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Contributed by Ren Houyoux, LVT

When performing a laser therapy treatment, selecting the appropriate treatment head for the intended technique as well as the selected power is imperative. When treating using an on-contact method, only the deep tissue applicators (also referred to as “massage ball” applicators) are appropriate to use. The two flat “cone” attachments can NEVER be used with this technique, as it is not their intended method of delivery and could cause harm to the patient or damage to the treatment head itself – their use is restricted to an OFF-contact technique.

Benefits of Treating On-Contact

There are several advantages to treating with an on-contact technique. First, making direct contact will reduce the amount of light reflection off the skin’s surface and maximize penetration into the deeper target tissues. Any time we operate off-contact, a certain amount of natural reflection from the surface of the skin and the hair coat occurs.

Second, by making contact and applying a moderate amount of pressure (similar to a massage), we are able to blanch the tissue and reduce the amount of incidental light absorption by hemoglobin in superficial capillaries, etc, thus further optimizing photonic saturation of deeper target tissues. Additionally, this massage-like technique not only feels good to the patient, it also encourages local blood blow.

Lastly, applying a combination of on-contact treatment while applying a moderate amount of pressure will compress superficial tissues (such as fat), bringing the target tissues closer to the laser’s point of emission. A myriad of deep musculoskeletal conditions can and should be treated with an on-contact technique, including osteoarthritis, sprains, fractures, tendinopathies, cystitis, asthma, and pneumonia.

 Benefits and Best Practices for On Contact Laser Therapy Blog Image 2

Ensuring Adequate Dose Delivery

In order to ensure complete saturation of the target tissues, the hand piece must be held perpendicular to the tissue surface. Any time we operate at any other angle than perpendicular (90⁰), the beam spot will be distorted, reflection from the tissue surface will increase, and there is an overall uneven distribution of light to the tissues.

In addition to treating perpendicularly, it is also important to remember to treat all limbs/extremities with a circumferential approach (from 360⁰) so as to fully and evenly illuminate the target tissues and structures.

Knowing Your Equipment

We should also be mindful of the parameters specific to each attachment head. The two attachment heads meant for an on-contact technique (also called “massage ball” or “deep tissue applicator”) each have their own power applications and beam divergence (widening). While the large deep tissue applicator can be used at any power and has a divergence of 3⁰, the small deep tissue applicator should NOT be used when operating over 3 watts, and it has a divergence of 13⁰.

Thus, we should select the appropriate treatment head as per the specifics of the case and should be able to “visualize” tissue exposure. So, while the large massage ball has a larger beam spot (at the surface of the lens) than the small massage ball, the latter has a more pronounced beam divergence (widening) as the laser gets further away from the hand piece.

That being said, the deep tissue applicators may be used with an off-contact approach when the situation allows. The beam of the large deep tissue applicator only diverges at a 3⁰ angle, meaning the beam itself remains highly collimated. This high-degree of collimation is ideal when performing intraoperative treatments when we cannot make contact with sterile tissues. Thus, a very specific area (such as a cystotomy incision, anastomosis, enterotomy, gastrotomy, etc.) can be treated from a short distance without compromising sterility.

 Benefits and Best Practices for On Contact Laser Therapy Blog Image 1

Maximizing Patient Comfort

Part of deciding on a treatment approach (i.e. on/off-contact) also depends on the amount of sensitivity a patient displays. If a patient is extremely painful, it may be needed to start therapy with an off-contact approach and work our way up to an on-contact technique once we’ve attained a significant clinical (palliative) response.

Sometimes, a patient may seem sensitive when it may actually be a “startle” response when the operator makes initial contact with the skin. This startle response could also be from a temperature gradient (i.e. the treatment head surface may be cold). It is useful for the operator to make initial contact nearby, but away from the painful tissues so as to minimize or prevent this type of response. Making initial contact with a non-painful part also decreases the stress the patient will experience. For example, a geriatric cat suffering from lumbar spondylosis can be relaxed by using the deep tissue applicator as a massage ball on the neck just prior to moving to the lumbar spine and starting treatment.

It is also important to determine if the patient is hypersensitive to touch, temperature, or both, especially in cases in which the laser operator is treating for chronic pain. This is particularly true over boney prominences, and in areas of thinned skin, especially of the elbow and the stifle. In these patients, as well as in any patient with a wound in the treatment area, treating in an off contact manner may be necessary. A simple technique that can differentiate between patients objecting to physical contact and those sensitive to warmth is to attempt to “treat” with the laser off, that is simply applying gentle pressure with the massage ball treatment head. If the patient does not object to this technique, but displays agitation or signs of discomfort during treatment when the laser is on, adjustments may need to be made in turning the power down (usually in increments of 2W) and attempting to treat again, following proper guidelines on monitoring patient comfort as discussed in previous blogs.

 

Proper treatment head selection and delivery technique are of crucial importance with any photobiomodulation (PBM) treatment. Following manufacturer guidelines and recommendations for treatment head use ensures safe treatments and optimal results, and should thus be strictly adhered to.

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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 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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