Nuts and Bolts The How to s of Laser Therapy. Session 407: Low Level Laser Therapy: The Nuts & Bolts of Clinical Application

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1 To comply with professional boards/associations standards: I declare that I (or my family) do have a financial relationship in any amount, occurring in the last 12 months with a commercial interest whose products or services are discussed in my presentation. Additionally, all planners involved do not have any financial relationship. Requirements for successful completion are attendance for the full session along with a completed session evaluation. Vyne Education and all current accreditation statuses does not imply endorsement of any commercial products displayed in conjunction with this activity. Session 407: Low Level Laser Therapy: The Nuts & Bolts of Clinical Application Doug Johnson, LAT, ATC, EES, CLS Leading the Way in Continuing Education and Professional Development. Nuts and Bolts The How to s of Laser Therapy

2 Nuts and Bolts of Super Pulsed Laser By Douglas Johnson, ATC, EES, CLS Copyright 2017, Multi Radiance Medical and Laser Therapy U All Right Reserved Version 1.0, June, 2017 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. Discussant 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 photobiomodulation. Recently he was named as a clinical advisor to Laser Therapy U, invited to speak at the Annual 2014 NATA Symposium, Euroscience 2015 London, and the NAALT/WALT 2014 conferences. He serves as a member of the NAALT Scientific Education Committee for the 2017 Program and currently serving as a member of the NAALT Board of Directors. Douglas Johnson, ATC, EES, CLS Senior Vice President, Clinical and Scientific Affairs Multi Radiance Medical LaserTherapyU He studied the effect of PBM on non specific knee pain (May 2014) and the thermal effects of multiple wavelengths on varying pigmented 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 His present area of research involves the precondition of athletes with photobiomodulation to improve athletic performance, accelerate recovery and reduce fatigue and injuries.. Discussant Disclosures: Travel expenses paid by, received salary from, and holds ownership interest with Multi Radiance Medical Serves on Advisory Board for North American Association for Photobiomodulation Therapy and LaserTherapyU Douglas Johnson, ATC, EES, CLS Senior Vice President, Clinical and Scientific Affairs Multi Radiance Medical LaserTherapyU I have disclosed all potential conflicts of interest of mine and my spouse/partner. For those conflicts of interest that could bias my participation as a planner, faculty or author, I agree to present information fairly and without commercial bias. My presentation, slides/handouts will not be labeled with logos or names of commercial interests, organizations or products..

3 Learning Techniques and Methods. Weighing The Available Research >5500.

4 . Abstract BACKGROUND AND PURPOSE: Low level laser therapy (LLLT) is proposed as a treatment for tendinopathies. This is the first systematic review focusing solely on LLLT treatment effects in shoulder tendinopathy. METHODS: A systematic review with meta analysis and primary outcome measures pain relief on 100 mm visual analogue scale (VAS) and relative risk for global improvement. Two independent assessors rated the included studies according to the PEDro scale. Intervention quality assessments were performed of LLLT dosage and treatment procedures according to World Association for Laser Therapy guidelines. The included trials were sub grouped by intervention quality and use of other physiotherapy interventions. RESULTS: Seventeen This review randomized shows controlled that trials optimal (RCTs) met LLLT the can inclusion offer criteria, clinically and 13 RCTs relevant were of high pain and 4 RCTs relief of moderate and initiate methodological a more quality. rapid Significant course and of clinically improvement, important pain relief both was alone found with and weighted mean differences (WMD) over placebo, for LLLT as monotherapy at mm (95% CI: to 28.44) in combination and as adjunct to with exercise physiotherapy at mm interventions. (95% CI: to 20.12). Our The findings WMD when challenge LLLT was used the in conclusions a multimodal physiotherapy in previous treatment multimodal regime reached shoulder statistical significance reviews over of placebo at (95% CI: ) mm pain reduction on VAS. Relative risks for global improvement were statistically significant physiotherapy at 1.96 (95% and CI: ) their lack and 1.51 of (95% intervention CI: ), quality for laser as assessments. monotherapy or adjunctive in a physiotherapy regime, respectively. Secondary outcome measures of shoulder function were only significantly in favour of LLLT when used as monotherapy. Trials performed with inadequate laser doses were ineffective across all outcome measures. CONCLUSION: This review shows that optimal LLLT can offer clinically relevant pain relief and initiate a more rapid course of improvement, both alone and in combination with physiotherapy interventions. Our findings challenge the conclusions in previous multimodal shoulder reviews of physiotherapy and their lack of intervention quality assessments. Abstract Background: Laser therapy has been proposed as a physical therapy for musculoskeletal disorders and has attained popularity because no side effects have been reported after treatment. However, its true effectiveness is still controversial because several clinical trials have reported the ineffectiveness of lasers in treating pain. Methods: In this systematic review, we investigate the clinical effectiveness of low level laser therapy (LLLT) on joint pain. Clinical trials on joint pain satisfying the following conditions are included: the laser is irradiated on the joint area, the PEDro scale score is at least 5, and the effectiveness of the trial is measured using a visual analogue scale (VAS). To estimate the overall effectiveness of all included clinical trials, a mean The weighted mean weighted difference in change difference of pain on in VAS change was used. of Results: pain on MEDLINE VAS is was the main source of mm the literature (95% search. CI, ) After the literature in favor search, of 22 the trials related active to LLLT joint pain groups. were selected. The average methodological quality score of the 22 trials consisting of 1014 patients was When 7.96 on we the only PEDroconsidered scale; 11 trials reported the clinical positive trials effects in and which 11 trials the reported energy negative effects. dose The was mean within weighted the difference dose range in change suggested of pain on VAS in was the review mm (95% by CI, Bjordal ) in favor of the active LLLT groups. When we only considered the clinical trials in which the energy et al. dose in 2003 was within and the in dose World range Association suggested in the for review Laser by Bjordal Therapy et al. in (WALT) 2003 and in World dose Association recommendation, for Laser Therapy the (WALT) mean dose effect recommendation, sizes were the mean effect and sizes were and mm in favor of LLLT groups, respectively. Conclusions: The review shows mm in favor of the true LLLT groups, respectively that laser therapy on the joint reduces pain in patients. Moreover, when we restrict the energy doses of the laser therapy into the dose window suggested in the previous study, we can expect more reliable pain relief treatments.. Abstract Background In recent decades, low level laser therapy (LLLT) has been widely used to relieve pain caused by different musculoskeletal disorders. Though widely used, its reported therapeutic outcomes are varied and conflicting. Results similarly conflict regarding its usage in patients with nonspecific chronic low back pain (NSCLBP). This study investigated the efficacy of low level laser therapy (LLLT) for the treatment of NSCLBP by a systematic literature search with meta analyses on selected studies. Method MEDLINE, EMBASE, ISI Web of Science and Cochrane Library were systematically searched from January Based 2000 on five to November studies, the Included WMD in studies visual were analog randomized scale controlled (VAS) pain trials outcome (RCTs) written in score English after that compared treatment LLLT was with placebo significantly treatment lower in NSCLBP in the patients. LLLT group The efficacy compared effect size was estimated by the weighted mean difference (WMD). Standard random effects meta analysis with placebo (WMD = [95 % CI = 17.42, 9.72], I was used, and inconsistency was evaluated by the I squared index (I 2 ). 2 = 0 %). Results Of 221 studies, seven RCTs (one triple blind, four double blind, one single blind, one not mentioning blinding, totaling 394 patients) met the criteria for inclusion. Based on five studies, the WMD in visual analog scale (VAS) pain outcome score after treatment was significantly lower in the LLLT group compared with placebo (WMD = [95 % CI = 17.42, 9.72], I 2 = 0 %). No significant treatment effect was identified for disability scores or spinal range of motion outcomes. Conclusions Our findings indicate that LLLT is an effective method for relieving pain in NSCLBP patients. However, there is still a lack of evidence supporting its effect on function.

5 . As Known As: +70 MeSH Terms Low level laser therapy Low reactive level laser therapy Low intensity laser therapy Low level light therapy Low energy laser irradiation Photobiomodulation Photobiostimulation Biomodulation Biostimulation Cold laser Soft laser Laser therapy Phototherapy Cold Laser Therapy 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. Red NAALT chronic wavelength treatment stimulation Photobiomodulation Laser milliwats What is in a Name? mw Low Level Laser Infrared coherence dose joules photons LEDs frequency pain Blue Light LLLT Super Pulsing Power Inhibition acute.

6 Photon absorption Photobiomodulation Cytochrome C Oxidase 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 Microcirculation ATP) formation Normalization Analgesic and synthesis Effect of Prostaglandin Normalization of specific Enhances and nonspecific wound repair immune factors Increase in Regenerates enzymatic formation Damaged and Tissue activation Monochromatic Lasers and General Uses Infrared Musculoskeletal Disorder and Pain Relief Red Wound healing and Pain Relief Green Laser Puncture Blue Dermatology and Antibacterial Violet Anti-viral

7 Mechanisms Increase in ATP synthesis Inflammation Enhancement of ATP synthesis LLLT Creation of ROS Increase in NO Dissociation Priority Principle TM Technique + = Dose Priority Principle Method Sequencing Effects of Dose: Low level laser can perform two very different biological processes: Tissue Repair Pain Relief

8 Dose Optimization Stimulation vs. Inhibition Stimulation Inhibition 80s 240s 400s TTP Toxicity 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 This ischemia will increase the pressure, creating an ischemic penetration of laser into the area under the laser aperture tissue up to 40 times for 630 nm and photobleaching (red) and 3 times for 830 nm phenomenon, where the first (infrared) as compared to noncontact. (Tuner and Hode) 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) Contact Non 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, 2005 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, anticoagulate therapy) Or to diminish the power or absorption of light (i.e. of pediatrics, wounds, or elderly)

9 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 Trigger Points and Spasms Review Contact Non Contact Scanning Woodpecker Trigger Point Technique Review

10 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 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 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

11 Priority Principle TM : Acute Chronic Swelling Inflammation Spasm Pain Tissue Repair ROM Functional Strength Method Dose Notes Acute Injury Inhibitory Rescue Protocol Local treatment Scanning Acute Injury Method Dose Notes Medium Rescue for injuries <48 hours Acute Supraspinatus Rotator Cuff Epicondylitis Medial Epicondylitis Lateral Extensor Pollicis Longus Hip Flexor Adductor Hamstring Trigger Finger Patellar Achilles Plantar Fascia 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

12 Oshiro s Chronic Pain Principle 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 Elimination of Swelling/Edema Inhibitory Woodpecker Treat Proximal Distal Ohshiro s Proximal Priority Scan each distal lymph node from Distal Proximal Elimination of Swelling/Edema Upper Extremity No. Primary Treatment area 1 Axilla 2 Medial anterior forearm 3 Dorsal radial aspect of the wrist

13 Elimination of Swelling/Edema Lower Extremity No. Primary Treatment area 1 Inguinal 2 Popliteal fossa 3 Lateral posterior malleolus Inflammation Stimulatory Inflammation Local treatment Inflammation Method Dose Notes Low Do NOT overstimulate Inflammation

14 Muscle Spasms and Trigger Points Inhibitory Adapted Pöntinen s Principle PhotoProbe Reassess and repeat PRN Pöntinen s Principle Method Dose Notes Spasm High Pontinen s Principle: Spasms: at palpable spasms in affected area, active and latent 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. 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 evaluatethetpandrecordanychangesinpainthreshold,painlevel(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:

15 Pain Inhibitory General Systemic Pain Relief Systemic: NRT, Dermatomes, Myotomes Scanning Roots and Trunks (NRT) Method Dose Notes Cervical Pain High 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 Thoracic Lumbar Sacral Nerve Roots and Trunks (NRT)

16 Pain Inhibitory Local Pain Relief Local treatment Tissue Repair Local Systemic Tissue Repair (Local) Stimulatory Tissue Repair (Local) Local treatment

17 Tissue Repair (Systemic) Stimulatory Systemic (Photohemotherapy or PHT) Static Proximal arterial pulsation Photohemotherapy Method Dose Notes Tissue Repair Low 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 Range of Motion Inhibitory ROM PhotoProbe Static

18 Increasing Range of Motion Method Dose Notes High 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. Standard of Care.

19 . Photobiomodulation therapy (PBMT) and/or cryotherapy in skeletal muscle restitution, what is better? A randomized placebo controlled clinical trial Paulo Roberto Vicente de Paiva, Shaiane Silva Tomazoni, Douglas Scott Johnson, Adriane Aver Vanin, Gianna Móes Albuquerque Pontes, Paulo de Tarso Camillo de Carvalho, Ernesto Cesar Pinto Leal Junior 50 Subjects Randomized, double blinded, placebo controlled study Intervention: Eccentric exercise of the quadriceps via Biodex Intervention: Phototherapy 40 J to 6 points on the quad Cyotherapy Ice 20 minutes to quad PBM + Cryotherapy Cryotherapy + PBM Placebo Data Collected: MVC (strength) DOMS (pain) CK (muscle damage) Assessments Baseline, 1, 24, 48, 72, and 96 hours Paiva PR, Tomazoni SS, Johnson DS, Vanin AA, Albuquerque Pontes GM, Carvalho PT, Leal Junior EC. Photobiomodulation therapy (PBMT) and/or cryotherapy in skeletal muscle restitution, what is better? A randomized placebocontrolled clinical trial [article in preparation] Results MVC Paiva PR, Tomazoni SS, Johnson DS, Vanin AA, Albuquerque Pontes GM, Carvalho PT, Leal Junior EC. Photobiomodulation therapy (PBMT) and/or cryotherapy in skeletal muscle restitution, what is better? A randomized placebocontrolled clinical trial [article in preparation] Laser Therapy U..

20 . Results VAS Paiva PR, Tomazoni SS, Johnson DS, Vanin AA, Albuquerque Pontes GM, Carvalho PT, Leal Junior EC. Photobiomodulation therapy (PBMT) and/or cryotherapy in skeletal muscle restitution, what is better? A randomized placebocontrolled clinical trial [article in preparation] Results CK Paiva PR, Tomazoni SS, Johnson DS, Vanin AA, Albuquerque Pontes GM, Carvalho PT, Leal Junior EC. Photobiomodulation therapy (PBMT) and/or cryotherapy in skeletal muscle restitution, what is better? A randomized placebo controlled clinical trial [article in preparation]. Photobiomodulation therapy (PBMT) and/or cryotherapy in skeletal muscle restitution, what is better? A randomized placebo controlled clinical trial PBMT alone was the best modality for post exercise recovery (p<0.05) compared to all comparators Improved MVC Decreased DOMS Reduced CK activity PBMT+Cryotherapy was also significantly better than placebo, cryotherapy and cryotherapy + PBMT (p<0.05). Improved MVC Decreased DOMS Reduced CK activity Cryotherapy, cryotherapy+pbmt and placebo did not improve any measured outcomes We conclude that PBMT used as single treatment is the best modality for enhancement of post exercise recovery. Paiva PR, Tomazoni SS, Johnson DS, Vanin AA, Albuquerque Pontes GM, Carvalho PT, Leal Junior EC. Photobiomodulation therapy (PBMT) and/or cryotherapy in skeletal muscle restitution, what is better? A randomized placebo controlled clinical trial [article in preparation].

21 . Why ice inhibits inflammation: Nick DiNubile: Seriously, do you honestly believe that your body s natural inflammatory response is a mistake? Inflammation is the first physiological process in the repair and remodeling of tissue. Without it, nothing after can happen Macrophages release the hormone Insulin like growth Factor (IGF 1) into the damaged tissues, which helps muscles and other injured parts heal Ice prevents the body from releasing IGF 1 It is IMPOSSIBLE to have tissue repair or remodeling without inflammation 2016 Laser Therapy U. Plantar Fasciitis Acute Chronic Swelling Inflammation Spasm Pain Tissue Repair ROM Functional Strength Method Dose Notes Tissue Repair Tissue Repair Spasm 1000 Hz x 2 minutes per spasm Tissue Hz (or Repair 250 Hz) Target/Dose or 1-2 min per location Tissue 50 Hz x 1-2 Repair minutes per location Pontinen s Principle: Medial Gastroc Direct Contact PHT to 4) Femoral 5) Popliteal, 6) Tibial 7) Dorsalis Pedis Venous Insufficiency Acute Chronic Swelling Inflammation Spasm Pain Tissue Repair ROM Functional Strength Method Dose Notes Swelling High Ohshiro s Proximal Priority 1) Groin, inguinal triangle of affected extremity 2) Popliteal Fossa of affected extremity 3) Lateral posterior malleolus of affected extremity Tissue Repair Low PHT to 4) Femoral 5) Popliteal, 6) Tibial 7) Dorsalis Pedis 6 3 7

22 Methods are the combination of a dose or dose rate and one or more techniques Acute Injury = Rescue = Inhibitory + Local 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 Remember to adjust doses either by time or frequency Dose Adjustment Be prepared to increase or decrease the dose in 1 minute or 2 J increments to achieve the desired response 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

23 Closing Comments and Questions Adjunctive Modalities Clinical Pearls Contraindication/Indications Summary Contact Information Websites 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 Decade rule Take the patient s age and divide by 10 Determines probable number of treatments to get a strong, positive outcome

24 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 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 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

25 Clinical Practice: Good: Technique Better: Dose Best: Methods 2017 Laser Therapy 2017 U. Laser Therapy U Laser Specific Resources:.

26 Thank You address for Douglas Johnson Website for Low Level Laser Therapy