Musculoskeletal Laser Therapy: Integrated Clinical Protocols
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Learn how to implement musculoskeletal laser protocols into your practice. Discover the key clinical breakthroughs in laser therapy and laser protocols. Receive an up-to-date syllabus with graphics and take-home notes. Takeaway information guaranteed to expand your clinical knowledge.
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Musculoskeletal Laser Therapy: Integrated Clinical Protocols
- 1. Dr. Robert G. Silverman DC, DACBN, MS, CNS, CCN, CSCS, CIISN, CKTP, CES, DCBCN, HKC, SFMA www.DrRobertSilverman.com info@drrobertsilverman.com Musculoskeletal Laser Therapy: Integrated Clinical Protocols
- 3. Pathogenesis of the cumulative trauma disorder Recovery Cycle Injury Cycle Frequency of Insult AmountofTissueInsult Symptomatic Injury Threshold Pathogenesis of the cumulative trauma disorder Injury Cycle Frequency of Insult AmountofTissueInsult Insufficient Tissue Recovery Between Injury Cycles Tissue Damage Accumulates Copyright Jerome M. True, DC
- 4. Integrating Laser into Practice “The most versatile healthcare tool of the 21st century”. Dr. Rob, January 2013 “No-pill pain buster”. Dr. Oz, January 2013
- 5. Blue Print • Find the cause • Explain the source • Determine effective treatment • Shorten treatment time
- 6. What Comes First? Injury Pain Altered Motor Control We should diagnose this FUNDAMENTAL QUESTION?
- 8. For Your Pain “Immediate pain reduction can be achieved by altering muscle activation and movement patterns” Spine, 8-6-2012. S. McGill, D. Ikede
- 9. Kinetic Chain = Functional Anatomy Muscles act in synergy not in isolation Muscular strain is applied along traceable “Myofascial Lines” Movement, not muscles
- 10. The Search Is On
- 11. Laser Focus • Laser: Light Amplification by Stimulated Emission of Radiation • A focused beam of light that emits photon energy • All photons travelling same direction at same wavelength = coherent light
- 12. Laser Focus “The cell is a machine driven by energy…in every medical tradition before ours, healing was accomplished by moving energy”. Albert von Szent-Gyorgi, 1967
- 13. Well, the answer is best explained using the basic principles of photochemistry How Does it work?
- 14. Branched Chain Effect… • A single photon can trigger a reaction in one cell that causes emission of several photons • These then trigger photon emissions in other cells like a chain reaction • This accounts for the fact that a tiny signal can be multiplied to cause a rapid and regenerating flow of energy through a bio system James Oschman, PhD. 2006
- 15. How It Works • LLLT stimulates cell activation processes which, in turn, intensifies physiologic activity • Healing is essentially a cellular process • Light energy initiates a cascade of reactions • From cell membrane – cytoplasm – nucleus – DNA • Cellular amplification
- 16. How can this “Star Trek” medicine benefit my patients? Photobiostimulation results in 2 basic responses: Increased Cellular Regeneration Increased Cellular Communication ATP Production Nervous system Living matrix Phospholipid cell membrane Hydration Due to Due to
- 17. Cell Regeneration Laser Therapy Causes Increased ATP Production, a Precursor to Cell Division Photons Absorbed by Chromophores on Cell Membrane Absorption into Molecules Leads to an Acceleration of Electron Transfer Reactions and ATP Production
- 18. Cell Communication Integrins: Receptors on Cell Surface Linking Cell to Surrounding Environment Unique Bidirectional Transmembrane Signal Transduction Photons are Absorbed and the Integrin System Aids in Transduction Olsen, I.M. and French Constant, 2005, BMC Biology 3:25
- 19. Laser Therapy 3 components integral to beneficial outcome LASER 1) Active ingredient 2) Dosage 3) Delivery Mechanism Specific wavelength (color) is component responsible for influencing biochemical cascades Intensity (power of light) determines a response. Too little limits response. Too much produces adverse effect Manner in which light is delivered determines proper tissue response and depth of penetration. Coherent, focused light insures deep tissue stimulation
- 20. Wavelengths • Expressed in terms of color. Each wavelength has different properties: • 635 NM is the frequency of a healthy cell • 635 NM is the absorbable dose • 635 NM is visible light • 635 NM is where DNA replication occurs (photobiostimulation) • 20 times more effective than longer wavelengths
- 21. Power and Wavelength • LLLT accelerates tension healing, increasing fibroblast proliferation and collagen synthesis • LLLT effective at reducing post-injury inflammation and accelerated soft- tissue healing • LLLT increases ATP…stimulating DNA synthesis and cell proliferation • 632.5-nm laser “produced a higher deposition of collagen, increasing the tensile strength of completely severed and surgically repaired rat tendons Comparative Study Using 685-nm & 830-nm Lasers in the Tissue Repair of Tenotomized Tendons in the Mouse, Photomedicine and Laser Surgery, Dec. 2006, vol.24(6), p.754-758
- 22. KEY • Wavelength (in NM) or color of the light should maximize cytochrome-C-oxidase (CCO) absorption
- 23. KEY • CCO – terminal enzyme of the mitochondrial respiratory chain, catalyzing the transfer of electrons from reduced cytochrome c to molecular oxygen • CCO may be considered to be a mitochondrial photo-acceptor • LLT at 635nm has ability to influence mitochondrial enzyme activity, in particular CCO, leading to mitochondrial activity and ATP synthesis
- 24. Frequency • Frequency is the blinking quality of the red line • Frequency (in Hz) – the number of light flashes per second. Allows for modulation of the light which can overcome clinical plateaus in patients • Frequency of 30 or less is visible to the naked eye • Over 30 – the pulse/blink is too fast to see and it appears as a continuous line
- 25. Dr. Rob’s Fab 5 Joint dysfunction EC Matrix Exercise/ergonomics/proprioception Laser therapy Nutrition: a) Diet b) Supplements
- 26. Laser/Pain Management Dr. Rob’s take: • By applying laser energy to affected areas, the frequency sensory nerve firing is increased, which subsequently increases the frequency of stimuli to the spinal cord, brainstem, and brain, in turn inhibiting pain at the spinal cord and brain stem levels
- 27. Don’t you need a lot of power for the light to penetrate? Too much power – not low-level laser
- 28. Low level laser therapy effect are biochemical and not dermal and cannot cause heating and thereby damage to living tissue Low level laser therapy
- 29. Arndt-Schulz Law • “Weak stimuli excite physiological activity, moderately strong ones favor it, strong ones retard it, and very strong ones arrest it.” • Biomodulation Restoring the cell back to its natural frequency
- 31. “Spontaneous healing…all the circuitry and machinery is there; the problem is simply to discover how to turn on the right switches to activate the process”. Spontaneous Healing Andrew Weil Using laser light to “turn on the right switches”
- 32. Muscle Test – Upper Body • C1 – Flex/extension • C2 – Flex/extension • C3 – lateral flexion • C4 – rotation • C5 – deltoid • C6 – bicep • C7 – tricep • C8 – finger flexors • T1 – finger abductors
- 33. Low Back and Pelvis MyotomesMuscles L1-3 Iliopsoas L2-4 Quadriceps L3 Sartorius L4,5 S1-3 Hamstrings L4 TibialisAnterior L5 Toe Extensors L5 Glute Medius S1 Peroneus L. & B. S1 Glut Max/TFL
- 34. Laser Muscles • SCM • Scalenes • Levator scap • Trapezius • Supraspinatus • Lat dorsi • Psoas • Glute max • Piriformis • Erector spinae
- 35. Laser “Locomotor Lock-In” • Resets NMS in 3D motion • 4, 9, 33, 60 • Facilitated bodies global integration • 5 sec.eyes open, 5 sec. eyes closed • Cross-crawl: right arm – left leg, left arm – right leg • Aim posterior midline-spine • Repeat pointing at brain.
- 36. Core Lock-In 4, 9, 33, 60 30 sec. each side
- 37. Dr. Rob’s Magnificent 7 1) Posture/pain 2) Overhead squat 3) 1-legged squat 4) Trunk stability push-up 5) Valgus jump test 6) Upper/lower muscle firing patterns 7) Push-up Functional Movement Assessment
- 38. Functional Movement Assessment (FMA) • FMA will make the invisible visible very quickly • Movement never lies • It tells the unique story of each individual’s history, compensations and adaptations • Dysfunctional movement patterns lead to: • Poor performance • Increased injury • Decreased durability and pain
- 39. Movement Adhesions limit movement limited movement creates compensations Compensations create stress Chronic stress creates adhesions
- 40. Key Laser therapy Protocols for Musculoskeletal Injuries
- 41. Carpal Tunnel Treatment Protocol • Laser at point/points of involvement (9,16,21,36) – 3 to 5 mins. max • Laser during movement – 30-60 sec. • Laser “locomotor lock-in” • Nerve floss • Corrective exercise • Nutritional protocol: B vitamins (B5, B6), omega-3 fatty acids • Mobilize, manipulate joint restrictions • Myofascial release
- 42. Carpal Tunnel
- 43. Rotator Cuff Injury Treatment Protocol • Laser at point/points of involvement: • Muscle/joint/scapular (9,16,42,53) • Laser during movement – 30-60 sec. • Laser “locomotor lock-in” • Corrective exercise • Nutritional protocol: see 3 Phases of Care • Mobilize, manipulate joint restrictions • Myofascial release
- 44. Exercise and LLLT for Subacromial Impingement • Conclusion: This double-blind, randomized control trial showed that LLT and exercise therapy is more effective than exercise therapy alone for the purposes of improving pain and active/passive ROM in patients with subacromial syndrome Clinical Rheumatology 2011; 30: p1341-46
- 45. Supraspinatus
- 46. Intervertebral Disc Tx Protocol (cont’d) • Core “lock-in” • Nutritional protocol: • Glucosamine chondroitin MSM complex • Omega-3 fatty acids • Turmeric, ginger, boswelia • Mg/calcium • Outer annulus – ca, mg, vit. D, boron, horsetail aerial parts, silica • Myofascial release • Mobilize, manipulate, flx/distraction, joint restrictions
- 48. Lat/Medial Epicondylopathy Tx Protocol • Laser at point/points of involvement: (9,16,42,53) • Laser during movement: 30-60 sec. • Laser “locomotor lock-in” • Corrective exercise • Core “lock-in” • Nutrition protocol • Myofascial release • Mobilize, manipulation, joint restrictions
- 51. Non Surgical Interventions for Rheumatoid Arthritis Christie et al PT Journal December 2007 • LLLT reduces Pain and improves function!! • Higher Quality of evidence than US, TNS, Heat, Exercise, ES, Acupuncture.
- 52. The low-level laser therapy application improves the healing process of the Achilles tendon of rats Conclusion: the laser treatment is effective during the healing process in tendons since there is more presence of gags and collagen types I and III in tendons submitted to low-level laser than in tendons without treatment. With respect to the active isoform of MMP- 2, the low-level laser with a pulsed emission is more effective than low-level laser continuous 2012 Fascial congress abstract. FR Guerra, CP, Vieira AA Aro, EP Pimentel
- 53. Effects of LLLT in the development of exercise- induced skeletal muscle fatigue and changes in biochemical markers related to post- exercise recovery Conclusion: pre-exercise irradiation of the biceps with an LLLT dose of 6 J per application location, applied in 2 locations, increased endurance for repeated elbow flexion against resistance and decreased post-exercise levels of blood lactate, creatine kinase, and C-reactive protein J Orthop Sports Phys Ther, 2010 Aug;40(8):524-32
- 54. Low-Level Laser Therapy for Sports Injuries Conclusion: LLLT is an effective treatment for sports injuries, particularly jumper’s knee, tennis elbow, and Achilles tendinitis Y. Morimoto, A. Saito, Y. Tokuhashi, Low level laser therapy for sports injuries. Laser Ther. 2013; 22(1):17-20
- 55. Getting Athletes Back in The Game: Low-Level Laser Therapy For Sports Injuries “Most athletes with chronic ankle sprains have a proprioceptive deficit in that injured ankle. Proper proprioceptive exercises coupled with laser therapy have enabled many of my athletes to avoid the recurrence so commonly seen with the injury.” Dr. Robert Silverman Dynamic Chiropractic, Aug. 1, 2014
- 56. Low level laser therapy (LLLT) in the management of neck pain Conclusion: LLLT reduces pain immediately after treatment in acute neck pain and up to 22 weeks after completion of treatment in patients with chronic neck pain Lancet, Nov. 13, 2009
- 57. LLLT Effectiveness • The International Association for the study of pain found “strong evidence” for LLLT on myofascial pain syndrome
- 58. A meta-analysis of the efficacy of laser phototherapy on pain relief Conclusion: These findings warrant the conclusion that laser phototherapy effectively relieves pain of various etiologies; making it a valuable addition to contemporary pain management Fulop AM, Dhimmer S., et al. Clin J Pain. 2010 Oct; 26(8):729-36
- 59. Frozen Shoulder: The Effectiveness of Conservative and Surgical Interventions Conclusion: Strong evidence for the effectiveness of laser therapy British Journal of Medicine 2011, Jan. 45(1), p.49-58
- 60. Treating TMJ Pain with Low-Level Laser Patients with functional TMJ pain reported significantly reduced pain scores (pain Visual Analog Scale) following five treatments with low-level laser therapy 0 5 10 15 20 25 30 Before laser therapy After laser therapy 27.5 4.16 Dostalova T, et al. Effectiveness of physiotherapy and GaA/As laser in the management of temporomandibular joint disorders. Photomed Laser Surg, 2012;30(5):275-80
- 61. Low-level light stirs in vivo stem cells to regenerate tissue • Researches have demonstrated for the first time that non-invasive, low-power light therapy can prompt stem cells inside the body to reconstruct tissue • Research promises a broad range of clinical applications in wound healing and bone growth • Led by Dr. David Mooney of Harvard University – the team used a low-power laser to trigger human dental stem cell to form dentin (hard tissue that is similar to bone and makes up bulk of teeth) P.R. Arany, Sci. Trans Med 6, 238 (2014)
- 62. Low-level light stirs in vivo stem cells to regenerate tissue (cont’d) • They outlined the precise molecular mechanism involved and demonstrated its abilities using multiple laboratory and animal models P.R. Arany, Sci. Trans Med 6, 238 (2014)
- 63. Neurodynamic test – Lower Extremity • Sciatic: slump or add neck flexion (SLR) – piriformis • Tibial: df/ev/SLR - posterior to the knee • Peroneal: pf/in/SLR – head of fibula/medial to b. femoris • Sural: df/in/SLR – bottom of calve • Femoral: prone knee bent – inguinal ligament
- 64. Laser Nerves • Brachial plexus – scalenes • Median – pronator teres, flexor retinaculum • Ulnar – olecranon and medial epicondyle • Radial – triangular space between T minor, LH triceps and humerus • Sciatic – piriformis muscle • Femoral – psoas • Tibial – posterior to knee • Peroneal – medial biceps femoris/head of fibula • Sural – calve region • Tarsal tunnel –at tunnel
- 66. Cell membrane Health Alpha-Linolenic Acid (ALA) (e.g., green vegetables, flaxseed oil) Steridonic Acid Eicosatraenoic Acid delta-5 desaturase EPA/DHA (e.g., fish oils) Cyclooxygenase Lipoxygenase Delta-4 desaturase (DHA critical) PGE3 LTB5 (anti-inflammatory) (anti-inflammatory) Linoleic Acid (LA) (e.g., corn, safflower, sunflower oil, grains) Gamma-Linolenic Acid (GLA) (e.g., evening primrose, borage, black currant seed oils) Dihomo-Gamma-Linolenic Acid (DGLA) delta-5 desaturase Arachidonic Acid (ArA) (e.g., grain-fed meat) Cyclooxygenase Lipoxygenase PGE2 LTB4 (pro-inflammatory) (pro-inflammatory) Competing Delta-6 desaturase Blocked by insulin, trans fats, alcohol, Stress OMEGA-3 EFA PGE1 (anti-inflammatory) OMEGA-6 FA Competing B3, B6, C, zinc, mg. (nutrient co-enzyme) Ginger, turmeric, bioflavonoids, boswelia (co- enzyme) Cell membrane
- 67. Laser directed to affected site Photon Enters Tissue Alters Cell Permeability Cellular Photochemical Reaction Absorbed into Mitochondria ATP+ Resulting Effects Rapid Cell Growth Increased Metabolic Activity Increased Angiogenesis Vascular Activity Suppression of COX-2 Pathway Decreased Inflammation
- 69. Choosing Your Next Laser • Regulating considerations – FDA-cleared • Therapeutic factor – laser light parameters: • Dose and frequency • Wavelength • Power • Modulation (pulsing) of light • Non-therapeutic factors: • Portability • Size and weight • Corded or cordless operation
- 70. What does the low-level laser do • Laser therapy – stimulates both the nervous system and site of tissue injury • Clinically proven to: • suppress inflammation • Increase oxygen and blood flow • Promote muscle calcium update • Increase neurotransmitter release • Key – by addressing the injury with a diverse tool it is possible to resolve the condition more effectively by suppressing not one but all contributors
- 71. Dr. Rob’s Sexy Six 1) Laser delivers light energy 2) Lasers can stimulate cell activity 3) Laser is classified based on its power supply 4) Wavelength (color) is the length of the wave of the light energy 5) The kind of tissues treated depends on wavelength and power supply 6) Laser companies do not always agree
- 72. Quote “A mind once stretched by a new idea never regains its original dimensions” Oliver Wendell Holmes
- 73. Q & A