applications of low level in podiatry: an in-depth look national meeting.pdf · •division head...
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APPLICATIONS OF LOW LEVEL
LASER THERAPY IN PODIATRY:AN IN-DEPTH
LOOK
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Contact Information
• Richard Silverstein, DPM
• Division Head Podiatry Section/Department of Surgery University of Maryland Harford Memorial Hospital
• 807-B South Union AvenueHavre De Grace, MD 21078
• www.unionfootcare.com
• (410)939-2627 office(410)627-7131 cell
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American Podiatric Medical Association Disclosure
• The following relationships with commercial interests existed during the past 12 months:
Erchonia Corporation
Akina Pharmaceuticals
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Lecture Goals
• To define what a Cold Laser is
• To understand the mechanism of action of Cold Lasers
• To review the current literature supporting Cold Laser therapy
• To identify how Cold Lasers can be utilized in the podiatric practice
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What is a laser anyway?
• Laser – Light Amplification by Stimulated Emission of Radiation
• Based on the principles of stimulated radiation by Einstein in 1917
• Lasers differ from other sources of light in that they emit light coherently
• This spatial coherence allows lasers to be focused to a tight spot or beam
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Cold Laser Therapy (aka Low Level Laser Therapy or
LLLT)
• “A form of medicine that uses low-level lasers or light-emitting diodes (LEDs). Other names include low-power laser, soft laser, cold laser, bio stimulation laser, therapeutic laser, and laser acupuncture.”
• 600-980 nm on the em spectrum
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Characteristics of Low Level Laser Therapy
• Accelerates cell growth & tissue repair
• Accelerates fibroblast & collagen production for faster wound healing
• Reduces inflammation
• Reduces scar tissue formation
• Reduces pain & acts as an analgesic
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Characteristics of Low Level Laser Therapy Cont’d.
• Induces angiogenesis
• Induces neurogenesis
• Stimulates an increase in intracellular energy
• Stimulates a cascade of physiologic effects to promote repair, regeneration & restoration of function
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What can we do with LLLT?
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Lower Extremity Relevant Applications of LLLT
• Acute Inflammatory Conditions
• Chronic tendon or ligament injury (plantar fasciitis)
• Chronic pain
• Osteoarthritis
• Complex regional pain syndrome
• Entrapment neuropathy
• Peripheral neuropathy
• Neuroma
• Neuritis
• Lymphedema
• Wound healing
• Fracture healing
• Eradicate dermatophyte infections
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Lower Extremity Relevant Applications of LLLT
• Reverse tendinopathy
• Reverse plantar fasciosis
• Reverse plantar plate derangement, a degenerative capsulopathy
• Non-invasive treatment of chronic tendinopathy, capsulopathy & fasciopathy
• Enhance angiogenic response in repair of compromised and degenerative tissues
• Pain control
• Restoration of function
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Effects of Low Level Laser Therapy
• Shortens the inflammatory phase
• Accelerates the repair process
• Stimulates tissue regeneration after injury
• Additionally increases plasma concentrations of prostaglandins, enkephalins and endorphins all playing a role in pain management
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What is the mechanism of action of low level laser therapy?
“PHOTOBIOMODULATION”
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How deep do cold lasers penetrate?
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How do we treat these conditions PRIOR to laser therapy?
• Educate the patient
• Dispense durable medical devices and utilize taping
• Recommend stretches and exercises to promote mobility
• Limit high impact exercises, recommend modifications at the work place
• Encourage disease management
• Prescribe NSAIDS
• Give steroid injections
• Recommend laser therapy
• Recommend surgical management
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What does the research show?
ARTICLE #1
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• The Study:
• 69 subjects enrolled in a placebo-controlled, randomized, double-blind study.
• 37 randomized to the active treatment group
• 32 were placed into the placebo group
• Treatment group treated twice a week for 3 weeks utilizing LLLT and were evaluated at 6 different time points.
• Utilized a 635 nm low level laser for treatment
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• Parameters Studied:
• Pain rating was recorded using a visual analog pain scale.
• Doppler ultrasonography performed to measure fascial thickness pre and post treatment.
• Study participants also completed the Foot Function Index.
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• Results:
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• Results:
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• Results:
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Analog Pain Scale
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Peripheral Neuropathy and Low Level Laser Therapy
• What does it mean?
• Large Nerve Fibers vs Small Nerve Fibers
• Common Causes:
- Diabetes Mellitus Types I and II
- Metabolic Syndrome
- Idiopathic / familial
- Alcohol Abuse
- HIV
- Pharmacologic toxins / Chemotherapeutic agents
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Clinical Presentation: Small Fiber Neuropathy
• Stocking and glove distribution
• Early hyperesthesia and pain, late hypoesthesia and numbness
• Pain is burning, superficial
• Impaired thermal and pain thresholds
• Decreased sweating
• Normal strength, reflexes and EMG
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Diagnosis: Epidermal Nerve Density
• Small C-fibers and A-delta fibers
• Established normative value based on body site
• Objective way to quantify and monitor neuropathy
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• Site Result Value Abnormal Low Normal•• Rt Foot 1.16 < 3.11 3.11 – 4.5
• Lt Foot 1.33
• Rt Calf 3.62 < 5.4 5.4 – 5.7
• Lt Calf 2.88
1NORMALSMALL FIBER
NEUROPATHY
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Before Laser:
Right Foot: 1.16After Laser:
Right Foot: 4.91
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Before Laser:
Left Foot: 1.33
After Laser:
Left Foot:
4.37
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Having Confidence in the Science
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Why incorporate Cold Laser treatment modalities into your
practice?• It is a safe and effective treatment to provide to patients in
pain.
• Incorporates the newest technology into our practice.
• Garner respect from patients and referring colleagues for being on top of the current trends and effective medical treatments.
• Safe to use in our diabetic patients and vascularlycompromised patients.
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Marketing the Laser
• Brochures and patient education
• Use your EMR to your advantage, you paid enough for it!
• Enhance your web site and direct your patients there
• Radio advertising
• ROI and pressure
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Bibliography
• Can LLLT have an impact for Small Fiber Neuropathy? Podiatry Today, volume 24, issue 6, June 2011, Kerry Zang, DPM, Janna Kroleski, DPM, Shahram Askari, DPM, and Sanford Kaner, DPM
• Low-level laser (light) therapy (LLLT) in skin: stimulating, healing, restoring Seminars in Cutaneous Medicine and Surgery, 2013 March; 32(1): 41-52. Pinar Avci, Asheesh Gupta, Mgesh Sadasivam, Daniela Vecchio, Zeev Pam, Nadav Pam, Michael Hamblin.
• The Nuts and Bolts of Low-Level Laser (light) Therapy. Annals of Biomedical engineering, February 2012, Volume 40, Issue 2, pp. 516-533. Hoon Chung, Tianhong Dai, Sulbha K. Sharma, Ying-Ying Huang, James D. Carroll, Michael R. Hamblin, February
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Bibliography cont’d.
• Low-Level Laser Therapy at 635 nm for Treatment of Chronic Plantar Fasciitis: a Placebo-Controlled Randomized Study The Journal of Foot and Ankle Surgery. Volume 54, Issue 5, September-October, 2015, 768-772. David M. Macias, MD, Michael J. Coughlin, MD, Kerry Zang, DPM, Faustin R. Stevens, MD, James R. Jastifer, MD, Jesse F. Doty, MD
• Ultrasonographic evaluation of plantar fasciitis after low-level laser therapy: results of a double-blind, randomized, placebo-controlled trial Lasers in Medical Science. Volume 25, 2010, 275-281. Olga Kiritsi, Konstantinos Tsitas, Nikolaos Malliaropoulos, Grogorios Mikroulis
• Low Level Laser Therapy for the Treatment of Chronic Plantar Fasciitis: A Prospective Study. Foot and Ankle International. June 2014;35(6):566-571.Jastifer JR, Catena F, Doty JF, Stevens F, Coughlin MF.
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• “Nearly all inventions are not recognized for their positive side when they're made. So, for example, scientists didn't go out to design a CD machine: they designed a laser. But we got all sorts of things from a laser which we never remotely imagined, and we're still finding things for a laser to do.”
Robert Winston
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THANK YOU!!!