scale of 1 to 10, 10 being the worst) and texture of the TP 6) If pain or spasm persists, reapply the entire treatment sequence, maximum of two additional times Pöntinen, Pekka, Low Level Laser Therapy as a Medical Treatment Modality, Art Urpo LTD Tampere, 1992, ISBN:

49 Pain Inhibitory General Systemic Pain Relief Systemic: NRT, Dermatomes, Myotomes Scanning 2015 Laser Therapy U. All rights reserved.

50 Priority Principle TM : Nerve Roots and Trunks (NRT) Acute Chronic Swelling Inflammation Spasm Pain Tissue Repair ROM Functional Strength Cervical Thoracic Lumbar Sacral Method Dose Notes Swelling Inflammation Spasm Pain Hz 1-2 minutes each area 50 Hz x 2 minutes or TARGET/DOSE 1000 Hz x 2 minutes per spasm 1000 Hz for 3-4 minutes Ohshiro s Proximal Priority Pontinen s Principle Systemic target (NRT) scanning affected level, above and below, bilaterally with majority of the time on affected side keeping to the no more than 3 levels

51 Nerve Roots and Trunks (NRT) 2015 Laser Therapy U. All rights reserved.

52 Priority Principle TM : Nerve Roots and Trunks (NRT) - Dermatomes Acute Chronic Swelling Inflammation Spasm Pain Tissue Repair ROM Functional Strength Pain Level Nociceptive Setting Hz Hz Hz Method Dose Notes Swelling Inflammation Spasm Pain Hz 1-2 minutes each area 50 Hz x 2 minutes or TARGET/DOSE 1000 Hz x 2 minutes per spasm See Chart Hz for 3-4 minutes per segment Ohshiro s Proximal Priority Pontinen s Principle Systemic target (NRT) dermatome scanning for pain (including radiating), LaserShower preferred

53 Pain Inhibitory Local Pain Relief Local treatment 2015 Laser Therapy U. All rights reserved.

54 Tissue Repair Local Systemic 2015 Laser Therapy U. All rights reserved.

55 Tissue Repair (Local) Stimulatory Tissue Repair (Local) Local treatment 2015 Laser Therapy U. All rights reserved.

56 Priority Principle TM : Tissue Repair (Primary) Acute Chronic Swelling Inflammation Spasm Pain Tissue Repair ROM Functional Strength Method Dose Notes Tissue Repair 5-250, 250 or 500 Hz 1-2 min or T/D Direct contact technique

57 Tissue Repair (Systemic) Stimulatory Systemic (Photohemotherapy or PHT) Static Proximal arterial pulsation 2015 Laser Therapy U. All rights reserved.

58 Priority Principle TM : Photohemotherapy Acute Chronic Swelling Inflammation Spasm Pain Tissue Repair ROM Functional Strength Method Dose Notes Tissue Repair 50 Hz x 5 minutes 1) Carotid Artery 2) Subclavian Artery 3) Brachial Artery 4) Radial Artery 5) Apex Beat (5 Hz Only) 6) Femoral 7) Tibial Artery 8) Dorsalis Pedis 9) Popliteal Artery (from behind) 10) Aorta 11) Renal 12) Aorta

59 Range of Motion Inhibitory ROM PhotoProbe Static 2015 Laser Therapy U. All rights reserved.

60 Priority Principle TM : Increasing Range of Motion Acute Chronic Swelling Inflammation Spasm Pain Tissue Repair ROM Functional Strength Method Dose Notes 1000 Hz x 1 min each ASHII Point ROM: to all affected and limited joints at 3-4 location per joint line (Tender points or AHSHI points) No of AHSHI Affected joint Points 2-3 Fingers 3-4 Wrist 4 Elbow 4-5 Shoulder 3-4 Cervical Spine 3-4 Thoracic Spine 3-4 Lumbar Spine 4-5 Hip 3-4 Knee 3-4 Ankle 2-3 Toes

61 Performance Stimulatory Performance Scanning PRE Event Treatment 2015 Laser Therapy U. All rights reserved.

62 Strength Stimulatory Strength Scanning PRE Event Treatment 2015 Laser Therapy U. All rights reserved.

63 Recovery Stimulatory Recovery Scanning POST Event Treatment 2015 Laser Therapy U. All rights reserved.

64 Endurance Stimulatory Scanning Endurance PRE Event Treatment POST Event Treatment 2015 Laser Therapy U. All rights reserved.

65 Priority Principle TM : Functional Strength (Performance) Acute Chronic Swelling Inflammation Spasm Pain Tissue Repair ROM Functional Strength Method Dose Notes Trapezii Functional Strength 250 Hz x 3 min for smaller muscle, 5 min for larger muscle scanning Performance Method: Performance, Strength, Endurance, or Recovery Upper Pectorals Gluteals Lover Abdominals Hamstrings Quadriceps Tibia Medial Gastrocnemii

66 2014 Laser Therapy U. All rights reserved. Methods are the combination of a dose or dose rate and one or more techniques Acute Injury = Rescue = Inhibitory + Local Chronic Injury = General Stimulation = Stimulatory + Local + Systemic Swelling = Ohshiro s Method = Inhibitory + Proximal Priority + Scanning Distal to Proximal Inflammation = Stimulatory + Static Muscle Spasm and Trigger Points = Pöntinen s Principle = Inhibitory + Photoprobes + Reassess and Repeat Local Pain = Inhibitory + Static General Pain = Inhibitory + NRT (or Dermatomes, Myotomes) + Scanning Tissue Repair (Local) = Stimulatory + Static Tissue Repair (Systemic) = Photohemotherapy = Stimulatory + Proximal arterial pulsation ROM = Inhibitory + Static + Photoprobe Performance = Stimulatory + Scanning + Pre Remember to adjust doses either by time or frequency

67 Recommendations LaserStim LaserShower Irradiance Irradiance Stimulatory Inhibitory <500 Hz >500 Hz Dose Dose Time Time Static Scanning 2014 Laser Therapy U. All rights reserved.

68 Dose Adjustment Be prepared to increase or decrease the dose in 1 minute increments to achieve the desired response

69 Clinical Practice: Good: Technique Better: Dose Best: Methods

70 Yo-Yo Effect Typically, if a patient's condition fluctuates between control (improvement) and exacerbation, this may indicate that the current area being treated or "stimulated" may not be the root cause of the issue

71 Priority Principle TM : Lateral Ankle Sprain Acute Chronic Swelling Inflammation Spasm Pain Tissue Repair ROM Functional Strength Method Dose Notes Hz x 3 minutes Rescue for injuries <48 hours Acute

72 Priority Principle TM : Lateral Ankle Sprain Acute Chronic Swelling Inflammation Spasm Pain Tissue Repair ROM Functional Strength Method Dose Notes Swelling Inflammation Spasm Hz 1-2 minutes each area 50 Hz x 2 minutes or TARGET/DOSE 1000 Hz x 2 minutes per spasm Hz for 3 minutes Ohshiro s Proximal Priority Pontinen s Principle Systemic target (NRT) -2 Pain or 1000 Hz x 2-5 minutes or Local targets

73 Priority Principle TM : Lateral Ankle Sprain Acute Chronic Swelling Inflammation Spasm Pain Tissue Repair ROM Functional Strength Method Dose Notes Tissue Repair Hz for 2 minutes or TARGET/DOSE Local targets and 50 Hz x 5 minutes and Systemic target (PHT) at Popliteal artery

74 Priority Principle TM : Lateral Ankle Sprain Acute Chronic Swelling Inflammation Spasm Pain Tissue Repair ROM Functional Strength Method Dose Notes Acute Hz x 3 minutes Rescue Swelling Hz 1-2 minutes each area Ohshiro s Proximal Priority Inflammation Spasm 50 Hz x 2 minutes or TARGET/DOSE 1000 Hz x 2 minutes per spasm Pontinen s Principle Pain Hz for 3 minutes or 1000 Hz x 2-5 minutes Systemic target (NRT) or Local targets Tissue Repair Hz for 2 minutes or TARGET/DOSE Local targets 5a and 50 Hz x 5 minutes and Systemic target (PHT) at Popliteal artery

75 Kiritsi, O., Tsitas, K., Malliaropoulos, N., & Mikroulis, G. (2010). Ultrasonographic evaluation of plantar fasciitis after lowlevel laser therapy: results of a doubleblind, randomized, placebo-controlled trial. Lasers in medical science, 25(2), Study outcomes of ultrasonographic appearance of the aponeurosis and by patients pain scores (VAS). the contralateral asymptomatic fascia was used as control Thirty individuals with diagnosis of unilateral plantar fasciitis Randomized, double-blind, placebo-controlled trial After enrolment, symptomatic individuals were randomly assigned to receive LLLT, or identical placebo, for 6 weeks. Ultrasonography and pain were performed at baseline and after completion of therapy Pain estimation on the visual analogue scale had improved significantly in all test situations (after night rest, daily activities) after LLLT when compared with that of the placebo group. (P = and P = 0.01, respectively) Ultrasound imaging showed non-significant improvements related to plantar fasciitis 904 nm gallium arsenide (GaAs) infrared laser may contribute to healing and pain reduction in plantar fasciitis Laser Therapy U. All rights reserved.

76 Priority Principle TM : Plantar Fasciitis Acute Chronic Swelling Inflammation Spasm Pain Tissue Repair ROM Functional Strength Tissue Repair Tissue Repair Method Dose Notes Spasm 1000 Hz x 2 minutes per spasm Tissue Repair Tissue Repair Hz (or 250 Hz) Target/Dose or 1-2 min per location 50 Hz x 1-2 minutes per location Pontinen s Principle: Medial Gastroc Direct Contact PHT to 4) Femoral 5) Popliteal, 6) Tibial 7) Dorsalis Pedis

77 Clinical Venous Pearls Insufficiency 2015 Laser Therapy U. All rights reserved. Combination of methods: Oshiro s Proximal Priority + Photohemotherapy Utilized for many other conditions: diabetic neuropathy, restless leg syndrome, edema, etc., where improvements in circulation are required Treatment should be done in a supine position with leg/ankle elevated (assist with lymphatic drainage)

78 Priority Principle TM : Venous Insufficiency Acute Chronic Swelling Inflammation Spasm Pain Tissue Repair ROM Functional Strength Method Dose Notes Swelling 1000, 3000, min per location Tissue Repair 50 Hz x 1-2 minutes per location Ohshiro s Proximal Priority 1) Groin, inguinal triangle of affected extremity 2) Popliteal Fossa of affected extremity 3) Lateral posterior malleolus of affected extremity PHT to 4) Femoral 5) Popliteal, 6) Tibial 7) Dorsalis Pedis 6 3 7

79 Priority Principle TM : Ulcers Acute Chronic Swelling Inflammation Spasm Pain Tissue Repair ROM Functional Strength Method Dose Notes Tissue Repair Hz for 2 minutes or TARGET/DOSE and Local targets and 50 Hz x 5 minutes Systemic target (PHT) at Dorsalis Pedis artery

80 Priority Principle TM : NRT Anterior Approach for the Cervical Spine Acute Chronic Swelling Inflammation Spasm Pain Tissue Repair ROM Functional Strength Method Dose Notes Swelling Inflammation Spasm Pain Hz 1-2 minutes each area 50 Hz x 2 minutes or TARGET/DOSE 1000 Hz x 2 minutes per spasm 1000 Hz for 2-4 minutes Ohshiro s Proximal Priority Pontinen s Principle Systemic target (NRT) scanning affected level, above and below, bilaterally with majority of the time on affected side keeping to the no more than 3 levels

81 Priority Principle TM : Triple Threat for Pain Relief Cervical Spine Acute Chronic Swelling Inflammation Spasm Pain Tissue Repair ROM Functional Strength Pain Level Nociceptive Setting Hz Hz Hz Method Dose Notes Inflammation Chronic Pain Hz x 2 min or DOSE 3000 Hz scanning x 9 min (21.48 J/cm 2 ) Hz scanning x 7 min (21.48 J/cm 2 ) 1000 Hz (Pain Level 1-3) Hz (Pain Level 4-6) Hz (Pain Level 7-10) Higher frequencies are often required in the case of the spine Stellate Ganglion Laser Block NRT: Acute: 3-5 min per location, scanning slowly no < 50 cm 2 Chronic: 5-10 min per location, scanning slowly no < 50 cm 2

82 Priority Principle TM : ALT#1b Quadruple Threat for Pain Relief (+ EMS) Acute Chronic Swelling Inflammation Spasm Pain Tissue Repair ROM Functional Strength Pain Level EMS Setting 1-3 Minimal 4-6 Moderate 7-10 Maximal Method Dose Notes Inflammation Chronic Pain Hz x 2 min or DOSE 3000 Hz scanning x 9 min (21.48 J/cm 2 ) Hz scanning x 7 min (21.48 J/cm 2 ) 1000 Hz (Pain Level 1-3) Hz (Pain Level 4-6) Hz (Pain Level 7-10) Higher frequencies are often required in the case of the spine Stellate Ganglion Laser Block NRT: Acute: 3-5 min per location, scanning slowly no < 50 cm 2 Chronic: 5-10 min per location, scanning slowly no < 50 cm 2 Indication: Pain ONLY Contraindication: Where the use of EMS is prohibited: ie: impaired sensation

83 Priority Principle TM : Triple Threat for Pain Relief Lumbar Spine Acute Chronic Swelling Inflammation Spasm Pain Tissue Repair ROM Functional Strength Method Dose Notes Inflammation Hz x 2 min or DOSE Higher frequencies are often required in the case of the spine Chronic Pain 3000 Hz scanning x 9 min (21.48 J/cm 2 ) Hz scanning x 7 min (21.48 J/cm 2 ) 1000 Hz (Pain Level 1-3) Hz (Pain Level 4-6) Hz (Pain Level 7-10) Lumbar Sympathetic Plexus Laser Block or Sacral Plexus Laser Block (treated contralateral side) NRT: Acute: 3-5 min per location, scanning slowly no < 50 cm 2 Chronic: 5-10 min per location, scanning slowly no < 50 cm 2

84 Priority Principle TM : Photohemotherapy for the Lumbar Spine Acute Chronic Swelling Inflammation Spasm Pain Tissue Repair ROM Functional Strength Method Dose Notes Tissue Repair 50 Hz x 5 minutes 10 Aorta 11- Renal 12 - Aorta

85 Closing Comments and Questions 2015 Laser Therapy U. All rights reserved. Adjunctive Modalities Clinical Pearls Contraindication/Indications Summary Contact Information Websites

86 Adjunctive Treatment Options Traction Massage Graston technique Mechanical vibration Continuous or pulsed ultrasound E-stim Ischemic compression Injection Dry-needling Stretching techniques that invoke reciprocal inhibition Assisted Soft Tissue Mobilization (ASTM)

87 Laser Therapy and Secondary Physical Agents Cryotherapy Use laser therapy PRIOR due to cytoprotection Heat therapies (US- EMS) Use laser therapy before, increased blood flow causes increased absorption of light by hemoglobin resulting in decreased penetration Massage (Massage, STM, ASTM) May do before or after Reduce pain/spasm prior to ease treatment After aggressive techniques Traction/Decompression May do before or after, depending on the specific goals of laser therapy Pain/spasm prior After aggressive traction after

88 Laser Therapy and Chiropractic Adjustments Adjustments May do before or after, depending on the specific goals of laser therapy Prior to reduce pain/spasm After aggressive adjustment to ease pain and decrease muscle tension

89 Decade rule Take the patient s age and divide by 10 Determines probable number of treatments to get a strong, positive outcome

90 Clinical Notes on Systemic Treatments A patient may experience an exacerbation of symptoms (e.g. temporary pain) during systemic treatments There is an increase in the blood supply to the tissue or system combined with a decrease in viscosity, improvement in the flow characteristics of the blood and the dilatation of the capillaries, precapillaries and arterioles The venous system cannot improve its flow characteristics as fast as the arterial system Creating stasis or congestion of the tissues causing the pain sensation and other effects

91 Clinical Notes on Systemic Treatments Temporarily suspend treatments for 1-3 days. Allowing the venous system to adapt to the increase in the overall blood flow When symptoms have diminished or disappeared, treatment sessions may resume NOTE, an exacerbation with laser therapy is regarded as a positive response indicating that the healing process has begun.

92 Treatment Frequency Local treatments may be given up to 3-4 times per day, using TARGET and DOSE Systemic treatments should be kept to no more than 30 minutes per day Stimulatory treatments should be done no sooner than 4 hours between sessions Inhibitory treatments may be done as needed

93 Contraindications: Absolute Contraindications: Pregnancy Cancer Fever (body temperature higher than f/38 c) During stages of acute infection (including localized infections) Over hemorrhages In the vicinity of pacemakers

94 Summary #2: Photoboimodulation is simply the absorption of light by cytochrome c oxidase (CCO) resulting in an increase in cellular activity. Methods are the combination of a dose or dose rate and one or more techniques Acute Injury = Rescue = Inhibitory + Local Chronic Injury = General Stimulation = Stimulatory + Local + Systemic Swelling = Ohshiro s Method = Inhibitory + Proximal Priority + Scanning Distal to Proximal Inflammation = Stimulatory + Static Muscle Spasm and Trigger Points = Pöntinen s Principle = Inhibitory + Photoprobes + Reassess and Repeat Local Pain = Inhibitory + Static General Pain = Inhibitory + NRT (or Dermatomes, Myotomes) + Scanning Tissue Repair (Local) = Stimulatory + Static Tissue Repair (Systemic) = Photohemotherapy = Stimulatory + Proximal arterial pulsation ROM = Inhibitory + Static + Photoprobe Performance = Stimulatory + Scanning + Pre Remember to adjust doses either by time or frequency 2015 Laser Therapy U. All rights reserved.

95 Contacts: address for Douglas Johnson Website for Low Level Laser Therapy Swedish Laser Association North American Association for Light Therapy World Association for Laser Therapy 2016 Laser Therapy U. All rights reserved.

96 Thank You

97 Priority Principle TM : Acute Chronic Swelling Inflammation Spasm Pain Tissue Repair ROM Functional Strength Method Dose Notes Acute Hz 2 min 1000 Hz Hz x 2 min Rescue Protocol: first 48 hours. Scanning Technique: directly over the injured area, Tx is PRN Chronic Based on Method PHT, URP, OCPP, SGLNB, LAcP Swelling Inflammation 1000, or 3000 Hz x 1-2 min 5, 5-50, 50 Hz x 2 min or T/D Ohsiro s Proximal Priority Spasm 1000 Hz 3-4 min Pontinen s Principle Red inflammation, blue infection, do not over treat Pain 1000, , 3000, or 5000 Hz 3-4 minutes Tissue Repair ROM Strength 5-250, 250 or 500 Hz 1-2 min or T/D + 50 Hz for 5 min 1000 Hz x 1 min each ASHII Point 250 Hz x 3 min for smaller muscle, 5 min for larger muscle scanning Scanning Technique along nerves, roots and trunks. Adjust dose based on whether pain is mild, moderate or severe. Direct contact technique + PHT to the proximal supplying artery Can be 3-5 per joint depending on the size of the animal and location. Performance Method: done prior to activity