For any practice utilizing laser therapy, it is crucial that a treatment design be formulated according to the types of patients that are treated, as well as taking into account the number of technicians trained to perform these treatments. Starting with a basic organization of setting out to do these treatments on a daily basis, the practice needs to start by having a core message to the clients when laser therapy is discussed.
Oftentimes, it is a veterinary technician who will be the laser safety officer of the practice and will take ownership of providing the benefit of this modality to the patients. From this person, others can be cross trained so that there is a system of redundancy and personnel availability at any given time when the practice is open.
Some practices are so invested in laser therapy that they will have a “designated daily operator” who will have scheduled outpatient appointments. In order for any practice to be efficient and reliable in having multiple operators deliver specific treatments for each patient, a laser treatment form must be documented in the patient’s daily record, this will ensure that all operators are on the same page when treating a specific patient.
Depending on the type of practice and the number of technicians trained to perform laser therapy treatments, it is not unusual for a practice to need several laser units. Some practices have a laser unit available for scheduled outpatient treatments, as well as another reserved for surgical or dental procedures, as well as being used to treat the hospitalized patients.
The attending veterinarian who has ordered laser therapy also needs to set specific goals for each patient, and to include a timeframe for either an intermittent course of treatments or establish a starting philosophy to treatment phases (induction, transition, and maintenance phases). This way, the client will also have reasonable expectations in how the patient should respond.
It is important to remember that “the plan” is only “the plan”. This may very well need to be adjusted as per the patient’s response to laser therapy. The conscientious laser operator will be sure to keep the attending veterinarian informed of the patient’s progress, as well as being prepared to deal with potential setbacks. The latter can occur early in the treatment phase as the patient starts to heal, they will get a false sense of security and may be prone to overdoing it with home activity, etc.
In order for a practice to be efficient in their use of this modality, multiple team members need to be adequately trained, a basic framework of scheduled appointments be set out, open communication between laser operators and attending veterinarians be maintained, and a hierarchy of oversight be established.
Intra-Articular (IA) injections are common place in human and equine medicine, whether being used for diagnostic or therapeutic procedures. In particular, IA injections have been a vital component of the successful treatment of osteoarthritis (OA). While similar benefits can be achieved for dogs with OA, the use of IA injections in the small animal practice is less common.
Why is this? Historically, IA injections weren’t a common procedure for OA treatment due to a lack of products available for small animal species and there was an educational void surrounding the use of those products. Additionally, there is a decreased comfort level in performing IA injections in smaller animals since the joint spaces are much smaller than that of the large hooved patients and the procedure is not as common place.
In today’s blog, we will discuss the uses of intra-articular Injections, products that are commonly used for IA treatments and educational opportunities that can equip the small animal practitioner with the skills necessary to perform these procedures.
Intra-articular injections can be used in a multi-modal approach for treating osteoarthritis or can be used for a variety of other indications including:
- Patients with residual post-operative intra-articular symptoms (effusion, discomfort, lameness)
- Supplementation/ alternative treatment to oral meds
- Post-surgical lavage
- Arthrocentesis for differentiating OA from inflammatory joint diseases
- Joint blocking for lameness workups
Which products are commonly used in IA injections?
- Regenerative Medicine Products
As discussed in our previous posts, regenerative medicine, which includes Platelet Rich Plasma (PRP) and Stem Cell therapies, utilizes the body’s own cells to heal and regenerate tissue. With minimal side-effects and treatment benefits lasting upwards of 9-12 months, regenerative medicine treatments are ideal for patients with mild to moderate osteoarthritis.
- Hyaluronic Acid (HA)
Hyaluronic Acid is a naturally occurring polysaccharide in the extracellular matrix of the body. HA has been synthetically manufactured for the treatment of OA in dogs, horses and humans. When injected, HA binds to receptors on the chondrocytes which induces cellular proliferation and extracellular matrix production. Typical treatment schedules require a series of loading phase (weekly administration) injections and re-administration every 3-6 months. Efficacy of HA injections varies depending on the molecular weight of the HA and can adversely affect tissue if injected outside of the joint capsule.
- Corticosteroids
Commonly used in human medicine, intra-articular injections of corticosteroids are recommended in several guidelines for the treatment of patients with OA but remain controversial. Corticosteroids prevent the formation of prostaglandins and are a powerful modulator of inflammatory pathways. However, it is not recommended for long term use (no more than 4 administrations/ year total) and can have negative side effects to the cartilage in the joint.
Now that we know what intra-articular injections can be used for and what can be administered using them, we’re ready to inject, right? For some that may be the next step. But for most of us, IA injections can seem daunting, especially if we’ve never done one before (or perhaps haven’t done them since the equine rotation back in vet school). The good news is that now there is a wealth of educational resources available to gain proficiency at IA injections, including the Companion Regenerative University events. Companion Regenerative University is a one-day live seminar where attendees learn the background to regenerative medicine and get the hands-on practice of performing intra-articular injections. To learn more about this course or to see when and where upcoming courses are taking place, click here.
Stay tuned for our next post where we will take a closer look at a case study involving a patient with a Fibrocartilaginous Embolism who got his step back thanks to regenerative medicine.
Light Up the Laser – Treatment Techniques to Optimize Outcomes
It is crucial to apply proper treatment techniques so that the therapy is not only delivered optimally, but safely as well. When combined, all the small details that the operator adheres to form a treatment which delivers therapeutic benefits to the patient.
The first set of proper treatment techniques apply to the laser therapy delivery platform itself. In order to allow the light energy to travel as efficiently as possible, the fiber needs to be fully unwound and should not be kinked or forcefully bent, this will also provide for minimal resistance when the hand piece is maneuvered by the operator. Selecting the appropriate treatment head is an important factor as well. For maximum patient comfort, the small treatment heads should only be used at a maximum power of 3 watts, never higher. The off-contact (often called “cone”) treatment heads should be held at about 1 to 2 inches from the tissue surface, never in direct contact with the patient’s skin or hair coat. The optical window of each treatment head piece must also be clean, intact, and free of any debris, defect, or scratches. The operator will select the appropriate protocol applicable to the condition / body part / surface area being treated. Once these parameters have been selected, we are then ready to begin treating the patient.
The patient should be allowed to position itself so that it is as comfortable as possible, as long as the target site remains accessible. A soft, fleece-like substrate (such as a pad, blanket, or bedding) also makes for an excellent material to rest on. It will also wick away urine if the patient is incontinent. Whenever possible, in treating musculoskeletal conditions, it is best to make direct contact with the deep tissue applicator (aka “the large massage ball” treatment head) so as to maximize penetration of the light energy into the tissues. If, however, we are dealing with exposed tissues such as with a hot spot, open wound, or a fresh surgical incision, a non-contact technique is required, holding the treatment head at 1 to 2 inches from the surface of the area being treated.
When performing the treatment, the treatment head is held perpendicular to the surface of the target tissues to ensure an even beam spot. The laser beam should make a full excursion, crossing over from the affected tissues into the nearby healthy tissue margins, never hovering over the same treatment area. As the treatment is being carried out, the operator will continuously move the hand piece at 1 to 3 inches per second so as to fully and evenly illuminate the treatment site, the hand piece should never be kept motionless when the laser is being delivered to the patient. The operator will also monitor the patient and treatment area for any possible increase in warmth, this is especially important when treating tissues which are heavily pigmented or with a dense hair coat. The latter also especially applies to the anesthetized patient, such as when treating dental extraction sites, for the patient will not be able to physically respond to any sensation of discomfort or excessive warmth.
Specific parts of the patient also carry inherent treatment nuances. When treating joints or an extremity, it is optimal to treat as circumferentially as possible, while putting that joint through a gentle passive range of motion (if possible) so that all aspects of the intra articular surfaces are well-illuminated. Any biomechanically associated structures to the target site should also be assessed and possibly considered for treatment, secondary sites are often affected due to the deterioration of the primary target structures and compensation changes in biomechanics. When treating with a contact technique, it is usually to the added comfort and medical benefit to the patient to apply a massage-like technique, but care should be taken to decrease applied pressure when passing over a boney prominence, such as a dorsal spinous process, as this may create discomfort in those areas. The laser operator should use both hands to constantly monitor the patient as the treatment is being carried out – feeling for increased coat temperature, withdrawal and/or muscle spasm during treatment.
Applying these treatment techniques is easily achieved, they are all small facets that together create an optimal treatment delivery of this cutting-edge medical modality. An experienced operator following these guidelines will be able to give the patient the full benefit of a treatment well designed and well carried out in a non-invasive manner.
