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Learn tips about Class IV laser therapy and other health related topics on the Companion Therapy Lasers blog!  Check back weekly for updated posts.

Contributed by Ren Houyoux, LVT

As the veterinary community is quickly learning, the applications for photobiomodulation therapy (PBMT) are nearly as varied as the different types of injuries and diseases we see in the patients who walk through our doors. To accommodate the rapidly growing range of uses for this technology, the market needed a delivery platform flexible enough to be used in a myriad of settings, species, and conditions. To satisfy this need for clinical versatility, Companion Animal Health developed the Empower Delivery System, which features four unique treatment head attachments, each designed to maximize therapeutic benefit, no matter what condition or animal you may be treating.

In this blog post we will discuss best practices for choosing attachments, including how to inspect them for defects prior to use and how to ideally match them based on their intended use. We will also discuss the optical properties of each attachment head, specifically the divergence (widening) that occurs and the corresponding impact on treatment.


Pre-Treatment Attachment Inspection

At all times when treating with laser therapy, we must ensure that the treatment head lens is clean and intact. Before starting each treatment, you should ensure there is an even beam spot visible from the aiming beam. If there is debris, hair, blood, oils, or any other foreign material on the surface of the lens, it has the potential to alter the laser beam as it is emitted. We recommend using a 70% isopropyl alcohol solution to clean these lenses, and then immediately drying them with a lint-free cloth or Kim wipes (not scrubs, paper towels, gauze, or other materials as they could cause a surface hazing to eventually develop over time).

Additionally, any damage to the lenses, such as fissures, cracks, pitting, surface blemish, hazing of the surface, or any other physical degradation could alter the laser beam. A damaged attachment must be immediately replaced if there are any signs of degradation.


Proper Attachment Selection

The primary factor to consider when selecting an attachment is the intended use. So, the size of the treatment area and the condition to be treated must both be taken into account. When tolerated and/or appropriate based on the condition being treated and patient response, laser therapy should be applied directly to the skin (or fur coat) using an “on-contact” treatment method, as there are multiple advantages of using an on-contact technique. With an on-contact technique, the deep tissue applicators should be used.

When operating the laser unit with an off-contact technique, the flat lens cone attachments should be used. With an off-contact technique, the attachment should be held over the tissues at about a distance of 1” – 3”. The cone attachments should NEVER come close or make contact with tissues. Also, the ‘hover distance’ from the tissues should be strictly adhered to when utilizing the cones, as the divergence could cause the beam to spread and expose unintended objects to the laser light.

Another important factor in treatment head selection is the power setting (measured in watts, abbreviated as W) at which the laser is set to operate. The small deep tissue and cone attachments are designed to be used at any power up to 3 W. Any time we are operating over 3 W, we need to be using the large deep tissue applicator or large cone attachment. This power range delineation is meant to account for irradiance (W/cm²), as well as to enhance both patient comfort and durability of the attachment.


The Effect of Divergence

Each treatment head lens has a specific effect on the laser beam as it is emitted though the lens and onto patient tissues. The widening (or “divergence”) of the beam as it is being emitted through the lens should be considered when treating to ensure proper energy delivery to target tissue. Thus, it is crucial that the operator be aware of each treatment head’s specific divergence and operate within the specified distance so as to prevent near-field objects from being exposed inadvertently.

The large deep tissue applicator has a divergence of only 3 degrees, so the beam emitted remains highly collimated. The small deep tissue applicator has a somewhat larger divergence of 13 degrees. Both cone (non-contact) attachments diverge the beam at a more extreme angle of 47 degrees. The operator’s understanding of the optical properties of each attachment is thus crucial in appropriate attachment selection, designing and carrying out valid, safe, and time-efficient treatments. The pictures below demonstrate this attachment-specific divergence as shown by the aiming beam when in ready mode or during beam emission.

Empower Delivery System Attchement Details_Companion

Just like any other tool we have, we must utilize the PBMT unit the way in which it was designed to operate. Correct attachment selection is as important as appropriate technique (hovering at 2” above tissue surface with the cone applicators, not closer or further away) when using the laser therapy unit correctly. The variety of attachments provides the operator with fluidity in treatment applications and thus the ability to address a variety of conditions in an array of patient species.

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Regardless of the condition being treated, a thorough and comprehensive documentation of medical care and patient response are a crucial part of the patient’s daily record (PDR). Yet, lack of complete documentation is one of the most common oversights in medical care. Although sometimes easier said than done, this oversight can be easily be prevented by simply taking the time to stay current on each patient’s record.

Thankfully, keeping up with patient records is a task we can make easier for ourselves by taking advantage of several allied technologies that are now available to us. Learning when and how to use these technologies will greatly decrease the time needed to provide a higher level of documentation (and care) for our patients.

Humans are very visual creatures, so it follows that documenting a case with pictures and short videos is of great value. Depending on the software being used by the practice, there are many ways to incorporate this data into most system platforms. For example, Avimark, Impromed, and Cornerstone (among others) can easily import pictures or videos from a camera, iPad, or other digital devices into a specific patient’s PDR. To the trained eye, these pictures can reveal a myriad of minute yet crucial details that would otherwise be left undocumented.

Stance Analyzer_ROM MeasurementAnother tool to consider is a goniometer. With this simple tool, we can accurately quantify the range of motion a specific joint allows. Not only can we assess level of debilitation with this tool, but we can also monitor a patient’s glide path of response to medical care as we treat the patient.

The goniometer is commonplace in veterinary practice, but is also oftentimes combined with another tool primarily utilized by rehabilitation practitioners – the Gulick device. This is a tape measure like tool used to measure the girth of an appendage. This is a very valuable tool to use when treating patients where a certain amount of muscle atrophy and cachexia have occurred. Learning to use tools like a Gulick device is not complicated and provides a valuable way to gauge a specific aspect of the patient in an objective manner.

Stance Analyzer_Golden Retriever 4_SmallA more advanced piece of equipment, called a Stance Analyzer, can accurately measure the percentage of total body weight being placed on each limb at standstill. Again, since we know the commonly accepted range for these values, the stance analyzer gives us another way to assess, and thus better treat, each patient as per their presentation and response to medical care. Similar technologies include the latest force plate analysis devices and gait analyzers, which additionally allow us to analyze a dynamic patient instead of a static stance and thus can help us possibly detect other gait abnormalities such as changes in stride length, etc.

Digital thermal imaging (DTI) is another example of an allied technology with which we can better assess our patients. This device allows us to visualize variances in thermal radiation being emitted from a patient. With this tool, we can detect not only areas that may be inflamed, but those where there may be other changes to blood flow as well. This technology can also be very useful in detecting tissue asymmetry, thus coordinating with our other tools in assessing any potential sites of overcompensation.

Utilizing and recording the results of these allied technologies not only helps us to provide thorough case documentation, but also allows the clinician to provide optimal care for each patient. The clinician and technician can better follow each case’s glide path of response and adjust further medical care accordingly. As with other modalities in veterinary medicine, all of these latest advancements in allied technologies are continuously being improved upon, so it would be advantageous to remain current on these developments and consider investing in technologies like these that are able to save staff time, while simultaneously improving standard of care.

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Elevating Multimodal Treatment by Making Laser Therapy Standard of Care Blog Post Photo_Owl and ElephantNext to its unique characteristics allowing patient stress, fear, and pain to be reduced, photobiomodulation therapy (PBMT) also has the ability to be utilized as an adjunct to standard of care for a myriad of conditions affecting species ranging from the smallest avian to the biggest elephant. PBMT offers us not only a noninvasive and painless tool, but it also affords the operator certain flexibility in its applications, as per the level of tissue disruption involved.

Certainly, each case is an individual instance and must be approached with an individual treatment design and delivery plan. Just as no two patients are the same, neither are the specifics surrounding the etiology / progression / current status and treatment care / etc. of each case. PBMT offers us the flexibility of addressing cases where there is any level of pain, inflammation, and/or tissue disruption. Most, if not all the patients we see, regardless of species, are likely to fit the bill in at least one of the three categories cited. Let’s take a look at some of the commonly-used ways in which a clinic can implement a successful PBMT program as an adjunct to standard of care.

Typically, a new adopter the modality will begin by using it for cases responsive to a short treatment course. Usually, these include acute conditions involving superficial tissues, such as pyotraumatic dermatitis and post-operative incisions. Naturally, as the operator’s knowledge base grows, so will the daily applications of the modality. Most operators report a positive experience in delivering this level of care. It is as therapeutic for the operator to provide this leading-edge level of care as it is for our patients to undergo it. The most challenging part of starting a successful and multifaceted PBMT program in a clinical setting is to overcome inertia. Once the ball gets rolling, it will naturally pick up speed.

Companion -739Once the operators have applied the early stages of making PBMT a core part of their multimodal approach to pain management, then the next natural evolution is to incorporate it with routine anesthetic procedures. Here, we see patients undergoing either a surgical or dental health procedure. In this setting, the therapy laser platform can again be utilized in a series of ways, from conditions such as gingivitis (the only reversible dental disease), going all the way up to multiple extraction sites or stomatitis. With surgical procedures somewhat more involved, like an extracapsular cruciate repair, a pre-op and post-op treatment would also prove to be of value. PBMT should also be highly considered as part of a convalescent care plan, especially when dealing with invasive or orthopaedic procedures (e.g. – FHO, TPO, TPLO, TTA, limb amputation, etc).

As with anesthetic patients, hospitalized patients should be given specific consideration and be offered the benefits of PBMT, especially while they are on location. Such examples that have shown the value of PBMT to standard of care include pancreatitis, HBC, degloving injuries, and snakebites, just to name a few. Typically speaking, “time is tissue” when it comes to injury to tissues (both soft and dense). The savvy laser operator is able to embrace this concept and thus understands to have a certain window of fluidity in the application of the modality. The operators’ knowledge base in PBMT and ability to be flexible with an in-patient approach treatment design and delivery, enables them to best address the individual needs and caveats of each case as a separate application (i.e. special considerations such as: active hemorrhage, neoplasia, or active growth plates).

Once a practice has reached this level of understanding and has applied a level of commitment in incorporating PBMT with their core values and message, and confident in its application, the final step is to incorporate it with long-term care plans. In this setting, the focus is on outpatient appointments, scheduled much as they would be for a DVM seeing outpatients. These are the long-term patients with incurable conditions where our goal (and reasonable expectation) is to manage the condition and prevent an active decline. Often, once a clinic gets to this level of focused care, a specific “daily designated laser operator” is usually assigned to the task of handling the daily appointments (larger practices with a sizeable technical staff will incorporate a rotation of daily operators so as to have everyone remain proficient in their technique).

Most practices successful in their integration and implementation of PBMT within their departmental daily modus operandi, in addition to the current standard of care, have proven the modality a synergistic behemoth in our ability to continue to adapt to, adopt, and successfully implement a dynamically evolving aspect of veterinary medicine. The successful and practical applications of PBMT are limited only by the specifics of the case and the ability of an operator to perceive the modality’s application for a specific case presentation. The initial inertia previously mentioned is quickly overcome and replaced by a momentum which will help propel any practice to the next level of patient care when PBMT is allowed to fully develop as a medical modality in clinical practice.


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