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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 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 ExampleDigital 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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When utilizing therapy laser units, ocular protection is the primary safety concern. Exposure to the eye is at the top of a short list of contraindications for photobiomodulation therapy (PBMT). While this medical modality is not applicable to this physical structure, it is of great value for a myriad of conditions affecting other parts of the body. We need to take precautions to prevent accidental ocular exposure, and we would never intentionally laser the eye itself. That being said, an experienced operator can certainly do periorbital treatments as long as they protect the eye itself.

Companion Glasses_Wavelength Close UpCompanion Glasses_Wavelength Close Up

Appropriate ocular protection is easily acquired and achieved. Only laser-safe eyewear of appropriate optical density (OD) specific to the wavelength(s) of light being used should be utilized as personal protective equipment (PPE). This very specific product should be provided by the manufacturer as part of adding PBMT to the practice, but may also be available from separate sources. Laser safe eyewear is always labelled with the wavelength(s) of light they are specific to (on the top or bottom edge of each lens) and with an appropriate optical density (OD). Thus, if the eyewear is not labelled with an optical density for specific wavelength(s), it is not considered to be laser safe.

Since varying therapy units utilize different wavelengths, it is important that ONLY the eyewear provided by the manufacturer be used. Protective laser eyewear is specific to the unit, so we cannot use protective eyewear provided with a surgical laser, for example, when using a therapeutic laser platform.

So, why is it that light outside our visible spectrum (~ 380nm – 700nm) can harmful to the eye? It’s very simple: the globe and the structures within are made to capture and focus light. As light enters through the eye, it is focused by the lens onto the retina for optimal reception and differentiation. While this is designed for average intensity of non-collimated light, we have naturally evolved to avoid excessive exposure with aversion reflexes such as blinking, squinting, etc. By definition, a laser beam of light has three properties: it is monochromatic, coherent, and collimated. Such a beam of light going through a lens would cause damage to the retina due to focusing an already intense beam of light.

Also, we must remain aware of the nominal ocular hazard distance (NOHD). This is the distance within which anyone (patient, operator, or observer) should be wearing laser safe eyewear during laser operation. NOHD can vary greatly as per the specifics of the unit, wavelengths, power, and equipment utilized (including type of treatment head). Following manufacturer recommendations and utilizing appropriate PPE ensures that we are operating well within safety margins.

Doggles_Full SetSome manufacturers may supply laser safe eyewear for pets as well. Companion Animal Health currently supplies Doggles®, which have had special laser safe lenses of appropriate optical density placed into the frames. Certainly, laser safe eyewear is the best option to protect the eyes of patients when treating around the head and/or neck or forelimbs, but there are also other ways to do this. There may be cases where Doggles may not be available, or the patient will not tolerate them, and in such instances, an operator can use their finger(s) or hand to shield the eyes. A piece of dark cloth can also to cover the eyes be used as any inorganic material will reflect light to a certain degree (depending on several factors as thickness, density, pigmentation, etc).

Baring Boulevard_B.C._CroppedThere are other tools we can use to shield the entire head of the patient itself, such as with the Comfy Cone® Elizabethan collars, made of dark, soft material that is comfortable for the patient to wear. The savvy laser operator may also have an assistant apply a series of distraction techniques for the patient during treatment sessions as well—simply petting the dog or cat, or offering food treats to keep the patient from investigating the laser treatment being administered.

Lastly, we also need to remember the required signage that needs to be prominently displayed when the laser is in use. Again, the manufacturer needs to provide this signage as it may slightly vary between different units. Each entryway leading in or out of the room where the laser is being used needs to have this sign as an added measure of safety.

It is important to remember that laser safe eye protection is not only our primary safety parameter, it is also one of the few and yet very specific guidelines set out by OSHA when it comes to the application of photobiomodulation therapy (PBMT). However, meeting this safety standard is easily achieved and should never be an issue in a clinical setting.

 

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