WEBVTT
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Hi guys, Welcome to another episode
of The Factor podcast. I'm your host,
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Jessica Riddle. If this is your
first time tuning in, welcome and
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thank you for listening. The topic
that we're covering today and in our next
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episode is therapeutic laser and its applications
for treating pain. Now, therapeutic laser
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and other light therapy devices have surged
in popularity in recent years, so much
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so that you'll be hard pressed to
attend any healthcare conference without seeing these types
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of devices there. In this two
part training, we will hear from Mark
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Callanan, a doctor of physical therapy
and the director of Clinical Education and Recovery
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Sciences for Aenovis, the company behind
brands such as Chattanooga and light Force lasers.
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We will talk about laser theory's role
in treating acute and chronic conditions and
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the more nuanced applications for ridiculopathy.
Doctor Callanan will also talk about treatment protocols
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that follow a patient's nerve pathways and
how the heat generated from high level laser
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can address muscle spasms and joint stiffness. This particular training which was originally offered,
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of course, in webinar form featured
a ton of great visuals, graphics
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and references to relevant research, so
you'll want to be sure to click in
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the webinar replay link in our show
notes. If you're more of a visual
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learner, Let's cue the interim music
and get started. Excited to be here,
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and today's talk is really designed to
just be an overview of what laser
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therapy is. There's a lot of
sort of smoke and mud out there in
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the space, so a lot of
misinformation, and I spent a lot of
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time trying to get information out to
everybody. So hopefully when we wrap things
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up today, you'll have a little
better feeling on how lasers really work from
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a mechanistic standpoint, some of the
recommendations from different groups and research that's supporting
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the use of lasers, so that
for those of you that are trying to
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really follow an evidence based path feel
comfortable that laser definitely fits into that category.
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So I'm a physical therapist by training
and receive my doctor in Physical therapy
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from Marymount University in Arlington, Virginia. I was in the outpatient space for
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or eighteen years before joining lighte Force
back in twenty seventeen. I was the
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director of clinical Education. A couple
of years ago, light Force was acquired
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by now a Novis, it was
DJO Global, and since that point I've
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been the director of Education and Marketing
for a Novis. So that's kind of
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what I've been up to and again
happy to be here today. So what
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we're going to go over today is
a general overview of the definition mechanisms of
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photo bimodulation, which is the term
for laser therapy now that's accepted in the
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research, take a look at some
current research as well as different support guidelines
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that are out there from the APPA, the American College of Physicians, the
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American it should be Academy of Orthopedic
Surgeons, a little bit of a TYPEOO
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there, And when we're done,
hopefully the takeaways will be that you'll understand
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how laser really impacts cells, Understand
how wavelength, power and dose seem will
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impact outcomes, be able to explain
the differences between high and low power lasers
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with regard to how the impact pain
because there is some differences there that are
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pretty significant, and explain how to
effectively incorporate laser with other treatment concepts in
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an evidence based manner. So when
you hear laser, not sure what comes
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into mind, but it might be
something like this. For your patients,
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when you mentioned laser, they very
well might be thinking about this. So
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it's really important to help provide good
instruction as to what it is and how
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it's going to help them, and
that it's a safe modality because when you
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mentioned laser, sometimes fear can become
an issue for those folks. So from
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an historical standpoint, back in nineteen
oh three, the only Nobel Prize that
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was ever awarded to a modality that
I'm aware of was awarded to Neil Spinson
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and it was used to treat these
large sort of purplish blotches called lupus vulgaris,
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and they found that if you use
light boxes with specific wavelengths that they
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were able to help clear that up. So that was a pretty big date
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over one hundred years ago now and
sort of the beginning or the advent of
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laser as we know it started.
Most people would agree in nineteen sixty seven
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where Andre Mester was a physicist and
he was looking at mice and trying to
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figure out if you put laser light
on their skin, if it created cancer's
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tumors. And it didn't do that, but it caused some hair growth to
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show up on their backs, and
that sort of sparked the question of what's
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going on there, And since then
research has been going on to figure out
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what happens when you put these special
wavelengths of light onto tissue. So from
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a chronological standpoint, these are just
some significant dates as far as laser goes.
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If you've noticed, if you've done
any research on literature or on laser,
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you would notice that there's a lot
more low power studies that are in
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PubMed or sin all. And the
primary reason for that in the United States
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is just that there's been thirty year
head start on FDA clearance for the lower
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power devices in two thousand and fours
when the FDA cleared use of Class four
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devices for human use for therapy.
So since that time, the amount of
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research that's been out has increased significantly, and there's been a number of significant
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endorsements from different groups for laser therapy. The World Health Organization APTA has made
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several different endorsements for different clinical pathways, which we'll talk about more in depth
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here later in the talk, as
well as some things from the American College
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of Physicians, the American Academy of
Orthopedic Surgeons, as well as a recent
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position paper from the CDC. So
definitely getting a lot of acceptance on this
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modality, which is exciting. If
you do look for research on this,
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you want to look underneath the term
photobiomodulation. This is the accepted term for
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laser and the most current research will
be underneath this. So if you're doing
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a meshad mesh heater search, you'd
want to use photobiomodulation plus whatever your topic
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you're looking for a low back pain
or neuropathy or whatever it might be,
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and you'll get the most current stuff. The other mesh header where most of
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the older research falls under is LLLT, which stands for a low level either
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a laser therapy or a low level
light therapy. It wasn't quite specific,
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but that LT moniker was used for
many many years as the primary mesh header.
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So looking under those two headers will
help you find out what's going on.
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I often hear there's no research on
laser. It's because people put in
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laser and low back pain and it's
not specific enough. So just the heads
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up on that. So when you
think about photobiomodulation. Think about is you're
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trying to impact cell metabolism. So
I put this picture of jumper cables on
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a battery when your car's dead.
The light kind of does the same thing
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and excite minochondria and sort of wakes
the cells up. So as light's absorbed,
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it impacts atp production, It impacts
nuclear function from an mRNA RNA function,
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which is important for cell replication,
as well as the number of things
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that happened at the membrane level.
So think of it as instead of a
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six cell going towards apoptosis or dying, the laser helps pretty much rejuvenate it.
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It's like putting sort of life paddles
on that cell and helps try to
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prevent it from having to pass away
and get basically gobbled up by macrophages and
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replaced. So when you put light
into the tissue, you're trying to impact
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the minochondria, and that is happening
on more specifically on the inner mitochondria membrane
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where you have the electron transport chain. So I have a little diagram here
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to help kind of walk through that, but basically what this is showing is
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the electron transport chain and as the
crab cycle pumps away, what happens is
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that it produces ATP. When you
have a damage cell or a cell that's
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at a low oxygen STE eight and
it's not in a healthy state, what
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will happen is that nitric oxide will
bound down here on this fourth ribosome on
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the electron transport chain cytochrome co oxidase. And the thought is that when light
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hits that it with very specific wavelengths, there's chromophores there that can absorb the
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light and it releases that nitrocoxide and
it frees up that block on the electron
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transport chain and allows normal oxidative phosphorylation
to take place. So it's a pretty
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cool little cartoon, but this format
doesn't work with that unfortunately. But that's
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what that was about. So from
a review standpoint, you basically you're putting
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light into the tissue. It's going
to increase the activity of cytochromesyoxidase. It's
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going to increase the mitochondria function,
which will increase auxygen consumption better ATP production,
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which will help restore the energy balance
in the cell to help it from
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basically going into apoptosis. So if
a patient were to ask you, how's
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it work? If you know these
little talking points here, you'll be in
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pretty each shape. So what is
indicated for Most companies use a similar indication.
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This is for light force. It's
our five to ten K clearance with
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the FDA, and basically it states
that the laser is able to be used
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to elevate tissue temperature for temporary relief
of minor pain joint pain and stiffness minor
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archrightis pain or muscle spasm, and
temporarily increase localized blood flow and increase relaxation
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of muscle. So this is essentially
the first submission for laser in the US,
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and most companies that basically just use
this as as a predicate to allow
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them to go to market underneath these
same parameters, know that this was submitted
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many, many years ago, and
it doesn't really bring into the account of
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all the different mechanisms of photobiomodulation.
So don't be fooled if you look at
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the indication statement on a laser and
feel that maybe it's not doing some of
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the things that you've read that it
can do. That's not really the intent
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of this the FDA clearance. It's
just what has been filed for usage for
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them for that device, and it
does impact what can be said on label
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about the device as far as marketing
and things of that nature. So that's
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another ten minute discussion we could get
into, but just understand if there's a
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mismatch of your understanding, that's probably
why. So more realistically, in the
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clinic, what can the laser do. It can treat a whole bunch of
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different things with regard to both acute
and chronic pains. It can help provide
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pain control that is non pharmacologic and
non invasive, hopefully be able to possibly
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delay some orthopedic procedures. There's been
many case studies that have been done looking
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at folks with say NEOA. They
get treated with laser with therapies and it
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helps prolong the time you needed to
get total n arthroplasty. So used as
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a management tool as well. Contra
indications for laser generally, they're pretty consistent
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for most of the companies. This
is from our LIGHTE Force units. Basically,
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wouldn't want to apply laser over a
pregnant abdomen or low back or SI
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area. You wouldn't want to do
it over growth plates for children, definitely
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want to try to avoid over electronical
components like pacemakers or pain pumps, things
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of that nature. Not that there's
a huge risk, but the thought is
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that you've got too much light on
a dark lead wire can possibly heat up
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and cause it to short out,
which would be a bad day for everybody.
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So we just advise people to stay
away from any type of electrical implant
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on the patient. You can treat
distal to it or approximal to it,
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but just not over it. How
would you like to get even more great
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retrainings, coupons and promotional offers from
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research and news you can use to
grow your practice and improve your patient care.
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If I've piqued your interest, you
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each Friday. Now back to the
show. And then you wouldn't want to
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try to treat over glandular tissues.
So mostly this comes into play in the
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neck. With the thyroid, you
wouldn't want to do that because it could
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overstimulate it and impact metabolism essentially over
the testes or an ovaries, they're pretty
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deep, so that's really not a
huge concern there, but you wouldn't want
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to target that with the treatment.
And then lastly, people that are taking
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photosensitive meds. Quoting asteroids is the
primary group that are impacting physical medicine that
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can make them photosensitive and more likely
to have a thermal injury on the skin,
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so you want to be very cautious
with that. We generally recommend waiting
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at least a week after somebody's got
a corticle steroid injection before doing laser treatment
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on them. But if they're on
some sort of oral prend zone or something
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like that, you'd want to ask
that patient some questions about how photosensitive they
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are with that medicine and then discuss
that with the patient. So you're going
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to get into wavelength and how that
impacts photobimodulation. And this is just a
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quick diagram of the electromagnetic spectrum.
So it goes from gamma rays which are
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where over there on the left,
and then can go all the way over
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towards radio waves. The wavelengths that
PBM utilize are in the near ANDFRED infrared
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range, so that's just north of
the visible light spectrum. So you'll see
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on most of the wavelengths for these
devices it's going to be somewhere between six
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hundred and thirty five nanometers and up
to maybe just a little bit over one
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thousand nanometers. And we'll get into
a little bit on why they might choose
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different ones, but just so you
kind of get a sense of where those
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wavelengths are in the spectrum, I
put this on here. Generally the frequencies
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go down as you go over towards
the right. So essentially, think about
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like gamma rays and X rays.
They're very high in energy, and that
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high energy, high frequency, they're
ones that can create problems with cells,
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so they can create cancers. That's
why you wouldn't want to sit with underneath
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an X ray for a long long
time, or underneath gamma rays. They
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can be carcinogenic. The wavelengths that
are used for photobimodulation, they do not
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cause they don't have enough energy to
cause changes in the cell that way,
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so they're not not a risk of
causing cancer, which makes it a very
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safe device to be able to use. So if all this talk about light
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and impacking cells seems a little funny, just to kind of bring it home
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a little bit, you probably are
more aware of photobiodulation than you think.
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If you just think about sunlight as
hitting plants being absorbed by chlorophyll and it's
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helping produce oxygen from CO two,
that is a classic example of photobimodulation.
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The thing to appreciate is that chlorophyll
is sensitive to two real peaks of light,
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so in the blue range as well
as in the red range. And
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so if you took those two wavelength
away from the light that comes from the
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sun, we probably run out of
oxygen because they would not be able to
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produce as nearly as much oxygen as
they do. So when you see someone
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growing possibly a plant in a basement
that maybe you've visited, you noticed that
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they have a blue light sitting over
those plants. This is the reason because
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the chloropho absorbs that blue light readily. So the good news is that these
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receptors that are in your cells the
cidochrom cooxidase. What this is trying to
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show is that there is a very
large band of wavelengths that they can react
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to. So over on the left
side they're most reactive in that six hundred
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range six to fifty range, but
then as you go down they have the
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ability to react to a lot of
different wavelengths. So when people see this,
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or if they just take a cursory
glance at their research, they would
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say, hey, why aren't all
the wavelengths for these devices in that red
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range six fifty? And there are
a lot of devices that are out there
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right now in this red light wavelength
and they're getting a lot of publicity.
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So what I would tell you is
that if you were trying to treat just
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so in a petri dish, that
red light would be great, Or if
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you're trying to treat things on your
skin, the red light is great.
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But the problem is that red light
is so readily absorbed by melanin in your
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skin, is that if that was
your primary wavelength, almost none of it
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is going to get below the skin, so it's almost too much of a
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good thing. So those devices that
are primarily just a red light that you're
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thinking, okay, I can create
some photobio modulation. I would just warn
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you, if your intent is to
treat wounds or things that are on the
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skin, probably a pretty good choice. But if you're trying to treat things
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that are below the surface of the
skin, tendons, joint capsules, possibly
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trying to get into a joint or
deeper tissue, that wavelength will not really
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penetrate very well. And I'll show
you a couple slides to help clarify that
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in a minute. So this slide
gives you a sense of absorption on the
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y axis, and then you have
wavelengths on the X axis, and they're
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getting longer as you move towards the
right. And what it just shows you
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is that you have different molecules that
absorb light at different wavelengths with different preference.
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So the important line to see on
that is melanin, which happens to
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grab a lot of light in that
six hundred range we were just talking about.
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But then you can see that melin
starts to get less as absorbative as
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you move towards the eight hundred to
mid nine hundred range. Once you go
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past one micron, which is a
thousand nanometers, Basically you can see that
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that dark line on the right,
that's water. It starts to absorb light
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preferentially. So if you have wavelengths
that get too long, like out in
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that range, they're going to basically
be absorbed by water, which isn't necessarily
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what you want to have happen.
And if you have wavelengths that are too
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short on the red side, they're
going to mostly get absorbed by melanin,
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which probably isn't what you want to
get done as well. So in the
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middle of this optical window, they
refer to it as that's sort of the
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sweet spot on trying to get light
where you want it to go. If
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you're trying to get blow the surface
of skin. There is no perfect wavelength
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because as you can see, you're
trading off for various things. Because when
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you really look at this science,
you realize that the intensity to the light
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as well as the wavelength all will
have an impact on how it gets absorbed.
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You could have the perfect wavelength but
not have enough of it and it
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won't create a change, or you
could get plenty of light down to a
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substance, but if it's not the
right wavelength, it won't it won't get
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absorbed and get impacted. So understand
that there's a lot of research that goes
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in to figure out the right combinations
of power and wavelength so that the devices
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are effective. So this diagram just
gives you a quick sense of how wavelength
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impacts depths. Not drawn to scale, but it gives you a sense of
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as when you're in this optical window. As the wavelengths get longer, generally
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they can penetrate deeper. So,
for example, the wavelengths that are used
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for light force equipment are eight hundred
and ten and nine hundred and eighty animeters.
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That they use two different diodes to
create those two wavelengths, and the
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reason why is they do a good
job of getting past the skin and they've
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been shown to get absorbed very nicely
by different tissues like muscles and nerves and
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things of that nature, which is
why they work so well in this space.
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But you'll see a lot of companies
use a lot of different exotic wavelengths
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that aren't those same two. Those
are the two pretty much most referenced and
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most researched wavelengths. There's some other
ones that show up. Just understand you
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need to understand how they're absorbed and
how well they penetrate when you're trying to
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think about which ones you want to
apply or what device you want to purchase
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to treat your patients, because it's
important. So that last diagram was wavelength.
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This one is power, and it
just goes to show you that if
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you have a fixed wavelength, but
you have more power. So in this
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example it's five watts versus ten watts, you can see that it's going to
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basically be able to go to the
same depth because wavelength will determine the ultimate
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depth that something can go, but
you'll just get twice as much light at
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that depth. So power is important
on delivery, like how many photons can
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I deliver to a tissue per second
at a given wavelength, And that's where
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when you start hearing, oh,
I have higher power makes it easier to
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treat these for tissues. This is
kind of the thought behind it, and
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we'll talk a little bit more about
that in just a second. So you've
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probably seen devices that are LEDs that
are on the market. Most of those
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are like take home type devices versus
the laser devices, but they both fall
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under this photobiomodulation umbrella, which is
true. So you need to know the
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differences between the two if you're thinking
about going down in one direction or another.
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There's some facts you want to know. So basically, when you have
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a white light or a LED,
they are considered incoherent light, meaning that
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they are like the picture on the
left, like people walking around in a
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mall, and they're just sort of
unorganized. Coherent light is unique to laser
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and that all the photons are moving
in sequence together. So that's one of
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the hallmarks of laser and that's what
makes it very effective at trying to get
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through tissue and get to depth.
So when you look at a laser that
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has a couple properties that are unique
to it. A it's monochromatic, meaning
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it's one wavelength, so it's a
very specific wavelength. The lens on a
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laser can be divergent, like they
are in therapy laser, so it starts
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out and then it kind of fans
out. But I'm sure you've all seen
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laser pointers or the sites on a
rifle. A laser rifle, they have
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a divergent angle of zero because they
want that light that can go and point
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hundreds of yards away and help target
something. I mean, they can even
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make lasers that can basically tell the
communication ones that can interact with satellites.
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So if you have enough power,
you can basically push you can push light
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for many, many, many miles. And then the last piece is that
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they are coherent, meaning that they're
in sequence with each other, and they're
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columnated, so they're going to go
very straight basically. So when you hear
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about classes of laser in the United
States, the FDA is the people that
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assign that. There's some other classes
that are on the international side of the
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world, but generally when you're talking
about therapy lasers, they're going to fall
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into either a Class two A,
which would be less than five million watts,
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which is essentially the power of a
laser pointer. You would have a
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Class three B, which would be
anywhere from six miliwatts up to four hundred
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and ninety nine miliwats, and then
anything over a half of watt, so
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five hundred miliwats or more is considered
Class four. There is no CLASSI five,
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so Class four is a large group
of devices that could be an industrial
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laser, it could be these photo
biomosulation devices. So surgical lasers are often
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Class four devices because they're trying to
cut, cauterize, and things of that
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nature. And some people get misinformed
to say, oh, if you have
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a Class four device, it's going
to be dangerous. Those are only for
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doing surgery, and it's not true. The surgical lasers have very specific wavelengths
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to attract water because they wanted to
cauterize, so they use longer wavelengths generally,
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and they have a very high intensity, so they make the spot very
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hot, and that's why they work
so well to cut and cauterized tissue.
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But obviously the intensities of the light
for the therapy lasers in Class four are
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set quite differently. So if anybody
tells you that, we take that wisdom
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with a great of salt. Generally, if you put them side by side,
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the LEDs, the nice thing about
them is that they can treat superficial
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conditions. Well, they don't have
a specific wavelength, but they can put
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00:23:17.720 --> 00:23:21.960
them in a pretty small band of
wavelengths, so it's not like a laser
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that is a single wavelength, but
it'll be in a range. Like for
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the average car that's made now,
the red tail lights are LEDs and so
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those ranges are usually between six thirty
five and six hundred and sixty nanometers.
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The nice thing about those devices is
they're cheap, they're light, and basically
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they can be used to treat superficial
things. Because of the low intensity of
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those lights, they generally don't treat
deeper conditions very well. So if you
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were trying to buy a device to
help with say, woundtealing or something along
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00:23:52.440 --> 00:23:56.400
those lines, and it was an
LED and it would say in the red
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range, it probably would work pretty
well based on the the research it's out
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00:24:00.839 --> 00:24:03.960
there. If you try to take
that same device and treat things that are
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00:24:03.000 --> 00:24:07.640
a couple of centimeters below the surface
of the skin, probably wouldn't work so
333
00:24:07.680 --> 00:24:11.680
well. So when you look over
there on the right for laser, they're
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00:24:11.720 --> 00:24:15.559
much better at treating to depth because
they can basically have much higher intensities.
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00:24:15.640 --> 00:24:18.559
So you can dial in the wavelength
that you want. So if you know
336
00:24:18.640 --> 00:24:19.839
that, hey, I want something
in the eight hundred range or nine hundred
337
00:24:19.920 --> 00:24:25.039
range, you can basically nail that
number and then you can basically put a
338
00:24:25.079 --> 00:24:27.920
lot more intensity or power behind that, which is really important when you're trying
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00:24:27.960 --> 00:24:33.079
to make cells change at depth.
So that's where the Class four devices or
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even the Class three B lasers that
they're used properly, can reach deeper tissues
341
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than the led SCN. So let's
talk a little bit about the impact on
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pain and tissue repair. This is
really a very interesting topic when it comes
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to light and understand that when you
talk about photobiomodulation as a family, they
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can generally create those second and third
part of this slide the short term changes
345
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as well as the lasting effects and
why, and that is that if you
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get enough light to the mitochondria,
you can have this impact on the inflammatory
347
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cascades. You can have an impact
on circulation via nitric oxide being released.
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So it's not uncommon that you treat
a patient if you dose it properly,
349
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they'll come back in a day or
two and say, hey, you know
350
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what, I think I'm feeling better. And that's because of these mechanisms that
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are listed here For that short term
and lasting effects. That first one within
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minutes part that generally has to be
done with higher intensity light. So the
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higher power class four lasers. This
is sort of where they shine u pun
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intended for being able to change pain
with your patients very quickly. So what
355
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they call irradiance or power density.
At higher levels they can impact afferent nerves.
356
00:25:41.519 --> 00:25:45.680
And that's what I want to talk
about here with this slide. So
357
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Vanessa Landa did this study twenty seventeen
or so, and it was an animal
358
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study. But what was cool is
she put light down by the dorser root
359
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aglia of the these nerves and animals, and she also did peatrie dish work
360
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and what she showed was these pictures
here on the right where when you put
361
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intense light on an affarent nerve you
can create varicosities, which is that web
362
00:26:10.880 --> 00:26:12.960
like look you're seeing there. So
it starts there on the upper left,
363
00:26:14.000 --> 00:26:18.720
which is sort of the control slide, and as you move to the upper
364
00:26:18.799 --> 00:26:22.079
right and then down to the middle
and down to the lower basically they were
365
00:26:22.240 --> 00:26:23.920
the nerve was getting exposed for a
longer periods of time, so they're getting
366
00:26:23.920 --> 00:26:26.759
more light to it, and you
can see that you created more of those
367
00:26:26.799 --> 00:26:30.720
sort of spider web looking which are
basically these sort of outbranchings that happen where
368
00:26:30.759 --> 00:26:36.920
the microtubules meet things is a if
you were to take light account, so
369
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that's happening from a chemical standpoint.
This is happening from a photochemical standpoint.
370
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But it's interesting that the nerve responds
very similarly to that sort of input and
371
00:26:45.920 --> 00:26:49.920
they both have a similar and that
it changes the pain of the ability of
372
00:26:49.920 --> 00:26:55.039
that nerve, and it does it
by the amount of ATP that's distributed amongst
373
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the nerve slows down the conduction velocity, and by doing so it some mechanis
374
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happening, but it's something that's happening
when you read. So what I was
375
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just trying to conclude there is that
when you hit afferent nerves with high intensity
376
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light, you basically can create this
change in the afferent the sea fiber for
377
00:27:18.440 --> 00:27:22.279
chronic pain and the adelta fibers for
more acute pain. And when that happens,
378
00:27:22.279 --> 00:27:26.039
you will actually change the performance of
that nerve, which will have an
379
00:27:26.079 --> 00:27:32.000
impact on a pain perception. So
this phenomena has to be done with higher
380
00:27:32.000 --> 00:27:33.480
power though, in order to make
it happen, which is pretty cool.
381
00:27:34.000 --> 00:27:38.799
So with regard to tissue repair,
these are just some different mechanisms that take
382
00:27:38.839 --> 00:27:44.759
place as far as the ways that
laser can help with tendons or muscles get
383
00:27:44.839 --> 00:27:48.200
better, so as far as increasing
collagen lay down by better fiber plastic activity,
384
00:27:48.640 --> 00:27:53.519
better blood flow to it via new
eplithylization, as well as better blood
385
00:27:53.519 --> 00:27:56.839
flow in the short term from nitrodoxide
release, all those things will get more
386
00:27:56.839 --> 00:28:03.119
oxygenated blood to the scene. And
then from macrophage activity, it increases their
387
00:28:03.160 --> 00:28:07.319
ability to chew up tissue that needs
to be replaced and repaired, which all
388
00:28:07.359 --> 00:28:11.480
are obviously a big help when you're
trying to replace damaged tissue. So an
389
00:28:11.480 --> 00:28:15.200
example that was this rabid study that
was done when they surgically basically cut the
390
00:28:15.240 --> 00:28:22.119
achilles and then sewda back together and
then they treated those tenons with laser and
391
00:28:22.200 --> 00:28:26.400
so doses was pretty small because it
was done essentially on in vitro, so
392
00:28:26.440 --> 00:28:30.920
the amount of dose that need is
very small. But you can see on
393
00:28:30.960 --> 00:28:33.920
the left side the collagen alignment looks
very different than that slide on the right
394
00:28:34.039 --> 00:28:37.960
where they did not use the laser. And what's cool is they take a
395
00:28:37.039 --> 00:28:41.640
magnified version of this and you can
really see that there's a very different look
396
00:28:41.680 --> 00:28:45.640
to that collagen on the left versus
the right, So if you were dealing
397
00:28:45.640 --> 00:28:48.400
with a lot of ten in repairs
and you were thinking about investing in a
398
00:28:48.440 --> 00:28:52.279
laser to try to help with your
outcomes, you can sort of get a
399
00:28:52.319 --> 00:28:55.559
sense of why it might be a
good idea to do that. So to
400
00:28:55.599 --> 00:29:00.279
make all this stuff happen laser,
it's important to have dosing on point.
401
00:29:00.680 --> 00:29:04.839
And basically, when you put light
into tissue, one of four things is
402
00:29:04.880 --> 00:29:07.480
going to happen. It's either going
to scatter, which means it's just going
403
00:29:07.519 --> 00:29:11.400
to spread out and that happens on
your skin quite a bit. It's going
404
00:29:11.440 --> 00:29:14.720
to be reflected, which means it
bounces off. It's going to be transmitted,
405
00:29:14.720 --> 00:29:15.960
which means it would go all the
way through. Like when you take
406
00:29:15.960 --> 00:29:19.960
an X ray of somebody, you're
transmitting those X rays through the tissue to
407
00:29:21.000 --> 00:29:25.160
the film and then the last would
be absorbed. And that's what you want
408
00:29:25.160 --> 00:29:27.200
with photoby modulation. You wanted to
get into the tissue, but you also
409
00:29:27.240 --> 00:29:32.240
wanted to get absorbed. So that's
an important concept to remember when you're looking
410
00:29:32.279 --> 00:29:36.160
at different papers or things. How
well does it get into tissue, but
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00:29:36.400 --> 00:29:40.279
ultimately how well does that wavelength get
absorbed. So when you talk about dose
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00:29:40.759 --> 00:29:42.880
with laser, you're really talking about
jewels percent of your square, which is
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00:29:42.880 --> 00:29:47.039
the amount of energy you put in
pre unit area, and that is going
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00:29:47.119 --> 00:29:51.160
to also factor into how many times
somebody is treated in a week or how
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00:29:51.160 --> 00:29:55.519
often they're treated in a planet care. So when you start talking about dose
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00:29:55.599 --> 00:29:57.839
specifically in a study and you're looking
at it, it should mention these four
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00:29:57.880 --> 00:30:02.519
things. The wavelength that was used, the area that was treated, the
418
00:30:02.559 --> 00:30:06.279
total energy that was applied, so
the administration time, and the power that
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00:30:06.440 --> 00:30:10.160
was used, which should also tell
you the size of the spot, which
420
00:30:10.200 --> 00:30:12.000
will give you a sense of what
they call a radiance or power density,
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00:30:12.359 --> 00:30:15.240
and then how many times they were
treated per week. You put all that
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00:30:15.279 --> 00:30:18.359
information together, you can have a
pretty good feel for the dosing and be
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00:30:18.400 --> 00:30:22.640
able to replicate that study. If
they don't put all that information in,
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00:30:22.839 --> 00:30:26.720
then you're probably going to have a
tough time replicating what you see, and
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00:30:26.839 --> 00:30:41.599
unfortunately a lot of papers do not
have all that information. Unfortunately, that's
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00:30:41.640 --> 00:30:45.079
it for today's episode. Be sure
to tune in for part two, where
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00:30:45.119 --> 00:30:49.119
doctor Callen and we'll talk more about
specific treatment guidelines and protocols for tissue depth
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00:30:49.400 --> 00:30:53.519
in order to achieve clinical goals.
We will also get a sneak peek into
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00:30:53.599 --> 00:30:57.839
the future of light therapy and new
innovations in Novus has in the works.
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00:30:59.920 --> 00:31:03.319
To miss it. Episode seventy four
drops in two weeks. If you found
431
00:31:03.319 --> 00:31:07.480
today's information valuable, do me a
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432
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433
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little bit helps. We'll see you
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like what you heard today, I
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435
00:31:22.319 --> 00:31:30.839
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sure to check those out
1
00:00:15.080 --> 00:00:19.239
Hi guys, Welcome to another episode
of The Factor podcast. I'm your host,
2
00:00:19.320 --> 00:00:22.839
Jessica Riddle. If this is your
first time tuning in, welcome and
3
00:00:22.879 --> 00:00:27.000
thank you for listening. The topic
that we're covering today and in our next
4
00:00:27.079 --> 00:00:33.159
episode is therapeutic laser and its applications
for treating pain. Now, therapeutic laser
5
00:00:33.200 --> 00:00:38.399
and other light therapy devices have surged
in popularity in recent years, so much
6
00:00:38.439 --> 00:00:42.840
so that you'll be hard pressed to
attend any healthcare conference without seeing these types
7
00:00:42.880 --> 00:00:47.039
of devices there. In this two
part training, we will hear from Mark
8
00:00:47.119 --> 00:00:52.240
Callanan, a doctor of physical therapy
and the director of Clinical Education and Recovery
9
00:00:52.280 --> 00:00:57.640
Sciences for Aenovis, the company behind
brands such as Chattanooga and light Force lasers.
10
00:00:58.640 --> 00:01:03.000
We will talk about laser theory's role
in treating acute and chronic conditions and
11
00:01:03.039 --> 00:01:08.799
the more nuanced applications for ridiculopathy.
Doctor Callanan will also talk about treatment protocols
12
00:01:08.799 --> 00:01:15.200
that follow a patient's nerve pathways and
how the heat generated from high level laser
13
00:01:15.519 --> 00:01:21.200
can address muscle spasms and joint stiffness. This particular training which was originally offered,
14
00:01:21.200 --> 00:01:25.280
of course, in webinar form featured
a ton of great visuals, graphics
15
00:01:25.319 --> 00:01:29.079
and references to relevant research, so
you'll want to be sure to click in
16
00:01:29.159 --> 00:01:32.400
the webinar replay link in our show
notes. If you're more of a visual
17
00:01:32.480 --> 00:01:46.359
learner, Let's cue the interim music
and get started. Excited to be here,
18
00:01:46.920 --> 00:01:51.159
and today's talk is really designed to
just be an overview of what laser
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00:01:51.200 --> 00:01:53.599
therapy is. There's a lot of
sort of smoke and mud out there in
20
00:01:53.719 --> 00:01:57.799
the space, so a lot of
misinformation, and I spent a lot of
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00:01:57.840 --> 00:02:02.280
time trying to get information out to
everybody. So hopefully when we wrap things
22
00:02:02.359 --> 00:02:07.079
up today, you'll have a little
better feeling on how lasers really work from
23
00:02:07.079 --> 00:02:13.039
a mechanistic standpoint, some of the
recommendations from different groups and research that's supporting
24
00:02:13.520 --> 00:02:15.039
the use of lasers, so that
for those of you that are trying to
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00:02:15.039 --> 00:02:20.759
really follow an evidence based path feel
comfortable that laser definitely fits into that category.
26
00:02:21.120 --> 00:02:24.960
So I'm a physical therapist by training
and receive my doctor in Physical therapy
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00:02:25.120 --> 00:02:30.680
from Marymount University in Arlington, Virginia. I was in the outpatient space for
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00:02:30.800 --> 00:02:35.439
or eighteen years before joining lighte Force
back in twenty seventeen. I was the
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00:02:35.520 --> 00:02:38.759
director of clinical Education. A couple
of years ago, light Force was acquired
30
00:02:38.800 --> 00:02:43.879
by now a Novis, it was
DJO Global, and since that point I've
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00:02:43.919 --> 00:02:49.560
been the director of Education and Marketing
for a Novis. So that's kind of
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00:02:49.560 --> 00:02:52.960
what I've been up to and again
happy to be here today. So what
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00:02:52.960 --> 00:02:55.800
we're going to go over today is
a general overview of the definition mechanisms of
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00:02:55.840 --> 00:03:00.919
photo bimodulation, which is the term
for laser therapy now that's accepted in the
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00:03:00.919 --> 00:03:06.520
research, take a look at some
current research as well as different support guidelines
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00:03:06.520 --> 00:03:09.280
that are out there from the APPA, the American College of Physicians, the
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00:03:09.319 --> 00:03:14.639
American it should be Academy of Orthopedic
Surgeons, a little bit of a TYPEOO
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00:03:14.680 --> 00:03:16.840
there, And when we're done,
hopefully the takeaways will be that you'll understand
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00:03:16.840 --> 00:03:22.800
how laser really impacts cells, Understand
how wavelength, power and dose seem will
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00:03:22.800 --> 00:03:25.800
impact outcomes, be able to explain
the differences between high and low power lasers
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00:03:25.840 --> 00:03:29.879
with regard to how the impact pain
because there is some differences there that are
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00:03:29.919 --> 00:03:35.520
pretty significant, and explain how to
effectively incorporate laser with other treatment concepts in
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00:03:35.560 --> 00:03:39.759
an evidence based manner. So when
you hear laser, not sure what comes
44
00:03:39.759 --> 00:03:44.039
into mind, but it might be
something like this. For your patients,
45
00:03:44.080 --> 00:03:46.960
when you mentioned laser, they very
well might be thinking about this. So
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00:03:46.960 --> 00:03:50.560
it's really important to help provide good
instruction as to what it is and how
47
00:03:50.560 --> 00:03:53.599
it's going to help them, and
that it's a safe modality because when you
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00:03:53.599 --> 00:03:58.159
mentioned laser, sometimes fear can become
an issue for those folks. So from
49
00:03:58.199 --> 00:04:01.879
an historical standpoint, back in nineteen
oh three, the only Nobel Prize that
50
00:04:02.000 --> 00:04:06.120
was ever awarded to a modality that
I'm aware of was awarded to Neil Spinson
51
00:04:06.439 --> 00:04:14.000
and it was used to treat these
large sort of purplish blotches called lupus vulgaris,
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00:04:14.000 --> 00:04:16.519
and they found that if you use
light boxes with specific wavelengths that they
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00:04:16.519 --> 00:04:19.600
were able to help clear that up. So that was a pretty big date
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00:04:20.040 --> 00:04:25.639
over one hundred years ago now and
sort of the beginning or the advent of
55
00:04:25.920 --> 00:04:29.560
laser as we know it started.
Most people would agree in nineteen sixty seven
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where Andre Mester was a physicist and
he was looking at mice and trying to
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00:04:34.439 --> 00:04:39.519
figure out if you put laser light
on their skin, if it created cancer's
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tumors. And it didn't do that, but it caused some hair growth to
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show up on their backs, and
that sort of sparked the question of what's
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00:04:47.319 --> 00:04:51.040
going on there, And since then
research has been going on to figure out
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what happens when you put these special
wavelengths of light onto tissue. So from
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a chronological standpoint, these are just
some significant dates as far as laser goes.
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00:05:00.800 --> 00:05:05.240
If you've noticed, if you've done
any research on literature or on laser,
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00:05:05.279 --> 00:05:10.519
you would notice that there's a lot
more low power studies that are in
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00:05:10.720 --> 00:05:14.199
PubMed or sin all. And the
primary reason for that in the United States
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is just that there's been thirty year
head start on FDA clearance for the lower
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00:05:17.079 --> 00:05:21.519
power devices in two thousand and fours
when the FDA cleared use of Class four
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00:05:21.519 --> 00:05:27.079
devices for human use for therapy.
So since that time, the amount of
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research that's been out has increased significantly, and there's been a number of significant
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endorsements from different groups for laser therapy. The World Health Organization APTA has made
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00:05:36.240 --> 00:05:41.800
several different endorsements for different clinical pathways, which we'll talk about more in depth
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here later in the talk, as
well as some things from the American College
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00:05:44.800 --> 00:05:48.720
of Physicians, the American Academy of
Orthopedic Surgeons, as well as a recent
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position paper from the CDC. So
definitely getting a lot of acceptance on this
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00:05:53.600 --> 00:05:56.879
modality, which is exciting. If
you do look for research on this,
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you want to look underneath the term
photobiomodulation. This is the accepted term for
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laser and the most current research will
be underneath this. So if you're doing
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00:06:04.000 --> 00:06:10.959
a meshad mesh heater search, you'd
want to use photobiomodulation plus whatever your topic
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00:06:11.000 --> 00:06:14.639
you're looking for a low back pain
or neuropathy or whatever it might be,
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00:06:15.000 --> 00:06:17.759
and you'll get the most current stuff. The other mesh header where most of
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00:06:17.800 --> 00:06:23.480
the older research falls under is LLLT, which stands for a low level either
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00:06:23.519 --> 00:06:26.720
a laser therapy or a low level
light therapy. It wasn't quite specific,
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00:06:27.079 --> 00:06:31.000
but that LT moniker was used for
many many years as the primary mesh header.
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So looking under those two headers will
help you find out what's going on.
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I often hear there's no research on
laser. It's because people put in
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laser and low back pain and it's
not specific enough. So just the heads
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up on that. So when you
think about photobiomodulation. Think about is you're
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00:06:49.480 --> 00:06:56.319
trying to impact cell metabolism. So
I put this picture of jumper cables on
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00:06:56.399 --> 00:06:59.519
a battery when your car's dead.
The light kind of does the same thing
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00:06:59.560 --> 00:07:03.279
and excite minochondria and sort of wakes
the cells up. So as light's absorbed,
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00:07:03.519 --> 00:07:09.720
it impacts atp production, It impacts
nuclear function from an mRNA RNA function,
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00:07:10.120 --> 00:07:13.439
which is important for cell replication,
as well as the number of things
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00:07:13.439 --> 00:07:16.000
that happened at the membrane level.
So think of it as instead of a
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six cell going towards apoptosis or dying, the laser helps pretty much rejuvenate it.
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It's like putting sort of life paddles
on that cell and helps try to
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prevent it from having to pass away
and get basically gobbled up by macrophages and
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00:07:30.319 --> 00:07:35.199
replaced. So when you put light
into the tissue, you're trying to impact
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00:07:35.319 --> 00:07:42.399
the minochondria, and that is happening
on more specifically on the inner mitochondria membrane
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00:07:42.560 --> 00:07:45.920
where you have the electron transport chain. So I have a little diagram here
100
00:07:45.920 --> 00:07:48.000
to help kind of walk through that, but basically what this is showing is
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the electron transport chain and as the
crab cycle pumps away, what happens is
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that it produces ATP. When you
have a damage cell or a cell that's
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00:07:58.600 --> 00:08:01.319
at a low oxygen STE eight and
it's not in a healthy state, what
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00:08:01.360 --> 00:08:07.160
will happen is that nitric oxide will
bound down here on this fourth ribosome on
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00:08:07.199 --> 00:08:13.120
the electron transport chain cytochrome co oxidase. And the thought is that when light
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00:08:13.240 --> 00:08:16.639
hits that it with very specific wavelengths, there's chromophores there that can absorb the
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00:08:16.720 --> 00:08:22.040
light and it releases that nitrocoxide and
it frees up that block on the electron
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00:08:22.079 --> 00:08:26.680
transport chain and allows normal oxidative phosphorylation
to take place. So it's a pretty
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00:08:26.680 --> 00:08:31.840
cool little cartoon, but this format
doesn't work with that unfortunately. But that's
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00:08:31.840 --> 00:08:35.600
what that was about. So from
a review standpoint, you basically you're putting
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00:08:35.639 --> 00:08:39.960
light into the tissue. It's going
to increase the activity of cytochromesyoxidase. It's
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00:08:39.960 --> 00:08:46.000
going to increase the mitochondria function,
which will increase auxygen consumption better ATP production,
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00:08:46.559 --> 00:08:48.679
which will help restore the energy balance
in the cell to help it from
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00:08:50.000 --> 00:08:52.840
basically going into apoptosis. So if
a patient were to ask you, how's
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00:08:52.879 --> 00:08:56.159
it work? If you know these
little talking points here, you'll be in
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00:08:56.200 --> 00:09:03.000
pretty each shape. So what is
indicated for Most companies use a similar indication.
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00:09:03.080 --> 00:09:07.200
This is for light force. It's
our five to ten K clearance with
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00:09:07.279 --> 00:09:11.960
the FDA, and basically it states
that the laser is able to be used
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00:09:11.960 --> 00:09:16.519
to elevate tissue temperature for temporary relief
of minor pain joint pain and stiffness minor
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00:09:16.600 --> 00:09:22.240
archrightis pain or muscle spasm, and
temporarily increase localized blood flow and increase relaxation
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00:09:22.320 --> 00:09:28.000
of muscle. So this is essentially
the first submission for laser in the US,
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00:09:28.080 --> 00:09:33.639
and most companies that basically just use
this as as a predicate to allow
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them to go to market underneath these
same parameters, know that this was submitted
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many, many years ago, and
it doesn't really bring into the account of
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all the different mechanisms of photobiomodulation.
So don't be fooled if you look at
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00:09:46.080 --> 00:09:50.120
the indication statement on a laser and
feel that maybe it's not doing some of
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00:09:50.159 --> 00:09:54.559
the things that you've read that it
can do. That's not really the intent
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00:09:54.799 --> 00:09:58.799
of this the FDA clearance. It's
just what has been filed for usage for
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00:09:58.840 --> 00:10:03.600
them for that device, and it
does impact what can be said on label
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00:10:03.639 --> 00:10:07.559
about the device as far as marketing
and things of that nature. So that's
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00:10:07.600 --> 00:10:11.279
another ten minute discussion we could get
into, but just understand if there's a
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00:10:11.279 --> 00:10:15.159
mismatch of your understanding, that's probably
why. So more realistically, in the
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00:10:15.200 --> 00:10:18.320
clinic, what can the laser do. It can treat a whole bunch of
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00:10:18.360 --> 00:10:22.840
different things with regard to both acute
and chronic pains. It can help provide
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00:10:22.000 --> 00:10:28.720
pain control that is non pharmacologic and
non invasive, hopefully be able to possibly
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00:10:28.720 --> 00:10:33.679
delay some orthopedic procedures. There's been
many case studies that have been done looking
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00:10:33.720 --> 00:10:37.320
at folks with say NEOA. They
get treated with laser with therapies and it
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00:10:37.399 --> 00:10:43.679
helps prolong the time you needed to
get total n arthroplasty. So used as
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00:10:43.679 --> 00:10:48.080
a management tool as well. Contra
indications for laser generally, they're pretty consistent
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00:10:48.200 --> 00:10:52.879
for most of the companies. This
is from our LIGHTE Force units. Basically,
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00:10:52.919 --> 00:10:56.320
wouldn't want to apply laser over a
pregnant abdomen or low back or SI
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00:10:56.440 --> 00:11:00.960
area. You wouldn't want to do
it over growth plates for children, definitely
143
00:11:01.320 --> 00:11:05.799
want to try to avoid over electronical
components like pacemakers or pain pumps, things
144
00:11:05.799 --> 00:11:09.159
of that nature. Not that there's
a huge risk, but the thought is
145
00:11:09.159 --> 00:11:13.840
that you've got too much light on
a dark lead wire can possibly heat up
146
00:11:13.200 --> 00:11:16.080
and cause it to short out,
which would be a bad day for everybody.
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00:11:16.399 --> 00:11:20.240
So we just advise people to stay
away from any type of electrical implant
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00:11:20.360 --> 00:11:24.159
on the patient. You can treat
distal to it or approximal to it,
149
00:11:24.240 --> 00:11:28.639
but just not over it. How
would you like to get even more great
150
00:11:28.679 --> 00:11:33.559
content from Factor in your inbox each
week? Things like early access to exclusive
151
00:11:33.600 --> 00:11:39.840
retrainings, coupons and promotional offers from
our online store, and timely updates on
152
00:11:39.960 --> 00:11:43.799
research and news you can use to
grow your practice and improve your patient care.
153
00:11:43.919 --> 00:11:46.360
If I've piqued your interest, you
should be sure to click on the
154
00:11:46.399 --> 00:11:50.759
Factor five Things Friday link in our
show notes. Simply give us your contact
155
00:11:50.759 --> 00:11:56.559
details and start getting our weekly Factor
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156
00:11:56.120 --> 00:12:00.879
It's a simple bullet point style format
with no fluff. There tons of great
157
00:12:00.879 --> 00:12:05.080
content and resources you can use for
continual professional growth, so be sure to
158
00:12:05.159 --> 00:12:09.200
visit the show notes. Click that
link and keep an eye on your inbox
159
00:12:09.240 --> 00:12:15.360
each Friday. Now back to the
show. And then you wouldn't want to
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00:12:15.360 --> 00:12:18.480
try to treat over glandular tissues.
So mostly this comes into play in the
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00:12:18.519 --> 00:12:22.360
neck. With the thyroid, you
wouldn't want to do that because it could
162
00:12:22.360 --> 00:12:28.159
overstimulate it and impact metabolism essentially over
the testes or an ovaries, they're pretty
163
00:12:28.200 --> 00:12:31.759
deep, so that's really not a
huge concern there, but you wouldn't want
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00:12:31.759 --> 00:12:37.080
to target that with the treatment.
And then lastly, people that are taking
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00:12:37.080 --> 00:12:43.279
photosensitive meds. Quoting asteroids is the
primary group that are impacting physical medicine that
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00:12:43.320 --> 00:12:46.679
can make them photosensitive and more likely
to have a thermal injury on the skin,
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so you want to be very cautious
with that. We generally recommend waiting
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at least a week after somebody's got
a corticle steroid injection before doing laser treatment
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on them. But if they're on
some sort of oral prend zone or something
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like that, you'd want to ask
that patient some questions about how photosensitive they
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are with that medicine and then discuss
that with the patient. So you're going
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to get into wavelength and how that
impacts photobimodulation. And this is just a
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quick diagram of the electromagnetic spectrum.
So it goes from gamma rays which are
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where over there on the left,
and then can go all the way over
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towards radio waves. The wavelengths that
PBM utilize are in the near ANDFRED infrared
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range, so that's just north of
the visible light spectrum. So you'll see
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on most of the wavelengths for these
devices it's going to be somewhere between six
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hundred and thirty five nanometers and up
to maybe just a little bit over one
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thousand nanometers. And we'll get into
a little bit on why they might choose
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different ones, but just so you
kind of get a sense of where those
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wavelengths are in the spectrum, I
put this on here. Generally the frequencies
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go down as you go over towards
the right. So essentially, think about
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like gamma rays and X rays.
They're very high in energy, and that
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high energy, high frequency, they're
ones that can create problems with cells,
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so they can create cancers. That's
why you wouldn't want to sit with underneath
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an X ray for a long long
time, or underneath gamma rays. They
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can be carcinogenic. The wavelengths that
are used for photobimodulation, they do not
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cause they don't have enough energy to
cause changes in the cell that way,
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so they're not not a risk of
causing cancer, which makes it a very
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safe device to be able to use. So if all this talk about light
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and impacking cells seems a little funny, just to kind of bring it home
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a little bit, you probably are
more aware of photobiodulation than you think.
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If you just think about sunlight as
hitting plants being absorbed by chlorophyll and it's
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helping produce oxygen from CO two,
that is a classic example of photobimodulation.
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The thing to appreciate is that chlorophyll
is sensitive to two real peaks of light,
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so in the blue range as well
as in the red range. And
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so if you took those two wavelength
away from the light that comes from the
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sun, we probably run out of
oxygen because they would not be able to
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produce as nearly as much oxygen as
they do. So when you see someone
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growing possibly a plant in a basement
that maybe you've visited, you noticed that
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they have a blue light sitting over
those plants. This is the reason because
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the chloropho absorbs that blue light readily. So the good news is that these
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receptors that are in your cells the
cidochrom cooxidase. What this is trying to
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show is that there is a very
large band of wavelengths that they can react
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to. So over on the left
side they're most reactive in that six hundred
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range six to fifty range, but
then as you go down they have the
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ability to react to a lot of
different wavelengths. So when people see this,
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or if they just take a cursory
glance at their research, they would
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say, hey, why aren't all
the wavelengths for these devices in that red
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range six fifty? And there are
a lot of devices that are out there
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right now in this red light wavelength
and they're getting a lot of publicity.
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So what I would tell you is
that if you were trying to treat just
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so in a petri dish, that
red light would be great, Or if
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you're trying to treat things on your
skin, the red light is great.
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But the problem is that red light
is so readily absorbed by melanin in your
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skin, is that if that was
your primary wavelength, almost none of it
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is going to get below the skin, so it's almost too much of a
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good thing. So those devices that
are primarily just a red light that you're
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thinking, okay, I can create
some photobio modulation. I would just warn
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you, if your intent is to
treat wounds or things that are on the
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skin, probably a pretty good choice. But if you're trying to treat things
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that are below the surface of the
skin, tendons, joint capsules, possibly
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trying to get into a joint or
deeper tissue, that wavelength will not really
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penetrate very well. And I'll show
you a couple slides to help clarify that
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in a minute. So this slide
gives you a sense of absorption on the
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y axis, and then you have
wavelengths on the X axis, and they're
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getting longer as you move towards the
right. And what it just shows you
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is that you have different molecules that
absorb light at different wavelengths with different preference.
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So the important line to see on
that is melanin, which happens to
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grab a lot of light in that
six hundred range we were just talking about.
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But then you can see that melin
starts to get less as absorbative as
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you move towards the eight hundred to
mid nine hundred range. Once you go
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past one micron, which is a
thousand nanometers, Basically you can see that
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that dark line on the right,
that's water. It starts to absorb light
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preferentially. So if you have wavelengths
that get too long, like out in
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that range, they're going to basically
be absorbed by water, which isn't necessarily
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what you want to have happen.
And if you have wavelengths that are too
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short on the red side, they're
going to mostly get absorbed by melanin,
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which probably isn't what you want to
get done as well. So in the
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middle of this optical window, they
refer to it as that's sort of the
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sweet spot on trying to get light
where you want it to go. If
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you're trying to get blow the surface
of skin. There is no perfect wavelength
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because as you can see, you're
trading off for various things. Because when
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you really look at this science,
you realize that the intensity to the light
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as well as the wavelength all will
have an impact on how it gets absorbed.
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You could have the perfect wavelength but
not have enough of it and it
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won't create a change, or you
could get plenty of light down to a
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substance, but if it's not the
right wavelength, it won't it won't get
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absorbed and get impacted. So understand
that there's a lot of research that goes
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in to figure out the right combinations
of power and wavelength so that the devices
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are effective. So this diagram just
gives you a quick sense of how wavelength
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impacts depths. Not drawn to scale, but it gives you a sense of
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as when you're in this optical window. As the wavelengths get longer, generally
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they can penetrate deeper. So,
for example, the wavelengths that are used
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for light force equipment are eight hundred
and ten and nine hundred and eighty animeters.
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That they use two different diodes to
create those two wavelengths, and the
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reason why is they do a good
job of getting past the skin and they've
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been shown to get absorbed very nicely
by different tissues like muscles and nerves and
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things of that nature, which is
why they work so well in this space.
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But you'll see a lot of companies
use a lot of different exotic wavelengths
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that aren't those same two. Those
are the two pretty much most referenced and
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most researched wavelengths. There's some other
ones that show up. Just understand you
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need to understand how they're absorbed and
how well they penetrate when you're trying to
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think about which ones you want to
apply or what device you want to purchase
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to treat your patients, because it's
important. So that last diagram was wavelength.
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This one is power, and it
just goes to show you that if
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you have a fixed wavelength, but
you have more power. So in this
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example it's five watts versus ten watts, you can see that it's going to
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basically be able to go to the
same depth because wavelength will determine the ultimate
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depth that something can go, but
you'll just get twice as much light at
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that depth. So power is important
on delivery, like how many photons can
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I deliver to a tissue per second
at a given wavelength, And that's where
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when you start hearing, oh,
I have higher power makes it easier to
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treat these for tissues. This is
kind of the thought behind it, and
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we'll talk a little bit more about
that in just a second. So you've
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probably seen devices that are LEDs that
are on the market. Most of those
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are like take home type devices versus
the laser devices, but they both fall
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under this photobiomodulation umbrella, which is
true. So you need to know the
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differences between the two if you're thinking
about going down in one direction or another.
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There's some facts you want to know. So basically, when you have
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a white light or a LED,
they are considered incoherent light, meaning that
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they are like the picture on the
left, like people walking around in a
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mall, and they're just sort of
unorganized. Coherent light is unique to laser
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and that all the photons are moving
in sequence together. So that's one of
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the hallmarks of laser and that's what
makes it very effective at trying to get
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through tissue and get to depth.
So when you look at a laser that
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has a couple properties that are unique
to it. A it's monochromatic, meaning
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it's one wavelength, so it's a
very specific wavelength. The lens on a
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laser can be divergent, like they
are in therapy laser, so it starts
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out and then it kind of fans
out. But I'm sure you've all seen
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laser pointers or the sites on a
rifle. A laser rifle, they have
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a divergent angle of zero because they
want that light that can go and point
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hundreds of yards away and help target
something. I mean, they can even
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make lasers that can basically tell the
communication ones that can interact with satellites.
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So if you have enough power,
you can basically push you can push light
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for many, many, many miles. And then the last piece is that
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they are coherent, meaning that they're
in sequence with each other, and they're
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columnated, so they're going to go
very straight basically. So when you hear
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about classes of laser in the United
States, the FDA is the people that
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assign that. There's some other classes
that are on the international side of the
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world, but generally when you're talking
about therapy lasers, they're going to fall
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into either a Class two A,
which would be less than five million watts,
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which is essentially the power of a
laser pointer. You would have a
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Class three B, which would be
anywhere from six miliwatts up to four hundred
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and ninety nine miliwats, and then
anything over a half of watt, so
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five hundred miliwats or more is considered
Class four. There is no CLASSI five,
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so Class four is a large group
of devices that could be an industrial
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laser, it could be these photo
biomosulation devices. So surgical lasers are often
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Class four devices because they're trying to
cut, cauterize, and things of that
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nature. And some people get misinformed
to say, oh, if you have
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a Class four device, it's going
to be dangerous. Those are only for
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doing surgery, and it's not true. The surgical lasers have very specific wavelengths
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to attract water because they wanted to
cauterize, so they use longer wavelengths generally,
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and they have a very high intensity, so they make the spot very
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hot, and that's why they work
so well to cut and cauterized tissue.
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But obviously the intensities of the light
for the therapy lasers in Class four are
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set quite differently. So if anybody
tells you that, we take that wisdom
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with a great of salt. Generally, if you put them side by side,
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the LEDs, the nice thing about
them is that they can treat superficial
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conditions. Well, they don't have
a specific wavelength, but they can put
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them in a pretty small band of
wavelengths, so it's not like a laser
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that is a single wavelength, but
it'll be in a range. Like for
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the average car that's made now,
the red tail lights are LEDs and so
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those ranges are usually between six thirty
five and six hundred and sixty nanometers.
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The nice thing about those devices is
they're cheap, they're light, and basically
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they can be used to treat superficial
things. Because of the low intensity of
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those lights, they generally don't treat
deeper conditions very well. So if you
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were trying to buy a device to
help with say, woundtealing or something along
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those lines, and it was an
LED and it would say in the red
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range, it probably would work pretty
well based on the the research it's out
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there. If you try to take
that same device and treat things that are
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a couple of centimeters below the surface
of the skin, probably wouldn't work so
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well. So when you look over
there on the right for laser, they're
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much better at treating to depth because
they can basically have much higher intensities.
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So you can dial in the wavelength
that you want. So if you know
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that, hey, I want something
in the eight hundred range or nine hundred
337
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range, you can basically nail that
number and then you can basically put a
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lot more intensity or power behind that, which is really important when you're trying
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to make cells change at depth.
So that's where the Class four devices or
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even the Class three B lasers that
they're used properly, can reach deeper tissues
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than the led SCN. So let's
talk a little bit about the impact on
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pain and tissue repair. This is
really a very interesting topic when it comes
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to light and understand that when you
talk about photobiomodulation as a family, they
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can generally create those second and third
part of this slide the short term changes
345
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as well as the lasting effects and
why, and that is that if you
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get enough light to the mitochondria,
you can have this impact on the inflammatory
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cascades. You can have an impact
on circulation via nitric oxide being released.
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So it's not uncommon that you treat
a patient if you dose it properly,
349
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they'll come back in a day or
two and say, hey, you know
350
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what, I think I'm feeling better. And that's because of these mechanisms that
351
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are listed here For that short term
and lasting effects. That first one within
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minutes part that generally has to be
done with higher intensity light. So the
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higher power class four lasers. This
is sort of where they shine u pun
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intended for being able to change pain
with your patients very quickly. So what
355
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they call irradiance or power density.
At higher levels they can impact afferent nerves.
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And that's what I want to talk
about here with this slide. So
357
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Vanessa Landa did this study twenty seventeen
or so, and it was an animal
358
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study. But what was cool is
she put light down by the dorser root
359
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aglia of the these nerves and animals, and she also did peatrie dish work
360
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and what she showed was these pictures
here on the right where when you put
361
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intense light on an affarent nerve you
can create varicosities, which is that web
362
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like look you're seeing there. So
it starts there on the upper left,
363
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which is sort of the control slide, and as you move to the upper
364
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right and then down to the middle
and down to the lower basically they were
365
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the nerve was getting exposed for a
longer periods of time, so they're getting
366
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more light to it, and you
can see that you created more of those
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sort of spider web looking which are
basically these sort of outbranchings that happen where
368
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the microtubules meet things is a if
you were to take light account, so
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00:26:37.000 --> 00:26:41.440
that's happening from a chemical standpoint.
This is happening from a photochemical standpoint.
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But it's interesting that the nerve responds
very similarly to that sort of input and
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they both have a similar and that
it changes the pain of the ability of
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that nerve, and it does it
by the amount of ATP that's distributed amongst
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the nerve slows down the conduction velocity, and by doing so it some mechanis
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happening, but it's something that's happening
when you read. So what I was
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just trying to conclude there is that
when you hit afferent nerves with high intensity
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light, you basically can create this
change in the afferent the sea fiber for
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chronic pain and the adelta fibers for
more acute pain. And when that happens,
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you will actually change the performance of
that nerve, which will have an
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impact on a pain perception. So
this phenomena has to be done with higher
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power though, in order to make
it happen, which is pretty cool.
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So with regard to tissue repair,
these are just some different mechanisms that take
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place as far as the ways that
laser can help with tendons or muscles get
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00:27:44.839 --> 00:27:48.200
better, so as far as increasing
collagen lay down by better fiber plastic activity,
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00:27:48.640 --> 00:27:53.519
better blood flow to it via new
eplithylization, as well as better blood
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00:27:53.519 --> 00:27:56.839
flow in the short term from nitrodoxide
release, all those things will get more
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00:27:56.839 --> 00:28:03.119
oxygenated blood to the scene. And
then from macrophage activity, it increases their
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00:28:03.160 --> 00:28:07.319
ability to chew up tissue that needs
to be replaced and repaired, which all
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00:28:07.359 --> 00:28:11.480
are obviously a big help when you're
trying to replace damaged tissue. So an
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00:28:11.480 --> 00:28:15.200
example that was this rabid study that
was done when they surgically basically cut the
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00:28:15.240 --> 00:28:22.119
achilles and then sewda back together and
then they treated those tenons with laser and
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00:28:22.200 --> 00:28:26.400
so doses was pretty small because it
was done essentially on in vitro, so
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00:28:26.440 --> 00:28:30.920
the amount of dose that need is
very small. But you can see on
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the left side the collagen alignment looks
very different than that slide on the right
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00:28:34.039 --> 00:28:37.960
where they did not use the laser. And what's cool is they take a
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00:28:37.039 --> 00:28:41.640
magnified version of this and you can
really see that there's a very different look
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00:28:41.680 --> 00:28:45.640
to that collagen on the left versus
the right, So if you were dealing
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00:28:45.640 --> 00:28:48.400
with a lot of ten in repairs
and you were thinking about investing in a
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00:28:48.440 --> 00:28:52.279
laser to try to help with your
outcomes, you can sort of get a
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00:28:52.319 --> 00:28:55.559
sense of why it might be a
good idea to do that. So to
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00:28:55.599 --> 00:29:00.279
make all this stuff happen laser,
it's important to have dosing on point.
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00:29:00.680 --> 00:29:04.839
And basically, when you put light
into tissue, one of four things is
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00:29:04.880 --> 00:29:07.480
going to happen. It's either going
to scatter, which means it's just going
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00:29:07.519 --> 00:29:11.400
to spread out and that happens on
your skin quite a bit. It's going
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00:29:11.440 --> 00:29:14.720
to be reflected, which means it
bounces off. It's going to be transmitted,
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00:29:14.720 --> 00:29:15.960
which means it would go all the
way through. Like when you take
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00:29:15.960 --> 00:29:19.960
an X ray of somebody, you're
transmitting those X rays through the tissue to
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00:29:21.000 --> 00:29:25.160
the film and then the last would
be absorbed. And that's what you want
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00:29:25.160 --> 00:29:27.200
with photoby modulation. You wanted to
get into the tissue, but you also
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00:29:27.240 --> 00:29:32.240
wanted to get absorbed. So that's
an important concept to remember when you're looking
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00:29:32.279 --> 00:29:36.160
at different papers or things. How
well does it get into tissue, but
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00:29:36.400 --> 00:29:40.279
ultimately how well does that wavelength get
absorbed. So when you talk about dose
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00:29:40.759 --> 00:29:42.880
with laser, you're really talking about
jewels percent of your square, which is
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00:29:42.880 --> 00:29:47.039
the amount of energy you put in
pre unit area, and that is going
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00:29:47.119 --> 00:29:51.160
to also factor into how many times
somebody is treated in a week or how
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00:29:51.160 --> 00:29:55.519
often they're treated in a planet care. So when you start talking about dose
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00:29:55.599 --> 00:29:57.839
specifically in a study and you're looking
at it, it should mention these four
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00:29:57.880 --> 00:30:02.519
things. The wavelength that was used, the area that was treated, the
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00:30:02.559 --> 00:30:06.279
total energy that was applied, so
the administration time, and the power that
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00:30:06.440 --> 00:30:10.160
was used, which should also tell
you the size of the spot, which
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00:30:10.200 --> 00:30:12.000
will give you a sense of what
they call a radiance or power density,
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00:30:12.359 --> 00:30:15.240
and then how many times they were
treated per week. You put all that
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00:30:15.279 --> 00:30:18.359
information together, you can have a
pretty good feel for the dosing and be
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00:30:18.400 --> 00:30:22.640
able to replicate that study. If
they don't put all that information in,
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00:30:22.839 --> 00:30:26.720
then you're probably going to have a
tough time replicating what you see, and
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00:30:26.839 --> 00:30:41.599
unfortunately a lot of papers do not
have all that information. Unfortunately, that's
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00:30:41.640 --> 00:30:45.079
it for today's episode. Be sure
to tune in for part two, where
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00:30:45.119 --> 00:30:49.119
doctor Callen and we'll talk more about
specific treatment guidelines and protocols for tissue depth
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00:30:49.400 --> 00:30:53.519
in order to achieve clinical goals.
We will also get a sneak peek into
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00:30:53.599 --> 00:30:57.839
the future of light therapy and new
innovations in Novus has in the works.
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00:30:59.920 --> 00:31:03.319
To miss it. Episode seventy four
drops in two weeks. If you found
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00:31:03.319 --> 00:31:07.480
today's information valuable, do me a
favor and give us a like or leave
432
00:31:07.480 --> 00:31:12.079
a review on your podcast platform.
Share this episode with a friend. Every
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little bit helps. We'll see you
next time. Hey guys, if you
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00:31:18.839 --> 00:31:22.160
like what you heard today, I
encourage you to visit our website at Factor
435
00:31:22.319 --> 00:31:30.839
hyphenstore dot com that's spelled fak tr
hyphenstore dot com to find out more information
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00:31:30.920 --> 00:31:34.359
about all that we have to offer. We have a variety of online offerings
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as well as our hands on Factor
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globe. Be sure to also check
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00:31:42.279 --> 00:31:47.359
these upcoming live webinar dates coming up
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