Dr. Robert G. Silverman - Integrating Laser into Practice

Integrating Laser into Practice
Dr. Robert G. Silverman
DC, DACBN, MS, CNS, CCN, CSCS, CIISN, CKTP, CES, DCBCN, HKC
www.DrRobertSilverman.com
[email protected]
Quote
“Absorb what is
useful, reject
what is useless”.
Bruce Lee
Integrating Laser into Practice
“No-pill pain buster”.
Dr. Oz, January 2013
“The most versatile
healthcare tool of the
21st century”.
Dr. Rob, January 2013
Pathogenesis of the cumulative trauma disorder
Symptomatic
Injury Threshold
Amount of Tissue Insult
Recovery
Cycle
Injury Cycle
Frequency of Insult
Pathogenesis of the cumulative trauma disorder
Amount of Tissue Insult
Insufficient Tissue
Recovery Between
Injury Cycles
Tissue Damage
Accumulates
Injury Cycle
Frequency of Insult
Copyright Jerome M. True, DC
Blue Print
•
•
•
•
Find the cause
Explain the source
Determine effective treatment
Shorten treatment time
What Happens to Movement
After Injury?
• What is it about pain that changes the way
people move?
Or
• What is it about the way that people move
that causes pain?
What Comes First?
Injury
Pain
Altered Motor
Control
We should diagnose this
FUNDAMENTAL QUESTION?
For Your Pain
“Immediate pain reduction can be achieved by
altering muscle activation and movement
patterns”
Spine, 8-6-2012. S. McGill, D. Ikede
Movement,
Not Muscles
Don’t add strength
to dysfunction
Movement Comes First
If movement is dysfunctional, all things built on that
dysfunction might be flawed
The Search Is On
Laser Focus
• Laser: Light Amplification by Stimulated
Emission of Radiation
• A focused beam of light that emits photon
energy
• All photons travelling same direction at same
wavelength = coherent light
Laser Focus
“The cell is a machine driven by energy…in every
medical tradition before ours, healing was
accomplished by moving energy”.
Albert von Szent-Gyorgi, 1967
How Does it work?
Well, the answer is best explained using the basic
principles of photochemistry.
A single photon can trigger a reaction in one cell that causes the
emission of several photons. These then trigger photon emissions
in other cells, and the effect spreads from cell to cell to cell like a
chain reaction.
These are called high-speed branched-chain processes.
How It Works
• Increase cellular regeneration
(this involves the physiology of cell metabolism, the
mitochondria and the synthesis of ATP)
• Increase cellular communication
(this involves the nervous system, phospholipid cell
membrane and the integrin system)
How It Works
• LLLT stimulates cell activation processes which, in
turn, intensifies physiologic activity
• Healing is essentially a cellular process
• Light energy initiates a cascade of reactions
• From cell membrane – cytoplasm – nucleus – DNA
• Cellular amplification
Wavelengths
• Expressed in terms of color. Each wavelength
has different properties:
– 635 NM wavelengths is the frequency of a healthy
cell
– 635 NM is the absorbable dose, e.g. WholeFood
supplement vs. Centrum or One-A-Day
– 20 times more effective than longer wavelengths
Why?
• Wavelengths between 400 to 660 NM have
sufficient energy to displace electrons in
atoms to a higher energy level
• This is desirable – the higher energy level
electron is now more available for donation,
expediting the efficiency of all human
physiological processes
Why? (cont’d)
• Longer wavelengths (above 660 NM)
penetrate deeper, but at a cost of reduced
electron volt ability to displace electrons to a
higher energy state. Just because there is
deeper penetration does not mean that it
excites electrons to higher energy level better
Power and Wavelength
• LLLT accelerates tension healing, increasing fibroblast
proliferation and collagen synthesis
• LLLT effective at reducing post-injury inflammation and
accelerated soft-tissue healing
• LLLT increases ATP…stimulating DNA synthesis and cell
proliferation
• 632.5-nm laser “produced a higher deposition of
collagen, increasing the tensile strength of completely
severed and surgically repaired rat tendons
Comparative Study Using 685-nm & 830-nm Lasers in the Tissue Repair of Tenotomized Tendons in the
Mouse, Photomedicine and Laser Surgery, Dec. 2006, vol.24(6), p.754-758
The efficacy of low power lasers in tissue repair and pain control:
a meta-analysis study.
Photomed Laser Surg. 2004 Aug(4): 323-9 Enwemeka, c et al.
• 34 peer reviewed papers in tissue healing and 9 in pain control
d=+1.81 and d=+ 1.11 respectfully
• Collagen formation d=+ 2.78
• Rate of Healing d=+ 1.57
• Tensile strength d=+ 2.13
• Pain Control d=+ 1.11
• Tensile Strength d=+ 2.65
• Conclusion: These findings mandate that LLLT is highly
effective in tissue repair and pain relief!
• Most effective wavelength 633 nm least effective 780nm!
Frequency
• Frequency is the blinking quality of the red line
• Frequency (in Hz) – the number of light flashes
per second. Allows for modulation of the light
which can overcome clinical plateaus in patients
• Frequency of 30 or less is visible to the naked eye
• Over 30 – the pulse/blink is too fast to see and it
appears as a continuous line
Practice Management Tip
• When using laser – remember patients are
unable to “feel” the laser
• Laser increases cellular regeneration
• Laser increases cellular communication
Dr. Rob’s Fab 5
Joint dysfunction
EC Matrix
Exercise/ergonomics/proprioception
Laser therapy
Nutrition:
a) Diet
b) Supplements
Laser/Pain Management
Dr. Rob’s take:
• By applying laser energy to affected areas, the
frequency sensory nerve firing is increased,
which subsequently increases the frequency
of stimuli to the spinal cord, brainstem, and
brain, in turn inhibiting pain at the spinal cord
and brain stem levels
Don’t you need a lot of power for the light to
penetrate?
Too much power – not low-level laser
Arndt-Schulz Law
• “Weak stimuli excite physiological activity,
moderately strong ones favor it, strong ones
retard it, and very strong ones arrest it.”
• Biomodulation
Restoring the cell back to its natural frequency
Connective Tissue: A body-wide signaling network?
Medical Hypotheses Vol 66, Issue 6,6-06, p.1074-11077
• Unspecialized “loose” connective tissue forms an
anatomical network throughout the body (the one-body
system)
• CT functions as body-wide mechanosensitive signaling
(communication) network that is separate from the NS, yet
also influences and is influenced by the nervous system
• CT signals direct cellular and tissue remodeling
• Since CT is intimately associated with all other tissues
including the viscera, connective tissue signaling may
influence the normal or pathological function of a variety of
organ systems (CT health determines organ health)
The extracellular matrix is composed of
tissues that serve multiple purposes
“The ECM is a conglomerate of substances
in which biochemicals and biophysical
properties allow for the construction of a
A
complex web that of connective tissues that
flexible network that integrates
information from loading and converts it
• Provide adhesion to cells
into mechanical capacities…It serves as a
scaffold
for adhesion
of cells mediated
by
• Act
as a structural
scaffold
integrins, dystroglycan, and proteoglycans
at the
surfaceparticipate
and of tyrosineinkinase
• cell
Actively
intracellular signaling
receptors. The interaction between the
ECM•and
the adhesion
molecules leads
to
Translates
mechanical
loading
into cellular response
activation of intracellular signaling
pathways and cytoskeletal
http://content.answers.com/main/content/img/McGrawHill/Encyclopedia/images/C
E157300FG0010.gif
rearrangement.”
Kjaer, M. Physiol. Rev. 84:649-698, 2004.
Key
• Extracellular matrix – the
fascial system is the
largest system in the body
and is the only system
that touches every other
system
IT’S ALL
CONNECTED
Nervous System
Fascia
Muscle
Pain/Performance
Movement
Joint
The Efficacy of Laser therapy in wound repair: a meta-analysis of
the literature
Photomed Laser Surg. 2004 Jun;22(3):241-7. Woodruff,LD et al.
• Determine overall effects on tissue healing from all double
blind studies ever done….24 studies looked at
• Overall mean effect of laser efficacy d=+2.22 both animal and
human
• Acceleration of healing d=+4.45
• Augmentation of collagen synthesis d=+1.80
• Increased Tensile Strength d=+2.37
• Reduced healing time d=+ 3.24
• Diminution of wound size d=+.55
• Conclusion: Laser therapy is an effective tool for promoting
wound repair
Summary of Erchonia
Pain Reduction Studies
• Study taken from another FDA-approved laser (this
company had a wavelength of 830 NM), which is
infrared and has different properties
• This company treated patients 15 times over 5
weeks. At the end of study: 6.5% decrease over the
placebo group for pain
• Erchonia PL3 treated patients 1 time with a 3-minute
protocol and diminished pain by 66% over the
placebo
Professional sports organizations
utilizing Erchonia Laser
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NBA
NFL
MLB
NHL
US cycle team (tour de France)
IronMan competitors
Road Runner’s Association
College athletes
Former Olympic athletes
Elite CrossFitters
Rules
• Non/pre-programmable head – nerve roots (4, 9, 33,
60)
• Programmable head – injury or ouch
AOI – area of involvement
• Laser shower: laser heads on tissue and nerve roots
• Cell communication – reestablishes cellular
communication. Laser area short period of time
“Spontaneous healing…all
the circuitry and machinery is
there; the problem is simply
to discover how to turn on
the right switches to
activate the process”.
Spontaneous Healing
Andrew Weil
Using laser light to
“turn on the right switches”
Muscle Test – Upper Body
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C1 – Flex/extension
C2 – Flex/extension
C3 – lateral flexion
C4 – rotation
C5 – deltoid
C6 – bicep
C7 – tricep
C8 – finger flexors
T1 – finger abductors
Low Back and Pelvis
Myotomes Muscles
L1-3
Iliopsoas
L2-4
Quadriceps
L3
Sartorius
L4,5 S1-3
Hamstrings
L4
TibialisAnterior
L5
Toe Extensors
L5
Glute Medius
S1
Peroneus L. & B.
S1
Glut Max/TFL
Laser Muscles
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SCM
Scalenes
Levator scap
Trapezius
Supraspinatus
Lat dorsi
Psoas
Glute max
Piriformis
Erector spinae
Clinical Judgement
Previous Experience
Neurodynamic Test
• Neurodynamics – a catch phase which describes
the moveable, slide-able nature of the nerves as
they wind through and around the structures and
conduit of the spine and extra-spinal structures
• Neurodynamic tests – meant to deduce
restrictions and resistances often described as
“interfaces”
• When adhesion is present, the gloss/glide of the
nerve, revealed by these tests, can theoretically
reveal it
Dr. Jay Kennedy, Should I Do Supine Decompression When There is a Positive Slump Test? DC Products
Review, Dec. 2012, p.22
Laser Nerves
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Brachial plexus – scalenes
Median – pronator teres, flexor retinaculum
Ulnar – olecranon and medial epicondyle
Radial – triangular space between T minor, LH triceps
and humerous
Sciatic – piriformis muscle
Femoral – psoas
Tibial – posterior to knee
Peroneal – medial biceps femoris/head of fibula
Sural – calve region
Tarsal tunnel –at tunnel
Neurodynamic test – Lower Extremity
• Sciatic: slump or add neck flexion
(SLR) – piriformis
• Tibial: df/ev/SLR - posterior to
the knee
• Peroneal: pf/in/SLR – head of
fibula/medial to b. femoris
• Sural: df/in/SLR – bottom of
calve
• Femoral: prone knee bent –
inguinal ligament
Functional
Movement
Assessment
There are local complaints but no local injuries
Which came first – the
or the
?
Tension in muscle pairs
Tender attachment points (referred pain)
Joint dysfunction (blockage)
This implies that all treatment regimes must be global and
treated from head to toe
Manipulative Therapy in Rehab of the Locomotor System, Karel Lewitt, p. 130
Quote
“The spinal cord is the keyboard on which the
brain plays when it calls for activity. But each
key in the console sounds not as an individual
tone, such as a contraction of a particular group
of muscle fibers, but as a whole symphony of
motion.”
Irvin Korr, pHD
Laser “Locomotor Lock-In”
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Resets NMS in 3D motion
4, 9, 33, 60
Facilitated bodies global integration
5 sec.eyes open, 5 sec. eyes closed
Cross-crawl: right arm – left leg, left arm –
right leg
• Aim posterior midline
• Hot disc – performed seated
Core Lock-In
4, 9, 33, 60
30 sec. each side
Key Laser therapy
Protocols for a
Doctor’s Office
Carpal Tunnel Treatment Protocol
• Laser at point/points of involvement (9,16,21,36) – 3
to 5 mins. max
• Laser during movement – 30-60 sec.
• Laser “locomotor lock-in”
• Nerve floss
• Corrective exercise
• Nutritional protocol: B vitamins (B5, B6), omega-3
fatty acids
• Mobilize, manipulate joint restrictions
• Myofascial release
Carpal Tunnel
Rotator Cuff Injury Treatment Protocol
• Laser at point/points of involvement:
– Muscle/joint/scapular (9,16,42,53)
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Laser during movement – 30-60 sec.
Laser “locomotor lock-in”
Corrective exercise
Nutritional protocol: see 3 Phases of Care
Mobilize, manipulate joint restrictions
Myofascial release
Supraspinatus
Intervertebral Disc Tx Protocol (cont’d)
• Core “lock-in”
• Nutritional protocol:
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Glucosamine chondroitin MSM complex
Omega-3 fatty acids
Turmeric, ginger, boswelia
Mg/calcium
Outer annulus – ca, mg, vit. D, boron, horsetail aerial
parts, silica
• Myofascial release
• Mobilize, manipulate, flx/distraction, joint
restrictions
Intervertebral disc
Lat/Medial Epicondylopathy Tx
Protocol
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Laser at point/points of involvement: (9,16,42,53)
Laser during movement: 30-60 sec.
Laser “locomotor lock-in”
Corrective exercise
Core “lock-in”
Nutrition protocol
Myofascial release
Mobilize, manipulation, joint restrictions
Lateral
Epicondylopathy:
Laser Protocol
Medial
Epicondylopathy:
Laser Protocol
Non Surgical Interventions for Rheumatoid
Arthritis
Christie et al
PT Journal December 2007
• LLLT reduces Pain and improves function!!
• Higher Quality of evidence than US, TNS, Heat, Exercise, ES,
Acupuncture.
The low-level laser therapy application
improves the healing process of the Achilles
tendon of rats
Conclusion: the laser treatment is effective during the
healing process in tendons since there is more
presence of gags and collagen types I and III in tendons
submitted to low-level laser than in tendons without
treatment. With respect to the active isoform of MMP2, the low-level laser with a pulsed emission is more
effective than low-level laser continuous
2012 Fascial congress abstract. FR Guerra, CP, Vieira AA Aro, EP Pimentel
Simple strategies first!
Choosing Your Next Laser
• Regulating considerations – FDA-cleared
• Therapeutic factor – laser light parameters:
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Dose and frequency
Wavelength
Power
Modulation (pulsing) of light
• Non-therapeutic factors:
– Portability
– Size and weight
– Corded or cordless operation
How does laser compare
to other modalities?
• Research – ultrasound has value, but laser has been
shown to close wounds more effectively
• Ultrasound tends to cause slight retraction of hard
and soft tissues, laser causes proliferation of these
tissues
1) Denir H, 2004. Comparison of the effects of laser and ultrasound treatments on experimental
wound healing in rats. J Rehab Res and Dev, Sept/Oct:41(5)
2) Linari, Gelvao, 2006. Comparative study of how low-level laser therapy and low-intensity pulsed
ultrasound affect bone repair in rats. Photomed laser surg, Dec:24(6) 735-40
What does the low-level laser do
• Laser therapy – stimulates both the nervous system
and site of tissue injury
• Clinically proven to:
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suppress inflammation
Increase oxygen and blood flow
Promote muscle calcium update
Increase neurotransmitter release
• Key – by addressing the injury with a diverse tool it is
possible to resolve the condition more effectively by
suppressing not one but all contributors
How does laser therapy
strengthen muscle?
• By delivering specific parameters of light that can
increase ATP production, promote calcium influx, and
support proper nervous system function and
neurotransmitter release
WOW
• Muscle contraction requires acetylcholine
• Acetylcholine causes an electric impulse
• Impulse releases Calcium from sarcoplasmic
reticulum (inactive form)to the sacroplasm
• ATP causes stronger contraction
WOW (cont’d)
• Stop contraction
• Calcium goes from sacroplasm
sarcoplasmic
reticulum
• More ATP the better the relaxation
• ATP is required for contraction and relaxation of the
muscle
• LLLT quickly and efficiently increases levels of ATP
How can low-level laser therapy
penetrate through clothing?
• Low-level laser emits approximately 45 BN
photons every second
• Clothing material will demonstrate some
degree of photon inhibition – the reaction at
the cellular level is a 1-to-1 reaction
• This requires 1 photon to excrete 1 electron
positioned with the photoreceptor
Why can’t I feel anything during
treatment?
• LLLT does not deliver significant amount of energy
therefore no friction-like reaction occurs which
produces heat
• The type of energy delivered does not vibrate or
oscillate the cell, therefore no photo-acoustic
sensation is experienced
How can a response be produced in a
matter of a few seconds
• Since low-level therapy is responsible for
modulating the energy state in which
electrons reside, an immediate increase in the
rate at which the photo receptor functions
coupled with an alleviation in energy
production is observed
Why the Erchonia PL5A Laser?
Increases ATP and decreases free radicals
Reduces pain and fibrosis; speeds tissue repair,
improves strength and ROM’s; turns on inhibited
muscles; synchronizes muscle coordination
Why the Erchonia PL5A Laser? (cont’d)
1) First cold-laser given FDA
market clearance
2) 635-nm/5mw
3) 2 heads
4) 4 programmable frequency
channels
5) Portable
6) Quick results
Cold-Laser Benefits
1) 632.8 nm wavelength > ATP
2) Causes immediate vasodilation
3) Increases levels of catalase and glutathione
peroxidase reducing H2O2 to H2O and O2
4) Reactivates SOD and catalase by absorbing 633nm laser light
5) Increases protein synthesis, bacterialcidal
6) Increased mitosis
7) Tissue regeneration
8) Improved immunomodulation
Dr. Rob’s Sexy Six
1)
2)
3)
4)
Laser delivers light energy
Lasers can stimulate cell activity
Laser is classified based on its power supply
Wavelength (color) is the length of the wave
of the light energy
5) The kind of tissues treated depends on
wavelength and power supply
6) Laser companies do not always agree
“The Dash”
Q&A