Monitoring tendon healing after highpower laser therapy with ultrasound

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1 Monitoring tendon healing after highpower laser therapy with ultrasound Dr. Jan-Hein Swagemakers Mathilde Pluim DVM Antonio Luciani DVM Tierklinik Lüsche GmbH

2 Excellent accuracy (averaging less than 5%) was demonstrated between the ultrasound generated areas and those measured from the tendons post mortem in 12 limbs. (Smith et al, 1994) Computerized ultrasonography provided an excellent tool for objective monitoring of healing tendons in horses and reliable prognostication of repair quality (van Schie et al, 2003) High resolution real time ultrasound and MRI both accurately reflect the tissue abnormalities in acute tendon injuries. MRI returned to normal as fibrogenesis ensued. Ultrasound images remained abnormal until fibrillar reallignment occured with completion of the healing process. (Crass et al, 2005)

3 Grading Mild tendinitis: tendon CSA up to 20% increased (compared to CSA of the opposite limb at the same site(s)) core lesion up to 15% of the total tendon CSA; If the affected area extends less than 20% of the length of the tendon Rehabilitation of Tendon and Ligament Injuries Carol L. Gillis, DVM, PhD A carefully controlled rehabilitation program combined with a regular ultrasound examination provides the best chance for equine athletes to return to full performance following tendon or ligament injury. Dept. of Surgical and Radiological Sciences, School of Veterinary Medicine, University of California at Davis, Davis, CA r 1997 AAEP.

4 Grading Moderate tendinitis the tendon CSA is 20 35% increased If any core lesion 15 30% of the total tendon CSA if the affected area extends 20 35% of the length of the tendon. Severe tendinitis if the tendon CSA more than35% increased if any core lesion seen is greater than 30% of the total tendon CSA; if the affected area extends greater than 35% of the length of the tendon

5 Grade 1 Grade 2 Grade 3

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7 Healing Good: -lameness, pain on palpation, heat, and swelling are absent -core lesion has filled in with collagen to the extent that it is faintly visualized (type I) or not visualized ultrasonographically -CSA of the tendon has decreased -the fiber pattern has improved one level (for example from poor to fair). Fair: -clinical signs are absent -ultrasonographically any lesions are faintly visible (type II) -CSA is the same or slightly increased -the fiber pattern has improved one level Poor: -if any clinical signs are still present -ultrasonographically any lesion is clearly visible (type III or IV) -the fiber pattern has not improved.

8 Rehabilitation protocol

9 High-power Laser therapy in athletes (Prof Parra + Ing Algeri seit 1989) Soccer Inter Milan Real Madrid Mancester United Juventus Turin Marathon Team Kenia Tennis Novac Djokovic Venus Williams Ski Alberto Tomba

10 Laser: light amplification by stimulated emission of radiation Type? Medium? Class? Wavelength? Low-level (<500mW) vs High-level (>500mW)

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12 Literature study University of Utrecht March 2014 M.E. Harmannij

13 Effects: Improvement of the microcirculation Increased activity of the mitochondria (ATP production) Proliferation of fibroblasts, proteine and collagen Decrease of inflammatory mediators Analgetic effect

14 FP4 Lasersystem Class 4 multifrequency laser (15 Watt) Four patented wavelengths produced simultaneously higher total energy in depth without the risk of burning the skin Penetration up to 7,2 cm Each frequency has different characteristics: - depth of penetration - Bio stimulation - anti-inflammatory - thermical effect

15 Diagnosis protocol Hospitalisation Daily treatment +/- 2 weeks minutes daily Treatment performed by technicians Transcutaneously, painless Exercise programm Weekly clinical and ultrasonographic re-check Logistic

16 Day 0 6 year old Showjumper stallion Acute lesion SDFT since 1 week

17 Day 7

18 Day 23

19 Data analysis of 150 horses

20 Average lameness- and ultrasound score of 150 horses (p <0,001) 2,5 2 1,5 1,92 1,49 1,44 1 0,5 0,71 1,11 0,37 Lameness degree Ultrasound degree 0 Before treatment After treatment 4 weeks after treatment

21 Settings Frequency

22 Settings gain

23 Transferred To pc

24 Person

25 Cross section reliable

26 Doppler

27 Elastography

28 UTC UTC algorithms can discriminate four different echotypes, related to matrix integrity

29 15 year old showjumper at international GP level (1.60) Subacute lesion since 4 weeks

30 Day 14 After 3 weeks back in training, jumping after 2 months

31 Another showjumper-sdft 1a 1b Lameness 2-3/5 PRP injection one week before FP4 Laser therapy over 3 weeks

32 6 Months 1a 1b Sound Beginning small obstacles month 4 Successful jumping at 1.40m level now Never got a completely normal ultra-sonographic appearance

33 Summary Laser does enhance tendon healing Ultrasonographic monitoring essential for optimal rehab plan Improvement in ultrasound will improve and enhance healing in the future

34 Take home message Adapt human rehab methods, equine rehab is often too careful Laser alone more succesful than combined Respect individual differences

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