Vet Laser Tx._Today Vet Mag.

A Supplement to September/OctOber 2016An official Journal of the nAVCLaser Therapyin Veterinary practiceDelayed Union Femur tvpjournal.comFracture Treated withLaser Therapy toStimulate Bone HealingThe Anti-inflammatoryBenefits of Laser TherapyThe Use of TherapeuticLaser for BicepsTendinitis in an ActiveLabrador Retriever

INTRODUCTION TO THERAPY LASERSPETER H. EEG, BSC, DVM, CVLF, FASLMSSince the invention of laser technology more than 50 absorbed by the desired chromophore(s).years ago, the use of low levels of visible and/or near It is important to note that the photobiomodula-infrared concentrated light has been known to reducepain, inflammation, and edema; promote healing of tion effect on the target agent can be photochemical,wounds, deeper tissues, and nerves; and prevent or photomechanical, photothermal, or any combination ofdelay cell death and tissue damage. Thousands of the three, depending on the interaction of the selectedreports of positive treatment outcomes associated wavelength(s) with the chomophore(s). In a therapeuticwith therapeutic laser photobiomodulation exist, setting, this interaction is evident as a biphasic dose-including studies of numerous medical conditions in dependent curve model for optimal treatment responseanimal models and in randomized controlled clinical (Arndt-Schulz curve).trials in people and animals. Despite these reports, lowlevel laser therapy (LLLT) and high power laser therapy Some identified examples of photobiomodulation’s(HPLT) remain sometimes controversial in mainstream positive effects include the following:human and veterinary medicine and surgery. • Increased ATP formation The photobiomodulation mechanisms underlying • Photodisassociation of nitric oxide, allowingthe positive effects of laser therapy at the cellular,tissue, and whole organ levels are becoming more and increased cytochrome C oxidase and increasedmore completely understood as measuring technology cellular respirationimproves. Basic research is finding better rationales for • Improved cell proliferation and regenerationchoosing among the laser wavelength parameters that • Re-establishment of normal tissue integritymake up the complete therapeutic effect. These param- • Increased extracellular fluid resorptioneters include power density, pulse structure, and treat- • Improved lymphatic and vascular integrityment time domains, all under the umbrella of irradiance • Flow reduction in nociceptor depolarization, therebyto the target tissue. Adjustment of these parameters reducing pain pathway windup or pain recognition.using various equipment has led to the publication of Effective application of laser therapymany positive studies associated with therapeutic out- photobiomodulation relies on a clear understandingcomes, as well some negative ones. These results dem- of user and patient safety, laser wavelength physics,onstrate how important it is not only to have a com- variable characteristics and penetration of the selectedplete understanding of the interaction of the various wavelength(s), and the expected photobiomodulatoryparameters of therapy laser wavelength administration outcome to the targeted cells, tissue, and/or organ.but also to carefully evaluate the equipment produc- Photobiomodulation of disease processes can being the wavelength(s) when applying laser therapy to advantageous to both patient and clinician when theproduce a positive clinical outcome for the patient. right wavelength and equipment are understood and used correctly with an appropriate expectation of Photobioactive wavelengths are generally considered outcome for the patient.to be within the 532- to 1064-nm wavelengths of About Dr. Eegvisible to near infrared light. Their target agents, Dr. Eeg is a Certified Veterinary Laser Fellow as well as achromophores, are either molecules or parts of Fellow of the American Society for Laser Medicine andmolecules found both inside and outside of cells. Surgery. He earned his veterinary degree from the Virginia–The concentrations and tissue depth of the target Maryland Regional College of Veterinary Medicine and is anchromophores are very relative when trying to internationally recognized speaker on several topics, includingdetermine the clinical outcome. The wavelength(s) pain management in humans and animals. He is also theselected must be able to reach and be preferentially author of Veterinary Laser Surgery: A Practical Guide as well as several veterinary articles. Dr. Eeg is the owner of Poolesville Veterinary Clinic in Poolesville, Maryland.WARRANTIES, LIMITATIONS. Eastern States Veterinary Association, Inc (NAVC) makes no warranties whatsoever, express, implied, or statutory. NAVC specifically disclaims any impliedwarranty of merchantability or fitness for a particular purpose. In no event will NAVC be liable to you or any third party for any indirect, punitive, special, incidental, or consequential damages(including loss of profits, use, data, or other economic advantage), however it arises, even if NAVC has previously been advised of the possibility of such damage. All rights reserved. No partof this publication may be reproduced in any form without written permission from the publisher. Entire contents ©2016 Eastern States Veterinary Association, Inc (NAVC).2 | A Supplement to TODAY’S VETERINARY PRACTICE | September/October 2016 | tvpjournal.com



DeLAyeD UnIon FemUR FRAcTUReTReATeD wITH LASeR THeRApy ToSTImULATe Bone HeALIngLISA A. mILLeR, DVm, ccRT, cVA (penDIng)We often think of wound healing cases that would mechanisms involved in bone repair when used in thebenefit from the application of laser therapy, or perhaps chronic phase. this is true not just for normal patients,challenging osteoarthritis cases that could use another but also for osteopenic patients, as well as those withmodality for pain relief. However, many clinicians may compromised healing, with documented improvementnot have immediately considered the application of laser in the osseointegration process and/or a higher amounttherapy (photobiomodulation therapy, or pbmt) for of newly formed bone in laser-treated groups comparedassisting not only in pain relief for veterinary patients with control animals in studies.with fractures, but also in stimulation of bone healing. Further controlled studies in veterinary patientsWhether the fracture has recently been surgically fixated should be performed to characterize the effects andor is showing signs of delayed union or non-union, optimal dosing for treating fractures; however, at thispbmt may be used as part of comprehensive fracture time, many practitioners utilizing laser therapy in clinicalmanagement. In addition to the many ways that pbmt practice on a daily basis are reporting success. therelieves pain, there is evidence in the literature for its use results and photos from one such case are shared below.in stimulating bone healing. History In a recent review of 25 relevant articles looking atthe application of pbmt in bone healing (13 in vitro A 1-year-old, spayed female mixed-breed dog wasand 12 animal studies), 11 in vitro studies showed surrendered to the humane society with an unknownpositive results withregard to accelerationof cell proliferation anddifferentiation and allanimal studies showedimproved bone healing atlaser-treated sites.1 Whilesome studies have shownthat pbmt’s effectswere more prominentwhen treatment startedduring the acute phase 123of the injury, most alsodemonstrated that laser Figure 1. radiograph of fracture obtained immediately after surgery.therapy still aided the Figure 2. radiograph of fracture obtained 8 weeks postoperatively.bone consolidation Figure 3. radiograph of fracture obtained 12 weeks postoperatively. Laser treatmentprocess and favored the started after this visit.4 | A Supplement to Today’s VeTerinary PracTice | September/October 2016 | tvpjournal.com

history of trauma (likely vehicular trauma) and a Other therapies included controlled weight-bearing/complete fracture of the proximal third of the left balancing exercises and slow leash walking. Otherwise,femur, which was soon repaired with internal fixation crate rest was recommended. the laser therapist reported(Figure 1). postoperative radiographic evaluation at 8 that the patient tolerated the treatments very well andweeks demonstrated no evidence of osteogenesis and was “comfortable and compliant” during her treatmentthe presence of a broken screw (Figure 2). exercise sessions.restriction was recommended, and repeat radiographswere obtained 4 weeks later (12 weeks postsurgery). After 12 laser sessions (16 weeks postsurgery),No clinical improvement was noted (Figure 3). the improved bone healing was already notedattending veterinarian diagnosed a delayed union, and, radiographically (Figure 5), with only a small defectas the patient was still non–weight-bearing, the owner left at the fracture site. by 20 weeks postsurgery (afterwas considering amputation. 18 laser sessions), complete union was achieved (Figure 6) and the patient was fully weight-bearing and soundPresentation at the completion of her treatment, according to her veterinarian.the patient was referred to Arlington park VeterinaryServices, in Kingston, Ontario, canada, where laser Discussiontherapy was instituted to attempt to stimulate bonehealing and assist with pain relief before further surgery the results of this case are not singular, and many smallwith possible bone grafting. Amputation was considered animal clinicians around the world have reported similaras a last resort if the patient did not improve. results from use of pbmt in treating delayed union or non-union fractures in their hospitals. Althoughtreatment appropriate recommendations for fixation and other standard of care treatments should always be made,the patient received laser therapy (Figure 4) with a practitioners are encouraged to consider the use of laserdose of approximately 10 J/cm2 delivered at a power of therapy as an adjunct to these treatments to aid in pain6 W continuous wave emission. therapy was applied relief and speed healing.circumferentially to the area 3 times weekly for 30 days(12 treatments), then twice weekly for 2 weeks, and Referencethen once weekly for 2 weeks (18 total treatments). 1. ebrahimi t, moslemi n, rokn ar, et al. the influence of low-intensity laser therapy on bone healing. J Dent (tehran) 2012; 9(4):238-248. 45 6Figure 4. Patient being treated at arlington Park Veterinary services.Figure 5. radiograph of fracture obtained 16 weeks postoperatively.Figure 6. radiograph of fracture obtained 20 weeks postoperatively.tvpjournal.com | September/October 2016 | A Supplement to Today’s VeTerinary PracTice | 5

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The AnTi-inflAmmATory BenefiTsof lAser TherApyDAviD s. BrADley, Dvm, fAslms The three broad responses laser therapy initiates are commonly listed as analgesic, anti-inflammatory, and biostimulatory or healing. This case study illustrates the very rapid and measurable anti-inflammatory effects.Figure 1. the patient, Bruno, presented with edema, Historybruising, and serous discharge at the suture line. The patient, a 10-year-old, 90-pound, neutered maleLaser therapy has gone from near obscurity to one of Labrador retriever named Bruno, presented after anthe top modalities and services being discussed and attack by a neighbor’s dog (Figure 1). The attackimplemented in veterinary practices today. Reasons for resulted in a full-thickness tear on the proximal medialthis change include a more thorough understanding of aspect of the left hindlimb. Bruno was taken to athe physiologic principles behind photobiomodulation, local emergency clinic for treatment and repair of thethe evolution of and improvement in laser equipment, laceration. The accompanying history indicated that theand, most importantly, the overwhelmingly consistent wound was cleaned and debrided and then sutured withpositive patient responses. 3-0 Securolon. The patient was administered antibiotics, anti-inflammatories, and analgesics and was released. The list of benefits and clinical conditions thatrespond to laser therapy is seemingly endless. PresentationThis is because of the basic mechanisms behindphotobiomodulation. These mechanisms have been Four days later, Brunodiscussed extensively elsewhere but are related to theprimary photochemical effects of improving blood flow presented to Dr. Boazto an area; improving tissue oxygenation; and improvingconversion of O2 to ATP within the mitochondria. This Man with swelling andis a basic biochemical reaction inherent in every cell inthe body. discharge from the injury site. Upon examination, the area was edematous, with a significant amount of bruis- ing and serous drainage (Figure 2). The suture line was still intact. Dr. Man recommended laser therapy, which was initiated that day. The laser used was a Figure 2. appearance K-Laser Cube 4. This laser of the suture line at delivers 4 therapeutic wave- presentation (Day 1). lengths simultaneously:8 | A Supplement to Today’s VeTerinary PracTice | September/October 2016 | tvpjournal.com

• 660 nm for superficial absorption and wound Discussion healing This case is typical of the consistent anti-inflammatory • 800 nm for accelerated ATP production responses observed with laser therapy. The primary • 905 nm for enhanced O2 release photochemical reactions initiate a cascade of secondary • 970 nm for increased blood flow. and tertiary reactions, including: • Increased production of nitric oxide along with othertreatment mediators that stimulate vasodilation and activation of An edema/congestion setting was used that delivers the lymphatic channels to reduce edema and facilitatethe energy primarily in a series of modulated pulse removal of cellular debrisfrequencies. Many studies have shown that using pulse • Stimulation of angiogenesis, which increases oxygendelivery in addition to continuous wave delivery enhances and nutrient transport to improve tissue repair, reduc-the clinical effects of laser therapy, particularly in wound es ischemia, and reduces all the negative events associ-healing (Figure 3). An average power of 2.5 W was used ated with a negative oxygen balance in tissueto deliver a total dose of 1050 J in a noncontact scanning • Production of reactive oxygen species (ROS) and superox-mode. This was approximated to deliver 5 J/cm2. ide dismutase (SOD) to help stabilize cellular membranes and balance the detrimental effects of free radical activity • Enhanced white blood cell activity, aiding in the removal of cellular debris • Increased production of prostaglandin I2 (PGI2), which has anti-inflammatory activity similar to other COX inhibitors • Reduction in levels of interleukin 1 and other proin- flammatory cytokines. These reactions, along with increased ATP production, facilitate more rapid tissue healing and repair, which leads to the kind of clinical response evidenced by this case. The K-Laser therapeutic laser is an extremely intuitive piece of equipment, and its broad range of applications makes it an extremely valuable adjunct to any clinic’s armamentarium. Proper training and good understand- ing of the principles behind laser therapy are still essen- tial for optimal success.Figure 3. Different delivery methods available on aK-Laser cube 4. Examination the following day showed obvious Figure 4. appearance of Figure 5. appearance ofimprovement (Figure 4). A second laser therapytreatment was administered. The next day, the area the suture line after 1 the suture line after 2 laserlooked well on its way to proper healing with nodischarge and very little evidence of any swelling laser treatment (Day 2). treatments (Day 3).or bruising (Figure 5). One more treatment wasadministered, and the owner was instructed to return atthe prescribed date for suture removal.tvpjournal.com | September/October 2016 | A Supplement to Today’s VeTerinary PracTice | 9

THe USe oF THeRApeUTIc LASeRFoR BIcepS TenDInITIS In An AcTIVeLABRADoR ReTRIeVeRJAmIe Joy, cVTJeSSIcA RycHeL, DVm, DAcVSmRHistory His owner was only interested in pursuing laser therapy, hoping for a rapid and complete recovery. Given theA 3.5-year-old, intact male black Labrador retriever observed degree of discomfort, the rehabilitation teamnamed Doc presented to his regular veterinarian for a was skeptical of full recovery and return to field trials incomplaint of right forelimb lameness. Doc, an active a short (2-week) time frame.field trial dog, had run a field trial about 10 days priorto presentation. the trial was over rough terrain, with treatmenta large number of obstacles and hills. Doc fell duringthe trial and afterward showed significant lameness. Initial laser therapy at the rehabilitation facility wasWithin days of the trial, right forelimb lameness administered: 1044 J at 6.0 W of continuous wavebecame progressively worse and Doc became minimally laser to the right shoulder, biceps, and surrounding softweight-bearing. Discomfort was so pronounced that he tissue. After this treatment, the owner reported minimalwould cry out when forced to use the limb, especially to mild improvement, but Doc was still largely non–in situations in which active range of motion was weight-bearing on the limb.required, such as stairs and hills. Over the 10 days priorto presentation, Doc was not improving and seemed to the following day, Doc returned to the rehabilitationbe experiencing progressively more pain even with light service with palpable warmth over the right bicepstrotting up hills or stairs. tendon, grade 4/5 lameness in the right forelimb, and marked, recurrent pain in the thoracolumbar spine. Doc’s regular veterinary team found pain with flexion pain evaluation at that visit was assessed at 7/10 on aof the shoulder and palpation of the biceps tendon modified visual analog scale. Super-pulsed laser therapyorigin. Shoulder radiographs were obtained and revealed was delivered with a frequency of 50 Hz for 5 minutes.mineralization in the region of the right biceps tendonor origin. musculoskeletal ultrasonography confirmed adiagnosis of biceps tendinopathy in the right shoulder.Doc was put on strict activity restriction, started oncarprofen (4.6 mg/kg once daily), and referred torehabilitation for evaluation and laser therapy.PresentationUpon initial presentation to the rehabilitation facility2 days later, examination findings from the referringveterinarian were corroborated, with observation ofmoderate to severe discomfort localizing to the bicepsorigin. In addition to shoulder pain, however, Doc hadmoderate to severe thoracolumbar soft tissue discomfort.10 | A Supplement to Today’s VeTerinary PracTice | September/October 2016 | tvpjournal.com

the right biceps origin was Discussiontreated for 5 minutes of super-pulsed laser therapy, and the typically, biceps tendinitis is a very challengingthoracolumbar spine was condition to treat and requires prolonged therapy and atreated for 15 minutes using slow return to athletic function. especially with evidencethe same settings. of chronic change in the tendon health, as was noted on diagnostics for this patient, it can take 3 to 6 months to Within hours after the achieve soundness and comfort after acute exacerbationsecond laser treatment, Doc’s of chronic biceps tendinosis in active dogs. Furthermore,comfort level was drastically many veterinarians are inclined to use nonsteroidalimproved, according to his anti-inflammatory drugs and rest to help patientsowner’s assessment at home. recover from this type of injury. response to therapy isDoc was more comfortable and usually slow, and pain episodes and lameness are usuallybetter able to bear weight on recurrent.the limb. Another super-pulsedlaser treatment was performed the addition of laser therapy for treatment ofthe following day, at which time his pain score was biceps tendinitis in this case, particularly when the3/10 and lameness had improved to grade 1/5 in the rehabilitation team switched to a super-pulsed laser forexamination room. to the surprise of the rehabilitation treatment, gave the patient immediate and long-lastingstaff, the thoracolumbar soreness had almost entirely improvement in comfort and mobility, allowing a rapidresolved. Doc’s attitude and general comfort were and successful return to athletic function. the use ofexcellent, and his owner reported increasing difficulty this type of therapeutic laser in general and specialtykeeping him activity restricted at home. practice is growing rapidly, not only because of its safety and ease of use but also because of the tremendous After this third treatment, Doc reached a level of efficacy that is seen in so many cases. Laser therapy iscomfort with which the owner was completely satisfied, known to be efficacious for treating inflammatory andand the owner began to slowly return him to activity pain conditions, healing wounds, treating infections,and swimming. Doc’s lameness score at this time was addressing peripheral and central nerve injuries, and0/5 in the examination room and 1/5 after activity. per reducing muscle spasm, pain, and strain after athleticthe evaluation of technical rehabilitation staff, back pain injury. tendon tissue is typically very slow to heal,was also resolved, with a pain score of 1/10. and once inflammation is present, resolution of inflammation is difficult to achieve. Doc went on to have 2 final laser therapy sessions, asthe owner originally wanted to try 5 sessions. the ownerand rehabilitation team noted complete resolution of hislameness. the owner was satisfied with his comfort andfunction in the field, and Doc was discharged back tohis regular veterinarian for follow-up.FoLLow-uPAt follow-up 8 weeks after the injury, Doc was runningwell in regular field trials. reintroduction to field trialtraining was gradual, beginning with lower-impact workand working up to full activity. Doc is now running on alltypes of terrain and exhibits no lameness in field trial train-ing or competition. the owner/handler considers recoveryto be excellent, and little time was lost in the trainingseason as a result of biceps tendinitis and lameness.tvpjournal.com | September/October 2016 | A Supplement to Today’s VeTerinary PracTice | 11

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