Laser Therapy Blog

Previously, we have looked at a general treatment approach, as well as treatment frequency for acute conditions in particular. Here, we will look further into treating chronic conditions. As opposed to acute conditions where our goal is resolution, the goal in treating chronic conditions is essentially to prevent an active decline with an incurable condition.

A complete recent physical examination is crucial when addressing a chronic condition, as it is likely that there have been compensatory changes in secondary or even tertiary biomechanically associated sites. For example, lumbar spine degeneration and iliopsoas muscle strain are often seen with the primary issue being degenerative joint disease of the pelvic limb (like with CCL rupture). Thus, a recent physical exam is a must as the progression of chronic disease can be quite dynamic and multifaceted. Not addressing all of the patient’s areas of pain or discomfort may lead to unsatisfactory results and difficulties managing client expectations. The natural progression of arthritis can be better assessed and addressed by reading and understanding the subtle symptoms that the patient develops as their condition continues to deteriorate.

It is just as important for the laser operator to have a thorough knowledge base in anatomy. Using the iliopsoas as an example, the operator must be able to visualize the target structure, from its origin at the lumbar spine to its insertion point at the lesser trochanter of the femur. The same principle applies to skeletal structure and neural pathways.

The third important aspect of treating chronic conditions lies in setting realistic goals and expectations prior to initiating a treatment regimen. Age is not a disease, but it is a consideration. Each case will have individual factors, which will be taken into account when establishing these goals. The adept operator will keep in mind that geriatric patients have a slower rate of response to therapy, partly due to a slower metabolic rate, but also potentially due to concomitant disease.

Primarily, promoting quality of life via a sustained palliative response is always the primary goal. Secondly, it is our long-term expectation to be able to prevent an active decline by slowing the progression of the disease. Lastly, we may also be able to taper pharmaceuticals or even discontinue them. There are so many unique factors that each case must be handled as a separate entity.

Once these three factors have been addressed, we can proceed with a complete picture and a common goal for the case. Typically, a chronic condition will need an extended induction (or initial) phase of treatments. This induction phase is usually around 6 treatments, but with these cases, it may extend up to 9 or 12 treatments before an effective and sustained clinical response is seen.

Unless the patient is in established pain, an every other day frequency is typically applied when starting laser therapy for these cases. Once significant clinical improvement is seen, the operator should consider tapering the treatment frequency so as to promote a continued response. In this fashion, the patient is expected to undergo several treatment phases, from frequent “induction”, to less frequent “transition”, and then long term “maintenance” phase treatments.

Sometimes, a client will report the patient seemed a little stiff after the first few treatments. Although this may seem unsettling, this is actually an encouraging sign of active tissue remodeling taking place. Remember, part of the cascade of events that happens with photobiomodulation is vasodilation and angiogenesis. It can be easily explained to the client by making the analogy of blood flow returning to a foot after it went numb from kneeling for too long. This is similar to the “pins & needles” feeling we get with reperfusion of tissues after an ischemic event. When noted, it should be transient and low grade, and is usually seen early after initiating the modality. If it is not seen, that does not mean that the patient is not responding effectively, it just means each patient is an individual and not a statistic.

As the patient progresses through treatment phases, we are able to maintain a clinical response while periodically tapering on the frequency of treatments. It is important for the client to be aware that regardless of the current treatment schedule, they are to return as soon as possible if there are any setbacks or sudden decline. Photobiomodulation offers the operator a certain flexibility in order to enable not only a long-term response, but be able to address acute to chronic events as well.

Many patients will benefit from long-term photobiomodulation therapy. Our patient base will also continually grow as we enable longer life spans via the advancements in the medical field. The savvy laser operator will also be dedicated to keeping an eye out for patients predisposed to arthritic changes, such as working dogs/athletes, chronic NSAID/opioid users, breed predisposed for DJD, patients with surgical implants or a history of traumatic injuries, etc.

As previously discussed, an individual approach in designing treatment frequency will yield optimal results when incorporating photobiomodulation into standard of care. Thus, it is important to remember that we must be flexible in our treatment delivery and remain fluid as the patient responds to medical care.

In past years, the “3-2-1” approach showed good results, but it is clear that taking an individual approach in treatment delivery yields optimal results. With this treatment approach, the patient received three treatments the first week, two the second week, and one final treatment the third week. Although this approach will yield results, it is not an optimal approach as it allows no flexibility in treatment delivery.

Acute conditions should be approached with resolution as our final goal. Examples would include a laceration, an abscess, a muscle sprain, etc. The primary goal, regardless of the condition, is always pain relief, but the biggest value in utilizing photobiomodulation is the fact that tissues are also physically being remodeled to return to function. With resolution as our final goal, the patient is expected to undergo a short course of treatments to reduce the convalescence period.

As with any condition, the patient must be assessed comprehensively and all factors be taken into account so as to set out reasonable expectations. A superficial condition like a laceration would benefit from a single treatment, much like many clinics are performing a single post-op treatment on spays/neuters, etc. as part of their multimodal approach to pain management.

Some acute conditions may benefit from a short series of treatment when there is a larger surface area of tissue disruption, such as with hot spots. These will respond nicely when incorporating photobiomodulation daily to every other day for a handful of treatments.

In some cases, conditions may benefit from even more frequent treatments. For example, patients in intractable pain despite standard of care (NSAID, opioids, CRI, etc.) need a more assertive delivery schedule. These patients are so debilitated that they are usually hospitalized, offering the caretaker the opportunity to treat as often as needed. Such cases could include pancreatitis, FLUTD, HGE, snake bite, severe degloving wounds, etc. In this instance, the patient may require multiple treatments daily to address for this pain. Photobiomodulation offers this flexibility to deliver two or even three treatments daily if the patient requires this amount of care. Once an effective clinical response is noted, we can then consider tapering the treatment frequency.

The frequency of treatment remains an area where photobiomodulation offers the operator the flexibility to address the patient’s needs and their conditions as individuals. As such, there is no “cookie cutter” approach to this – it is best addressed as per the patient’s presenting condition and ensuing glide path of response.

As we continue to delve further into Platelet Rich Plasma and how it treats conditions, the most common questions that arise during discussions are:

1. Do we want white blood cells in our PRP?
2. If so, which white blood cells do we want to include?

In this post, we will explore the different types of white blood cells, their functions and whether they are beneficial or detrimental in Platelet Rich Plasma.

What are White Blood Cells?

White Blood Cells (WBCs), also known as Leukocytes, make up the majority of the body’s immune system. Their main purpose is to protect the body from foreign substances and various types of infections.

What are the different types of White Blood Cells?

1. Neutrophils
2. Monocytes
3. Lymphocytes
4. Eosinophils
5. Basophils

What are their functions and are they beneficial when included in Platelet Rich Plasma?

1. Neutrophils

• Basic Function: Neutrophils are the first responders during an infection or injury. When there is a site of injury, they destroy germ cells through a process called phagocytosis, which in Ancient Greek literally means “to devour”. Neutrophils also kill invading cells through the release of reactive oxygen species and antimicrobial peptides which are toxic to the invading germ cells. ¹
• Role in PRP: Neutrophils have been shown to release damaging molecules which can degrade collagen and other tissues along with extracellular matrix molecules. Neutrophils also release pro-inflammatory cytokines which leads to further damage in the tissue. Therefore, their inclusion in Platelet Rich Plasma, specifically for arthritic applications, is not recommended. ²

2. Monocytes

• Basic Function: The three main functions of monocytes are: phagocytosis, facilitation of communication between the innate and adaptive immune systems, and cytokine production.³
• Role in PRP: It has been found that Monocytes are associated with an increase in cellular metabolism and collagen production in fibroblasts. It has also been found that monocytes moderate the release of anti-angiogenic cytokines such as interferon-ɣ and IL-12.⁴ Therefore their inclusion in Platelet Rich Plasma is considered beneficial.

3. Lymphocytes

• Basic Function: Lymphocytes are the patrolling cells in the circulatory system that are responsible for recognizing and responding to invading pathogens. They are characterized into three subtypes: T-Cells, B-Cells and Natural Killer Cells (NKCs). T and B cell’s main function are to recognize pathogens and moderate the inflammatory response through the release of cytokines and antibodies. They also are accountable for adaptive immunity, meaning should the same pathogen be encountered again, the body is ready to respond with antibodies. Natural Killer Cells play a major role in defending the body from both tumors and virally infected cells. They are activated when cytokines (called interferons) are released, and produce cytotoxic granules that specifically destroy the altered cells.
• Role in PRP: Currently the significance of Lymphocytes in Platelet Rich Plasma unknown. It is known that platelets activate Lymphocytes as part of the healing cascade through elevated levels of IL-6, however their benefit or detriment to PRP is still unclear.

4. Eosinophils

• Basic Function: Eosinophils are most commonly known as a defense mechanism against parasites and are important mediators of allergic reactions.
• Role in PRP: Eosinophils are known to produce several beneficial growth factors including VEGF, PDGF and TGF-β. These growth factors are associated with angiogenesis, cellular proliferation and extracellular matrix formation.⁵ Therefore their inclusion in Platelet Rich Plasma may be beneficial in tissue repair.

5. Basophils

• Basic Function: Basophils are also recognized to play a role in parasite defense and allergic reactions. They release several proteins that increase vascular permeation and regulation of the inflammatory process.
• Role in PRP: The role of Basophils for PRP are relatively unknown. Basophils are known to secrete pro inflammatory cytokines but little is known if these are beneficial or detrimental to a PRP sample.

What is the bottom line?

With the current knowledge and research surrounding White Blood Cells, it is generally understood that a PRP sample should include an increase in Monocytes and a decrease in Neutrophils. Knowledge regarding the role of Lymphocytes, Eosinophils and Basophils in PRP is still limited, therefore absolute decisions on their inclusion or exclusion cannot be made. But as our understanding of White Blood Cells and their roles in PRP continue to evolve, formulations of PRP in the future may change to treat a specific condition, moving this from a personalized medicine to a precision medicine.

Stay tuned for our next blog where we will answer your questions about Platelet Rich Plasma. To submit a question for our next blog, email heatherw@companiontherapy.com.

References:

1. Mayadas, T. N., Cullere, X., & Lowell, C. A. (2014). The Multifaceted Functions of Neutrophils. Annual Review of Pathology, 9, 181–218. http://doi.org/10.1146/annurev-pathol-020712-164023
2. Helen L. Wright, Robert J. Moots, Roger C. Bucknall, Steven W. Edwards; Neutrophil function in inflammation and inflammatory diseases. Rheumatology (Oxford) 2010; 49 (9): 1618-1631. doi: 10.1093/rheumatology/keq045
3. Nichols, B. A., Bainton, D. F., & Farquhar, M. G. (1971). DIFFERENTIATION OF MONOCYTES : Origin, Nature, and Fate of Their Azurophil Granules. The Journal of Cell Biology, 50(2), 498–515.
4. Sundman, E.A. et al. (2013). The Anti-inflammatory and Matrix Restorative Mechanisms of Platelet-Rich Plasma in Osteoarthritis. The American Journal of Sports Medicine.Vol 42, Issue 1, pp. 35 – 41
5. Duarte, J. et al. Platelet-Rich Plasma: Regenerative Medicine: Sports Medicine, Orthopedic, and Recovery of Musculoskeletal Injuries. Springer Science & Business Media, Oct 29, 2013 pp 220