Lasers - The Variables,

The Secret Tips, and the

Research

Laurie McCauley, DVM, DACVSMR,

CCRT, CVA, CVC
Canine Rehabilitation Institute
11

Lasers in General
All Lasers have some good effects
Goals
Know enough to use your laser to the
best of its ability
Know when and why to use a laser
Know probe position for common
indications

Local Effects
Calcium ion balance is altered
Cell Cytochrome respiration
(cytochrome c oxidase) is enhanced
Decreased Inflammation
Edema
Effusion
Decrease COX-2, IL-1, TNF, PGE2-
a
Generate reactive oxygen species
(ROS) in low levels which are
“messengers” 3
 Local and Systemic Effects
Enhance Healing
Increase ATP to allow cells enhanced
function at low doses
Tendon injury in rats -
60mW, 80mW and 100mW -
Significantly increased Type III
collagen
80mW Significantly increased Type I
collagen - majority of collagen in
ligaments, tendon, and bone
4

Local and Systemic Effects

Enhance Healing -
Skin lesions healed fastest 633nm
532nm, 633,nm 810nm, 980nm,
10,600nm in rat wounds &
burns
Rat skin with created wounds
Skin healed best with 685nm
Collagen fibers below organized
and matured best at 830nm
5

Local and Systemic Effects

Decrease Pain
Decrease ATP release from mitochondria
in nerve cells therefore diminished
nerve transmission and resulting in
diminish pain transmission
Chow used 830nm at 8J/cm2

6
Local and Systemic Effects

Decrease Pain
Suppressed electrically and noxiously
evoked action potentials including pro-
inflammatory mediators
Inhibitory effects of Peripheral nerves may
reduce acute pain by direct inhibition of
nociceptors

Local and Systemic Effects

Enhance Healing -
Nerve tissue
600nm range, 800nm range, and
904/905nm range
Increased blood flow (3W over sham, 1W
and 6W

Proper 

Penetration

n Deep penetration is not always the

goal
n Skin issues are best treated with
wavelengths in the 600-700nm
wavelength range for penetration is
0.5-1cm deep
n When treating deep structures use
contact with increasing pressure
 Enhance Your Effect
n “We generally observed a decrease in
reflectance while transmittance, absorption
and scattering coefficients increased owing
to compression. We speculate that these
effects are contributed by the shape changes
of cellular components, index-mismatch
reduction and the increased scatter and
chromaphore concentration.”

n Chan, Eric K, et. al., “Effects of Compression on Soft Tissue Optical Properties,”
IEEE Journal of Selected Topics in Quantum Electronics, Vol 2, No 4, December
1996.

Enhance Your Effect

n Coupling with pressure Increased transmission
rate by 51.5% compared with using contact
without pressure, and 92.6% compared with
using a 2-mm skin-diode distance.
n Nussbaum, Ethne L, et. al., “Transmission of phototherapy through human skin:
dosimetry adjustment for effects of skin color, body composition, wavelength and
light coupling to skin,” Proc. Of SPIE Vol 6140, 6140H, (2006)

n Contact with pressure can stretch skin

thinning out Melanin density and causes
ischemia which decreases hemoglobin – both
absorb laser energy allowing better
penetration

Systemic Effects
•Light flows into the tissue,
bounces around, has effect locally
and generally.
•Studies by Tuner and Hode –
•Laser on one side of bilateral skin wound
healed the treated side significantly, but also
sped healing of the non treated side
•Neck and shoulder pain bilaterally was
treated on one side with pressure pain
threshold sig. improved bilaterally, more on
treated side.
 Systemic Effects
n Longer treatment times means
increased absorption by the blood and
therefore greater distant effects

Variables - Power- Determines

Class
Class IIIb - <500mW
Class IV - >500mw
At tissue level -
J/cm2 (Power per Area)
Total Joules (Total Power)

Different power can have different effects

Different wavelengths require different
amounts of energy to have an effect in
the tissue
14

Variables - Wavelength
904/905nm
Deepest penetration
Least absorbed by chromophores
Best for pain and Chronic joint disorder
Bjordal - studies and met-analysis
Use Point to Point saturates tissue
Need least total power for effect
High Power and pulsed or super-pulse

15
 Variables - Wavelength
800-865nm
Middle penetration
Better for inflammation
Absorbed most by
melanin
Be careful on black
skin dogs
Need slightly less then
double 905nm total
16
dose

Variables - Wavelength
600-700nm
Superficial (mm)
Absorbed most by
hemoglobin and
melanin
Low doses or it will heat
tissue quickly
Only need low doses/
low power as it is used
to treat skin 17

Variables - Wavelength

970-980nm
Absorbed most by water
Needs more energy to
get deep penetration
Creates heat due to
increased absorption
in superficial tissues

18
Variables - Wavelength - Depth

Penetration of Laser Light at 808nm and

980nm in Bovine Tissue Samples
In equal conditions, 1W/cm2, through
bovine tissue
808nm penetrated 3.4cm
980nm penetrated 2.2cm
Hudson D E, et al. Photomedicine and Laser Surgery. Vol 31, Num 4,
2013

19

Depth
Deep tissue needs a higher
surface dose as there is
attenuation in the tissue
If the probe is in direct contact
with the skin, there will less
reflectance
Shorter wavelengths give a
small but fairly round ball
under the tissue while longer
wavelengths give more of an
egg shape light distribution.
20

Variables - Frequency

No clear consensus
Continuous wave
Superpulsed (>40,000 Hz)
Nanoseconds
25-75W
High power, low time, little to no
heat
Chopped or Switched
Up to 15 W
Heat 21
 Variables - Frequency

Continuous wave - no pulses

Hz = pps (pulses per second)
< 100 Hz for acute pain
~ 5,000 Hz for contaminated wounds
Meta-analysis - if one frequency
doesn’t work or stops working, trying
another has significantly positive
effect
22

How to Treat
n Figure out the area
– Biceps tendon 10-15 cm²
– 1/2 Business Card = 25cm²
– Business Card size = 50cm²
•Bigger Animal
n GSD to Mastiff hip
•Deeper Tissue
– Index Card size = 100cm²
n Parapsinal musculature •More Total Energy

Point to Point vs Scanning

n Scanning – continuously moving the probe to
“Scan” the treated area.
– Some areas need more energy and you can keep
going back to these (edema, thickened tendons,
trigger points…) and by moving over the areas
you can be constantly evaluating the tissue.
– More for healing as lower doses go into the tissue
more frequently
– Need to use this technique for high power class 4
lasers to prevent over heating of the tissue
n T & H
 Positioning with Different
Heads
n Toes n Spine
n Carpus n Mouth
n Elbow n Ears
n Shoulder n Muscle and Tendons
n Tarsus n TMJ
n Stifle n Abdomen (Urethra;
n Hip spay scar)
n Neck n Post surgical

Where to Laser
n Hip
– Lateral
– Sartorius
– Gluteals
– Medial Jt Cap
– +/- Pectineus
Surrounding
Tissue is
EXTREMELY
Important!!!

Stifle & Hip

11
27
 Where to Laser
n Back or Neck
n Not over bone – better if point toward S. C.
n Over lumbo-sacral space

Back

13
29

Neck

14
30
Mouth and
Ear

15
31

Tarsus & Carpus

16
32

Elbow &
Shoulder

17
33
 Toes

18
34

Where to Laser
n Trigger Points
– Brachiocephalicus
– Biceps Brachii
– Deltoids
– Infraspinatus
– Triceps
– Gracilis
– Sartorius
– Gluteal
– Iliocostalis
– Quadriceps

DJD
n Early stages – more likely to obtain prolonged
benefit
n Later stages – pain relief is shorter lived
n Best effect in quality of live if to treat all
affected joints
n Ailioaie C, Lupusoru-Ailioaie L M. Beneficial effects of laser therapy in
early stages of rheumatoid arthritis onset. Laser Therapy. 1999; 11 (2):
79-87
n Brosseau L, Welch V, Wells G et al. Low lwvel laser therapy (class I, II,
and III) for treating rheumatoid arthritis. In: The Cochrane library. Issue
4, 2000 Oxford:Update software
n Obata J et al. Clinical effects of laser irradiation for the control of disease
activity in chronic rheumatoid arthritis. Surgical and Medical Lasers.
1990; 3 (3): 140. (abstract)
 Sports Injuries
n Acute injuries can be treated with higher
doses
n Chronic injuries treated with higher doses
may become more painful initially
n Delayed onset muscle soreness should be
treated asap, muscles can be treated before
activity with reduced oxidative stress

Sports Injuries
n Oedema – Ohshiro’s principle – Tx
proximal to distal (enhances lymph
drainage)
n Vasodilitation, dec platelet aggregation
n More energy is needed when there is
more edema
n We treat to effect not just by J/cm²
– Make sure to not go over desired amount

Inflammation
n Some studies show decreased effect with
steroid usage, others show positive
results when used with steroids
(compared to steroids alone)
n Less effect of the laser when steroids
were on board in regards to collagen
organization and fibroblast number
n Reis S R, Medraso A P, Marchionni A M, Figueira C,
Fracassi L D, Klop L A. Effect of 670nm laser therapy and
dexamtheasone of tissue repair: a histological and
ultrastructural study. Photomed Laser Surg, 2008; 26 (4):
307-313.
 Contact vs 

No Contact
n Open wounds
– Probe is held off the skin, penetration is
decreased as is the intention
– Treat the periphery of the wound with contact
– Give open area less dosage then periphery
n Any time there is no contact, there is loss of
energy to the tissue due to reflection and
refraction by the skin and SQ tissue
n Deeper the problem, the firmer the contact
of the probe on the tissue with Class 3b and
low power power class 4

No Contact and 

Continual Motion
n Higher Power Class 4 lasers need to have space
or a spacer and need to have continual motion
– Massage ball or spacer allows for consistent
space to better estimate treatment dose
– Constant motion allows the energy to dissipate
to reduce thermal accumulation
– When high amounts of energy enter the tissue,
some is converted into heat. This energy/
photons can not be used for other effects
(other then the heat effect)

Treatment 

Intervals
 Treatment Intervals
n We find 2-3 times a week for 6-10
treatments for tendon and ligament
injuries work best
n Skin lesions we treat twice a week till
healed
n Arthritis we will treat 2-3 times a week
for 6-10 treatments and then monthly
or as needed

Dose Depends on Machine

Recommendations
n Start with individual machine
recommendations, then play with different
doses.
n Laser.nu

Indications for Laser

n Skin – wounds, burns, bruising, post
surgical, ear infections, stomatitis, gingivitis,
hot spots, anal gland ruptures, lick
granuloma
n Tendons & ligaments – tendonitis, sprains,
strains, partial tears
n Muscle – fatigue post event, trigger points,
Iliopsoas injuries, fibrotic myopathy
n IVDD and Neurological Accident (FCE,
hemorrhage), nerve damage post trauma
 Indications for Laser
n Joints – Osteoarthritis, Rheumatoid Arthritis,
TMJ issues
n Pain – Acute or Chronic, Post surgical
n Bone healing post fracture or surgery
n Cystitis & blocked cats
n Intra-operational – enhance perfusion to
intestines
n Metabolic - Liver, Kidney, GI tract
n Ear and skin infections
n Sprains & Strains

Contraindications
n Eyes or where laser energy could penetrate
the retina
– Wear goggles esp. when lasering the face
n Tattoo – ink absorbs energy and causes heat
n Areas of known or suspected neoplasia
n Areas of active bleeding with hemorrhagic
disorders
???Aural hematomas
n Active epiphysis (if heating tissue)

Tricks of the trade

n Skin issues do best with wavelength
in the 600-700nm range
n Strained / Thickened tendons should
be treated until they are significantly
closer to normal size
 Fibrous Tissue Treatment
n Fibrous tissue found at the
medial stifle and elbow can
be diminished or eliminated
in one (mild to moderate) or
multiple (moderate to severe)
treatments

n May be decrease of
inflammation in joint capsule

Laser – Tricks of the Trade

n High powered lasers can burn dark skin or coat
dogs so if you are going to use it, wet the fur
first (chromophore – absorbs some of the
energy before it goes into tissue)

n Pain relief can start immediately but takes 15-30

minutes for full effect, so treat the most painful
area first and recheck it when you are done
treating all areas (giving it the most time)
– Clients are impressed to see the pain gone so
quickly

Laser – Tricks of the Trade

n Special Lens glasses on your
patients as well as your clients
– OSHA requires glasses for
humans
– Many animals thoroughly RELAX
n Pressure points?
 Tricks of the Trade
n Start with protocols
– When comfortable go up or down on power
– I will go up to 6J/cm² for OA Pain on a Large dog,
Large Joint (ie hip - more tissue to treat) 1 time only
n Cover more tissue then you think you need to
n Keep a hand on the treatment area
– Not in the beam
– Rarely heats but watch dark coat or skin
dogs
– There have been cases of significant burns or
hair smoking - know what you are doing

Tricks of the Trade

n Go against the fur when possible – less
hair in the way
n Hold probe perpendicular to the body
or close to it for the least reflectance
– Up to 30 degrees is fine
– Except when your target is cartilage

Tricks of the Trade

n Don’t aim at bone if there is not bone
pain (aim at bone if fracture, bone
bruise, tendon over bone), aim at
muscle tendon and ligament, and into
joint (less light as there is less tissue)
– i.e. not into patella, but all around it
aiming some into the joint (Meniscus), on
Patella ligament, on Quadriceps Tendon,
medial and lateral collateral ligaments
– To get both cartilage surfaces: Medial –
point up & Lateral - point down
 LEDs Do Have Some
Benefit
n ~$500
– For the “Neon Clients”
n Skin issues
n Superficial muscle issues
n Easy to use
n Can not blind them
n FDA approved for humans

65 Questions???
Questions???