Introduction to New High Power High Dose Class IV Laser Therapy

Introduction to New High Power High Dose Class IV Laser Therapy
Bruce R. Coren, DVM, MS Founder Class IV Laser Therapy

HDLT-HPLT High Dose – High Power Laser Therapy
HPLT was first introduced to the medical field in by then CEO of Avicenna Laser Technology, Inc, Bruce R. Coren, DVM, MS. The company invented and developed the first High Power Therapeutic Laser to receive FDA clearance in 2003.

TMA – Technological Medical Advancements is a spin off from Avicenna and was founded not only to advance the field of Laser Medicine but also to bring other innovative medical devices to the market place. TMA offers the most powerful laser platforms in the world and thus allowing physician's of all medical disciplines the capability to heal injuries previously refractive to traditional medical care.

Design of the TMA Laser The TMA laser was designed from the ground up to be a therapeutic medical laser.

It was developed using research by our own biomedical engineers and clinicians as well as collaboration with a major medical school and university optics department.

We investigated important criteria such as wavelength, power and power density, optics and beam delivery in order to afford the greatest penetration and delivery of a therapeutic dose capable of stimulating tissue healing in deep seated pathologies.

LASER— an acronym for: Light Amplification by Stimulated Emission of
Radiation

It could well stand for – Latest Advance For Surgeon to Enhance
LASER It could well stand for – Latest Advance For Surgeon to Enhance Revenue Just a little humor. However, from a marketing perspective, the advertising of laser therapy in your practice differentiates you from your competitors and could possibly increase your income via the influx of patients looking for new answers to old problems.

Surgical Lasers in Medicine
Are used to cut, coagulate, and evaporate tissues. This type of laser replaces the scalpel blade. Surgical lasers accomplish their objective through excessive heating of tissue are used to cut, coagulate and evaporate tissues. This type of laser replaces the scalpel of the surgeon. There are several advantages to laser surgery. One of the major benefits is that it is often referred to as "bloodless surgery." Laser procedures usually involve less bleeding than conventional surgery. The heat generated by the laser keeps the surgical site free of germs and reduces the risk of infection. Because a smaller incision is required, laser procedures often take less time (and cost less money) than traditional surgery. Sealing off blood vessels and nerves reduces bleeding, swelling, scarring, pain, and the length of the recovery period. Of course laser surgery is not without risk. Like traditional surgery, laser surgery can be complicated by: Hemorrhage Infection Perforation of an organ or tissue. Laser surgery can also involve risks that are not associated with traditional surgical procedures. Being careless or not practicing safe surgical techniques can burn or destroy healthy tissue. Although many laser surgeries can be performed in a doctor's office rather than in a hospital, the person guiding the laser must be at least as thoroughly trained and highly skilled as someone performing the same procedure in a hospital setting.

The TMA Laser is the only laser available on the market that was designed to accomplish both surgical and therapeutic procedures.

Lasers in Medicine Therapeutic Lasers are used for the stimulation of cell function. The biological effect is photochemical not thermal, as is the case with surgical lasers. Therapeutic Lasers are used for the stimulation of cell function. The biological effect is photochemical not thermal, as is the case with surgical lasers.

Comparison of “Class IV” Surgical and Therapeutic Lasers
Surgical lasers collimate high amounts of laser energy into a beam of high intensity resulting in tissue destruction

High Power Therapeutic Lasers take a high amount of laser energy but instead of beam collimation you get beam divergence resulting in tissue stimulation

Who is using Diowave Veterinarians - Equine and Small Animal Human
- Physical Medicine and Rehab - Pain Management - Orthopedists, Neurologists, - Family Practice

Chiropractors and Physical Therapists
Podiatrists, Naturopaths and DOM’s MLB, NBA, NFL College Sports Teams Medical and Veterinary Colleges United States Military VA Hospitals

Biological Effects of Therapeutic Lasers
Laser therapy aims to bio-stimulate injured and dysfunctional tissues. Clinical studies and trials of Class III & IV laser technology indicate the following beneficial effects of light therapy on tissues and cells.

Cellular Effects of Laser Energy
Chromophores are components of molecules which absorb light. Compromised cells and tissues respond more readily than healthy cells or tissues to the transfer of energy that occurs between laser therapy emitted photons and the receptive chromophores found in various cells and sub-cellular organelles. Laser energy causes photochemical reactions in the cells. Laser light photons are absorbed by receptors (chromophores) on the mitochondria which are located within the cells. This causes increased production of cellular energy (ATP), which leads to normalization of cell function, pain relief, and healing. The result is that laser therapy has a significant effect on damaged cells and tissues while normative biological constituents are appreciably less effected. A more in-depth explanation regarding the physiological effects of laser therapy will be described in greater detail, later in this presentation.

Leading to a biological cascade of events.
The stimulation of chromophores on mitochondrial membranes incites the production of ATP. Leading to a biological cascade of events. Compromised cells and tissues respond more readily than healthy cells or tissues to the transfer of energy that occurs between laser therapy emitted photons and the receptive chromophores found in various cells and sub-cellular organelles. Laser energy causes photochemical reactions in the cells. Laser light photons are absorbed by receptors (chromophores) on the mitochondria which are located within the cells. This causes increased production of cellular energy (ATP), which leads to normalization of cell function, pain relief, and healing. The result is that laser therapy has a significant effect on damaged cells and tissues while normative biological constituents are appreciably less effected. A more in-depth explanation regarding the physiological effects of laser therapy will be described in greater detail, later in this presentation.

Increased Growth factor response within cells and tissue as a result of increased ATP and protein synthesis. Accelerated cell reproduction and growth leading to faster repair of damaged tissues.

Increased metabolic activity- via increase in enzyme outputs, oxygen and nutrient availability.
Stem cell activation

Wound Healing Effects of Laser Therapy
Faster Wound Healing - Laser significantly increases fibroblast and collagen production which are essential for tissue repair. Improved Vascular Activity - Increased capillary production leads to faster wound closure. .

Greater Tensile Strength - Surgical repaired wounds heal with greater tensile strength, including skin, tendon, ligament and fascia. Scar Tissue Reduction - Wounds heal with less scar tissue formation.

WOUND DAY 7 SID TX 4 WATTS-3000 JOULES
Wound Healing - Vet WOUND DAY 1 WOUND DAY 7 SID TX 4 WATTS-3000 JOULES

Wound Healing- Human PRE-LASER AND AFTER TWO
MONTHS OF TRADITIONAL THERAPY AFTER TWO 5 MINUTE LASER THERAPY TREATMENTS AT 7.5 WATTS

Immune System Effects of Laser Therapy
Strengthening the immune system response via increasing levels of lymphocyte activity and through a newly researched mechanism termed photo-modulation of blood.

Acute Inflammation Reduction
Stabilization of cellular membrane Lubart R, Friedman H, and Lavie R. Photobiostimulation as a function of different wavelengths. The Journal of Laser Therapy. Vol 12. World Association of Laser Therapy Karu T. et al. Changes in absorbance on monolayer of living cells induced by laser irradiation. IEEE Journal of Selected Topics in Quantum Electronics. IEEE Lasers and Electro-Optical Society. December (6):982. De Castro E Silva Jr. O, et al. Laser enhancement in hepatic regeneration for partially hepatectomized rats. Lasers in Surgery and Medicine (1):73-77 Immediately after an acute injury event, the body, in response to the disruption of the integrity of vascular, soft tissue, connective tissue and neurological processes, initiates a series of biological responses. The inflammatory reaction consists of both vascular and cellular events. Injury responsive components such as Mast cells, Bradykinins and Prostaglandins are activated along with the vascular responses and cellular membrane reactions. All of these combined processes and events are represented by the symptoms of edema, inflammation, pain and functional debility. Laser therapy can be effective in mediating both the symptoms and the underlying inflammatory process by the following actions: The first is the stabilization of cellular membrane — Ca++, Na+ and K+ concentrations, as well as the proton gradient over the mitochondria membrane are positively influenced. This is accomplished in part by the production of beneficial Reactive Oxygen Species aka (ROS) wherein triplet oxygen molecules absorb laser light, producing singlet oxygen molecules. These ROS’s modulate intracellular Ca++ concentrations and laser therapy improves Ca++ uptake in the mitochondria.

Acceleration of leukocytic activity Increased Prostaglandin synthesis Reduction in Interleukin 1(IL-1). Enhanced lymphocyte response Increased angiogenesis Temperature modulation Beneficial acceleration of leukocytic activity results in enhanced removal of non-viable cellular and tissue components, allowing for a more rapid repair and regeneration process.

Laser Therapy Cytochrome Activation Ros Production Ca, Na, K Ion Changes Cell Membrane Changes Proton Gradient Change ATP Increase Vasodilation PG Synthesis IL-1 Decrease A summary flowchart of the cellular cascade in reducing tissue inflammation is presented here. The cumulative effect of these multiple inter-active processes and events, is an accelerated inflammatory cycle, with diminished symptoms and earlier normalization. Since laser therapy does not exacerbate the inflammatory process, but rather condenses the time frame from onset to resolution through acceleration of processes, it can be used immediately post injury. This rapid initiation of therapy in acute inflammation will assist in limiting the scope, and duration, of the inflammatory event, and minimize the pain and severity associated with it. Most of the beneficial effects seen from laser therapy in the treatment of acute inflammatory events, will also have medical efficacy as laser therapy is initiated in more chronic inflammatory conditions. While the treatment regimen and course of therapy may be modified in chronic situations, the physiological responses and interactions remain consistent. Chronic conditions may require longer treatment times and results will vary with the patient, the condition, and the length of the chronicity associated with the condition. Increased Leukocyte Activity Enhanced Lymphocyte Response Temperature Modulation Angiogenesis SOD Production

Summary of LT Biological Effects
Accelerated Tissue Repair Accelerated Cell Growth Faster wound Healing Reduced Scar Tissue Formation Anti-Inflammation Anti-Pain (Analgesia)

Summary of LT Biological Effects contd..
Improved Vascular Activity Increased Metabolic Activity Improved Nerve Function Immunoregulation Trigger Point Resolution Acupuncture Pt. Stimulation

High Power - High Dose Laser Therapy as it Pertains to the Spine
Decreased inflammation of disc, nerve roots and the cauda equine Increase microcirculation of spinal structures Accelerate healing of annular defects Decreased formation of abnormal/non functional scar tissue

Decreased scar tissue and non-osseous hypertrophic changes
Reduce pain associated with PRP – prolotherapy injection Decrease or even eliminate need for epidurals

High Power – High Dose Laser Therapy as it Pertains to the Lower Extremities
Decreased inflammation of nerve tissue Accelerated Reinervation of nerve fibers Increase blood flow and microcirculation of tissue structures

Accelerate healing of open wounds
Decreased formation of abnormal non- functional scar tissue Increase synovial fluid and cartilage production

Increase collagen and fibroblast production
Increase osteoblastic activity and fracture healing Decreased bony edema – osteochondral bone bruise

Laser Safety Overview Safety Training begins with YOU!
Class IV Laser Beams can cause damage to the eyes Safety Glasses must be worn by everyone in the treatment area AKA Nominal Hazard Zone (NHZ) Safety Training begins with YOU! Class IV Laser Beams can cause damage to the eyes. Safety Glasses must be worn by everyone in the treatment area which is also known as the Nominal Hazard Zone (NHZ)

Laser Safety Safety protocols must ensure sufficient precautions are taken to protect the health and safety of employees and patients. Use of safety goggles to prevent retinal exposure is paramount. Develop safety protocols to ensure sufficient precautions are taken to protect the health and safety of all employees and patients.

Laser Safety Laser safety eyewear is not a primary mode of protection
They do not replace proper laser safety education, training, and careful clinical practice. With Class IV lasers, the health care provider, the patient and anyone in the treatment area, must wear safety goggles. However it is important to note that laser safety eyewear, is not a primary mode of protection. Safety eyewear is not designed to protect against the primary beam. So, do not shine the laser beam toward anyone’s eyes, even if they are wearing protective eyewear. Limited protection is provided by proper protective eyewear against the primary beam and in general, full protection, against a reflected beam. The protective eyewear that came with your laser is manufactured specifically for the wavelengths emitted by the Avicenna laser. Do not use protective eyewear from other manufacturers as they will not provide the same level of protection. Additional eyewear may be purchased from your local Avicenna sales representative.

Laser Safety Lesion Fluorescein angiography
If laser radiation is focused onto the retina, the light sensitive rods and cones can become damaged, resulting in temporary or permanent loss of vision. Class 4 lasers are particularly dangerous to the eye. Absorption of ultraviolet and far infra-red radiation by the eye can potentially result in a corneal burn or cataract formation. Here is a picture that demonstrates the effect of laser radiation on the retina. Note the lesions on the back of the eye depicted by the letter F. Fluorescein angiography of retina after laser irradiation

Laser Safety Training Equipment Purchase, Service, Quality Assurance
Room Design Protective Equipment / Optical From a comprehensive review of the literature and international standards, it is seen that the possibility of serious laser incidents can be reduced by serious consideration of the following 8 factors. They are… 1. Training Take time to review this safety information with your staff, develop your own safety protocols, or contact your Avicenna sales representative to do an in-service for your staff covering the topic of laser safety in your office. Also read and re-read the Avicenna users manual provided with your laser. 2. Equipment Purchase, Service, Quality Assurance Contact your Avicenna Sales representative once a year for instructions on getting your laser checked for calibration and other safety related inspections. 3. Room Design Careful consideration should be given to the design and physical layout of a room intended for laser use. An important physical parameter which is discussed in the literature by International laser safety experts is the concept of the “Nominal Ocular Hazard Distance” (NOHD) which is “the area surrounding the laser delivery system exit port where the MPE (maximum permissible exposure) is expected to be exceeded". This parameter is also referred to as the Nominal Hazard Zone (NHZ) . As with all disciplines, laser has its own terminology. Within your treatment area you need to: Be aware of windows where people could receive unintentional exposure Be aware of Doors and Reflective surfaces Doors should be locked while your laser is in operation to prevent entry into the treatment area. Reflective surfaces should be covered in order to avoid reflective exposure. Warning Signs should be posted outside of the treatment area to alert people of the presence of the laser. And the Layout of Room should be user friendly so as to avoid distraction during the use of the laser device. 4. Protective Equipment / Optical Hazards As we’ve mentioned, laser safety eyewear is not a primary mode of protection. They are not designed to protect against the primary beam. Limited protection however is provided by proper appropriate eyewear against the primary beam and in general full protection against a reflected beam. 5. Routine Procedures It is important, for the protection of patients and staff members, to have procedures in place for the routine administration of laser therapy and the execution of emergency medical plans in the event of an accidental exposure. 6. Administrative Controls/Management The healthcare provider is responsible for all treatment carried out in their office, whether they personally perform the service or not. Contained within their internal Health and Safety policy manual, must be administrative arrangements and an explicit policy for the safe use of lasers. A practice would find it extremely difficult to defend itself against litigation if little or no attention had been given to laser safety matters. We encourage all of our customers to address the following essential elements; (i) allocation of responsibility, (ii) development of clinic rules, (iii) definition of laser controlled areas, (iv) development of laser safety training and a well-defined formal definition of what constitutes an authorized user, and (v) a formal methodology for dealing with incident reports. 7. Electrical Hazards All laser equipment needs to be installed in accordance with the National Electric Code (NFPA 70) and the Occupational Safety and Health Act. The following problems have frequently been identified during installations: Uncovered electrical terminals Improperly insulated electrical terminals Non earth-grounded or improperly grounded electrical outlets Excessive wires and cables on floor that create a fall or slip hazard

Laser Safety Hazards Routine Procedures
Administrative Controls/Management Electrical Hazards From a comprehensive review of the literature and international standards, it is seen that the possibility of serious laser incidents can be reduced by serious consideration of the following 8 factors. They are… 1. Training Take time to review this safety information with your staff, develop your own safety protocols, or contact your Avicenna sales representative to do an in-service for your staff covering the topic of laser safety in your office. Also read and re-read the Avicenna users manual provided with your laser. 2. Equipment Purchase, Service, Quality Assurance Contact your Avicenna Sales representative once a year for instructions on getting your laser checked for calibration and other safety related inspections. 3. Room Design Careful consideration should be given to the design and physical layout of a room intended for laser use. An important physical parameter which is discussed in the literature by International laser safety experts is the concept of the “Nominal Ocular Hazard Distance” (NOHD) which is “the area surrounding the laser delivery system exit port where the MPE (maximum permissible exposure) is expected to be exceeded". This parameter is also referred to as the Nominal Hazard Zone (NHZ) . As with all disciplines, laser has its own terminology. Within your treatment area you need to: Be aware of windows where people could receive unintentional exposure Be aware of Doors and Reflective surfaces Doors should be locked while your laser is in operation to prevent entry into the treatment area. Reflective surfaces should be covered in order to avoid reflective exposure. Warning Signs should be posted outside of the treatment area to alert people of the presence of the laser. And the Layout of Room should be user friendly so as to avoid distraction during the use of the laser device. 4. Protective Equipment / Optical Hazards As we’ve mentioned, laser safety eyewear is not a primary mode of protection. They are not designed to protect against the primary beam. Limited protection however is provided by proper appropriate eyewear against the primary beam and in general full protection against a reflected beam. 5. Routine Procedures It is important, for the protection of patients and staff members, to have procedures in place for the routine administration of laser therapy and the execution of emergency medical plans in the event of an accidental exposure. 6. Administrative Controls/Management The healthcare provider is responsible for all treatment carried out in their office, whether they personally perform the service or not. Contained within their internal Health and Safety policy manual, must be administrative arrangements and an explicit policy for the safe use of lasers. A practice would find it extremely difficult to defend itself against litigation if little or no attention had been given to laser safety matters. We encourage all of our customers to address the following essential elements; (i) allocation of responsibility, (ii) development of clinic rules, (iii) definition of laser controlled areas, (iv) development of laser safety training and a well-defined formal definition of what constitutes an authorized user, and (v) a formal methodology for dealing with incident reports. 7. Electrical Hazards All laser equipment needs to be installed in accordance with the National Electric Code (NFPA 70) and the Occupational Safety and Health Act. The following problems have frequently been identified during installations: Uncovered electrical terminals Improperly insulated electrical terminals Non earth-grounded or improperly grounded electrical outlets Excessive wires and cables on floor that create a fall or slip hazard

Laser Safety-Reflective Surfaces
Medical Instruments (Reflex Hammers, Stethoscope) Jewelry (Rings, Watches, Earrings) Treatment Table Mirrors, Door Knobs and other Fixtures Reflection of a laser beam off a surface is a major risk factor with the use of Class IIIb and Class IV lasers. Review of laser accidents indicate that the reflected beam is often the culprit in accidental ocular exposures. Greater reflection occurs from flat mirror like surfaces, characteristic of many metallic medical instruments like those mentioned on this slide. Medical Instruments like Reflex Hammers & Stethoscopes Jewelry, including Rings, Watches and Earrings Treatment Table components including the Frame, Face Paper Holder and adjustment Knobs Mirrors in the treatment area And Door Knobs and other Fixtures

Optical Hazards Lets talk a little more about the risks associated with ocular exposure. As you can see from this illustration, the cornea, vitreous humor and ocular lens strongly absorb ultraviolet and far infra-red radiation.

Optical Hazards Microwaves and Gamma radiation entering the eye pass directly through the eye without absorption.

Optical Hazards Visible and near infra-red radiation entering the eye is brought to a high energy density focus on the retina. This is the mechanism that we are concerned about. This is why everyone in the treatment room, also known as the Nominal Hazard Zone, must wear eye protection. Laser light can do 4 different things when it hits an object. Laser energy can…

Optical Hazards Reflect Absorb Transmit Scatter Reflect Absorb
Transmit or Scatter For this reason we tie it with the acronym rats.

Laser Classifications
Now let’s move onto our next topic which is laser classifications. Laser products are classified into five groups according to the different degrees of hazard; Classes 1, 2, 3A, 3B, and 4. As the class number increases, the maximum allowed power output also increases. Consequently, for class 3b and class 4 lasers, additional engineering safety features are required, and a comprehensive laser safety management structure must be in place within the office.

Class 1 Lasers Class 1 lasers are products where the strength of the laser beam does not exceed the Maximum Permissible Exposure (MPE) value. Therefore, for Class 1 laser products, the output power is below the level at which it is believed that eye damage will occur. Exposure to the beam of a Class 1 laser will not result in eye injury, and may therefore be considered safe. Examples of such products include laser printers and compact disc players. Compact Disc Players Laser Printers

Class 2 Lasers Class 2 lasers are limited to a maximum output power of 1 milliwatt or one thousandth of a watt, and the beam must have a wavelength between 400 and 700 nm. A person receiving an eye exposure from a Class 2 laser beam, either accidentally or as a result of someone else's deliberate action, will be protected from injury by their own natural aversion response. This is a natural, involuntary response, that causes the individual to blink and turn their head, thereby terminating the eye exposure. Repeated, deliberate exposure to the laser beam may not be safe. Some laser pointers and barcode scanners are Class 2 laser products.

Class 3a Lasers Class 3a lasers are higher powered devices than Class 1 and Class 2, and may have a maximum output power of 5 mW, or 5 times the Accessible Emission Limit (AEL) for a Class 1 product. The laser beam from these products exceed the maximum permissible exposure for accidental viewing and can potentially cause eye injuries, but the actual risk of injury following a short, accidental exposure, is still small. Please note the two laser types shown above. The Erchonia laser retails for around $12,000. The Office Depot laser pointer retails for $ Both emit a beam that is 5 mW at the 635 nm wavelength. This is why Jan Tuner stated that he was concerned about US practitioners paying a lot of money for very low-powered lasers, leaving us with dissatisfied customers and discredit from those who are supposed to use laser therapy in medicine. Office Depot Laser Pointers

Class 3b Lasers Class 3B lasers may have an output power of up to 500 mW (half a watt). Class 3B lasers may have sufficient power to cause an eye injury, both from the direct beam and from beam reflections. The higher the output power of the device, the greater the risk of injury. Class 3B lasers are therefore considered hazardous to the eye. However, the extent and severity of any eye injury arising from an exposure to the laser beam of a Class 3B laser will depend upon several factors including the radiant power entering the eye and the duration of the exposure. Examples of Class 3B products include the now obsolete low-level lasers and LED devices used for physiotherapy treatments and many research lasers. LLLT

Class 4 Lasers Class 4 lasers have an output power greater than 500 mW (half a watt). There is no upper restriction on output power. Class 4 lasers are capable of causing injury to both the eye and depending on the parameters, the skin, they could also present a fire hazard if sufficiently high output powers are used and focused statically on an area for a period of time. Lasers used for laser displays, laser surgery. “high power” laser therapy, and cutting metals, may be Class 4 laser products. This concludes our topic on Laser Classifications. Now lets move on to contraindications and indications of laser therapy. Surgical Lasers Therapeutic Lasers

Human Contraindications
Pregnant Females Epiphyseal Lines In Children Pacemaker Thyroid, Gonads, & Testicles Light Sensitive Medications Corticosteroids Intolerance Eyes Carcinoma Hemorrhage Immuno-Suppressant Drugs Sympathetic Ganglia, The Vagus Nerves & Cardiac Region In Patients With Heart Disease Contraindications for the use of laser therapy are listed in your Avicenna Users Manual provided with your Class IV laser. They are as follows: Do not apply infrared light to abdomin or lumbosacral region during pregnancy. (Laser is contra-indicated for use over the pregnant uterus. It may be used on the pregnant woman in other regions.) Do not apply infrared light to the epiphyseal lines in children. Do not apply infrared light to the thorax or over a pacemaker in patients with pacemaker implants. Do not apply infrared light over the thyroid gland, ovaries and testicles. Do not apply infrared light to patients who are taking drugs that have heat or light sensitive contraindications, such as but not limited to certain types of steroids. The question that we routinely ask patients is, “Do you sunburn easily or are you intolerant to sunlight?” Health care providers must be aware that there is a chance of photosensitivity secondary to laser therapy. Many products, including prescribed medications, over-the-counter patent medicines, and a wide range of personal care products can increase the skin's sensitivity to light. This can result in photosensitivity, an intense reaction of the skin which can cause burning (or erythema) in a much shorter time period than would normally be expected. Photosensitivity can be caused by products applied directly to the skin or from medications or other substances that have been ingested. Do not apply infrared light over areas recently injected with corticosteroids Do not apply infrared light when individual intolerance of the treatment is noted Do not shine laser light into eyes, with or without eyewear protection (Class 3b and Class 4 lasers are potentially harmful to the retina. Safety goggles must, be worn by the patient, practitioner, any individuals in the treatment area.) Carcinoma- Laser therapy is contraindicated for patients with cancer. Hemorrhage- It is conceivable that laser-mediated vasodilation may worsen the hemorrhage Immuno-suppressant Drugs- Laser Therapy may increase the function of the immune system and decrease the effects of their pharmacotherapy Treatment Over Sympathetic Ganglia, The Vagus Nerves & Cardiac Region is contraindicated In Patients With Heart Disease- Laser therapy may significantly alter neural function, and is therefore contra-indicated over these regions in patients with heart disease)

All Lasers are Not Created Equally
Although all therapeutic lasers bio- stimulate tissue, that is where the similarities end. Laser Therapy is all about Physics!

Therapeutic Laser Classifications
Therapy lasers are classified based on their power output Class IIIa = lasers 1 to 5mw of power (laser pointers) Class IIIb = lasers 6 to 500mw in power

Class IV = lasers above 500mw of power
TMA Laser Platforms = 1,000 – 60,000 mw maximum continuous wave output

Clinical Laser Medicine
What we would like to do is find a volunteer with knee pain to demonstrate the efficacy of high dose laser therapy While we finish the lecture we will treat the patient and have him/her give you feed back as to how the pain level and range of motion have changed.

You Cannot Treat a Target That You Cannot Reach.
The Technology Laser Therapy 101 Rule #1: You Cannot Treat a Target That You Cannot Reach. Let’s give you a couple rules based on some of the information that we’ve discussed thus far. People ask me all of the time, what is the best laser? I could just answer by stating, at the present time it’s Avicenna. But given that I represent the company, I’m sure most people would think that I have a bias, so I like to give them the reasons why a given laser may or may not be effective. The first is that, You cant’ treat a target that you can’t reach. Secondly, I add to this, that once you reach your target, you have to have enough energy to stimulate a positive physiological change within a reasonable amount of time. Who cares if you can deliver 2000 joules of energy if it takes you 6 hours to do it.. Remember that 65% of all laser energy get absorbed by the skin and subcutaneous tissue. This barrier is one of the most obvious reasons why low-power lasers fail to get positive clinical outcomes on a routine basis.

X-Ray Physics = Laser Physics Rule # 2
The Technology X-Ray Physics = Laser Physics Rule # 2 X-ray physics and laser physics are derived by the laws of energy within the electromagnetic spectrum. Would you use the same x-ray factors to take a picture of a hand and a pelvis? Of course not, your pelvic x-ray would look like the one on your screen. Power and penetration are just as important in x-ray as they are in laser therapy, yet, there remains much “smoke and mirrors” in the field, promoting misinformation about the penetrating abilities of extremely low power laser devices. After going through and comprehending the training section on laser physics, you have the benefit of knowledge on your side.

Overstimulation With Laser Energy Only Exists in a Petrie Dish
The Technology Laser Therapy 101 Rule #3: Overstimulation With Laser Energy Only Exists in a Petrie Dish We discussed in part 1 of your training, 1 in-vitro study performed with a thin tissue culture revealed that excessive energy may have an inhibitory effect on cell physiology. To-date there have been no in-vivo studies that have reached an upper limit for therapeutic laser dosage where inhibition of physiological processes occur. Avicenna Laser Technology has conducted four years of clinical trials within the human and veterinary markets and has demonstrated high-power laser therapy to be a completely safe therapeutic modality, meaning 0 adverse events, with diagnostically demonstratable positive therapeutic outcomes, utilizing today's "goal-standard" outcome assessments for functional restoration and pain. As of January 2006, over 2000 people per day are being treated safely and effectively within the recommended Avicenna high power laser parameters.

The Technology Laser Therapy 101 Rule #4:
Understimulation and Lack of Penetration are the #1 Reasons for Poor Clinical Outcomes! We’ve shared with you the perspectives of top key opinion leaders and researchers in the field of laser therapy, that have pointed out that, understimulation and Lack of Penetration are the #1 Reasons for Poor Clinical Outcomes!

Energy Medicine and Therapeutic Laser Physics
The therapeutic dosage of laser energy is measured in Joules Dosage is a function of the lasers power output For every one watt of continuous laser power output, one joule of laser energy is delivered per second of time

For a pulsed laser the energy delivery depends on the duty cycle
For a pulsed laser the energy delivery depends on the duty cycle. Duty cycle tells us what percentage of time the laser is on or actively firing. If the duty cycle is 50% then the laser at 1 watt only delivers 0.5 Joules / Second. For any given time period a continuous wave laser delivers twice as much energy than laser with a 50% duty cycle

Laser Physics The shorter the wavelength, the more readily the energy is absorbed in the body. The higher the wavelength, the deeper the penetration of photon energy. The shorter the wavelength, the more readily the energy is absorbed in the body. The higher the wavelength, the deeper the penetration of photon energy. Why is this important? (Next Slide)

Absorption Curve 980 nm: Low melanin, low water, low hemoglobin absorption thus an optimal wavelength to choose when designing a therapy laser for stimulating tissue at greater depths of penetration.

Laser Tissue Interactions

Physiological Effects Light – Tissue Interactions
65% of laser energy is absorbed in the skin and subcutaneous tissue layers with the following having a high affinity for absorption: Hemoglobin in blood Melanin in skin, hair, moles, etc. Water (present in all biological tissue) Each type of tissue has its specific absorption characteristics depending on its specific components (for example, skin is composed of cells, hair follicles, pigment, blood vessels, sweat glands, etc.) The main absorbing structures within tissue are: Hemoglobin in blood Melanin in skin, hair, moles, etc. Water (present in all biological tissue) However a not so well-know fact surrounding laser light is that 5% of all laser energy is absorbed by the skin and subcutaneous tissue. That’s right…. 65% Is it any wonder why low power, Class III lasers, fail to provide the therapeutic energy necessary to stimulate favorable physiological changes on a consistent basis?

How Laser Light Penetrates Tissue
As light energy hits the surface of the skin and subsequent deeper layers, some of it is scattered and some of it is absorbed and some is reflected At each tissue interface less energy is available to pass further through to the next layer because of the effects of absorption, reflectance and transmission

Laser Penetration Laser Energy is just another form of energy on the electromagnetic spectrum. Depth of penetration is determined by wavelength and energy density. Just like with x-rays when deeper penetration is required, more energy must be delivered to reach the target tissues.

Clinical Therapeutic Laser Penetration
Prime Determinants of Laser Penetration and Concomitant Tissue Stimulation are: Power – measured in Watts or milliwatts

Wavelength – measured in nanometers
Power Density – measured in mw / cm2 Frequency – continuous wave versus pulsing

Importance of Power Density
Since approximately 65% of the energy delivered is lost in the epidermis If you don’t start with enough energy on the skin, there will not be enough to stimulate cell healing in deeper tissues

If you do not have sustained power density over a long enough period of time treatments may be ineffective

Single Wavelength, Multiple Wavelength, Continuous or Pulsed Wave Laser
A laser with two or more wavelengths only has the ability to penetrate as deep as each individual wavelengths allows Most class iv lasers that pulse or have a high duty cycle coupled with multiple wavelengths of energy emission will not penetrate as deep as CW lasers of a single wavelength or lasers that can pulse but still maintain a high average power output

Continuous wave lasers = 100% duty cycle, laser is always delivering energy which is needed to overcome absorption in the superficial layers Newer generation of TMA lasers can now pulse yet still maintain a high average power output allowing for greater tissue saturation with less thermal effects

In Laser Medicine 1 + 1 Does Not Equal 2
Dual wavelength lasers only penetrate as deep as each wavelength individually. Penetration is not additive. There is no validated clinical benefit to this scenario. It is more of a marketing

For purposes of penetration it is more advantageous to have one wavelength of greater power that stimulates cell metabolism and tissue regeneration at all tissues densities in its pathway

Is There A Magical Wavelength?
Throughout our 13 years of clinical experience using a 980nm treatment beam, we have experienced stellar results with both superficial and deep pathologies. We still feel once you are treating within the infrared spectrum, power, power density and dosage are the key to better clinical outcomes.

Sponge Theory In order to achieve penetration one must create significant energy density to overcome absorption in the superficial layers of the skin. With low power or pulsed lasers it is like pouring small amounts of water onto a large sponge (the dermis and subcutaneous tissues) and expecting the water to leak through.

In order to do so you must saturate the superficial layers of the sponge- with enough water-energy to soak the sponge-superficial tissue structures So as you pour more water-energy over the sponge it will start to penetrate or leak through.

This it what is needed to penetrate and why it is important to deliver a high amount of laser energy/dosage on the skin Especially if you want to reach deep seated pathologies.

How Much is Enough 49-73 mw/cm2 for cell stimulation1
EFFECTS OF INFRARED LASER EXPOSURE IN A CELLULAR MODEL OF WOUND HEALING Mark D. Skopin and Scott C. Molitor, Department of Bioengineering, University of Toledo, Toledo OH This study shows an optimal wavelength (980 nm) and power density range for wound healing and tissue stimulation Point out that this study was done with OUR laser so we know from this how to establish our protocols, does the competition?

Laser & Tissue Powers Tissue Layer Max Power (mw/cm2) Epidermis 206
Dermis Layer Dermis Plexus Super 2nd Dermis Layer 115 Dermis Plexus Prof. 93 Muscle Tissue Snapshot in time, when laser is applied clinically its over time so power density and time are both important Power Setting 5 Watts, 3.0cm spot size, 980nm This is a snapshot in time. Calculated using computer models by U of Toledo.

Translation – As laser light or energy penetrates through the body more and more energy is absorbed so by the time you start reaching deeper structures there is not enough therapeutic energy to cause adequate tissue stimulation Thus the reason why low power lasers as well as pulsing lasers cannot effectively treat deep seated pathologies.

Other Factors Affecting Lasers Penetration
Duty Cycle – 100% Laser is firing continuously Duty Cycle – 50% Laser is firing 50% of the time. This will not only cut energy delivery but it will also affect ability to penetrate.

Pulsing – Lasers that pulse also do not emit continuous energy
Lasers that can operate at 100% continuous wave output or pulse the laser energy while still maintaining a high average power output is key to treating deep seated pathologies and better clinical outcomes.

Class III vs. “Class IV” Laser Beams
With a high power output the laser beam can easily penetrate deeper joints especially when compared to a class iii laser which at best only offers superficial penetration.

Why Therapeutic Lasers Fail
Under penetration - The typical low level or cold laser or weak or pulsed class iv laser does not concentrate the laser energy sufficiently to allow for adequate penetration

Under-dosage – The typical low level or cold laser or weak or pulsed class iv laser does not deliver enough energy to adequately stimulate deep seated inflammatory conditions

TMA protocols are successful because they call for delivery of significantly larger amounts of therapeutic energy than industry standard protocols.

TMA-Diowave Philosophy
TMA’s goal has always been to build the most efficacious laser available to deliver the best outcomes. Our lasers are built from the ground up and are designed to get patients who have failed traditional therapy better

Many other lasers are built based on economic factors or from taking laser from other markets like dentistry and converting them into weak class iv lasers There are no shortcuts to treating deep seated pathologies and one must deliver the correct dosage of laser energy in order to get the best outcomes.

“The Key to Better Outcomes”
Higher the power output of laser energy The Greater The Penetration and Dosage The Faster the Therapeutic Outcome

The Quicker the Patient Returns to Normal
This is the main reasons we keep advancing our technology and developing more powerful lasers.

Why More Power is Better
More power equates to deeper penetration, faster delivery of the proper therapeutic dosage, and ultimately better outcomes A 30 watt laser will not only penetrate deeper, it will put more therapeutic energy to the target pathology It will do this 3X faster than a 10 watt laser and 5X faster than a 12 watt laser with a duty cycle of 50%

Recommendations for High Dose Laser Therapy
Small Joint – lb. Pet = 6,000 Joules Small Joint – lb. Pet = 9,000 Joules Large Joint lb. Pet = 9,000 Joules

Large Joint- 50-100 lb. Pet 12-15,000 Joules
Equine Dosages are typically Double the Small Animal Dosage for Large Joints Even more for back pathologies

Evidence Based Medicine
The effects of HPLT can easily be documented Clinician’s can measure results using outcome assessment tools: Pressure Algometer Inclinometer , Goniometer Thermal Imaging and Doppler Studies VAS, PDQ – Pain Disability Questionnaire

Lasers vs. Standard Modalities Currently Used to Treat Neuromusculoskeletal Pathologies
The nice thing about laser therapy is… that it is a modality…. that literally “does it all”. It reduces inflammation, reduces pain, accelerates healing, reduces muscle spasms and trigger points, increases circulation and so on…..plus it has been shown to provide one other characteristic that other modalities don’t do…..does you know what that is? The answer is … Regeneration...it stimulates the proliferation of chondrocytes and osteoblasts. That’s right! Lasers have been shown to reverse inter-articlar loss of cartilage and… accelerate the healing of fractures and bone implants. Additionally, laser has been shown to accelerate the repair of peripheral nerves.

PHYSICAL PARAMETERS OF SOME COMMON CLASS IV LASERS
LASER BRAND (In watts) MDO(1) DUTY CYCLE (2) MPTD(3) JPM(4) CPW(5) WARRANTY TMA - Diowave 60 60 100 60 w 3600 $834 3 yr TMA - Diowave 30 30 30 w 1800 $1,167 TMA - Diowave 15 15 15 w 900 $1,600 TMA - Diowave 10 10 10 w 600 $1,500 Litecure 15 7.5 7.5 w $1,800 2 yr Litecure 10 5 5.0 w $1,750 Klaser 12 6 50 3.0 w 360 $3,667 Klaser cube 15 2.5 w 450 $3,600 Cutting Edge 1.1 0.5 75 <1.0 w 45 $20,000 not published Cutting Edge 3.3 1.1 105 $15,000 Class iii lasers 0.75 variable 0.75w 60-180 4, ,000 1-3 yr

MDO = Maximum Diode Output
Duty Cycle = Average Time Diodes Are Firing MPTD = Maximum Penetrating Therapeutic Dosage.

Because wavelength and power determine
penetration, and each wavelength penetrates independently, the maximum penetrating dose is no greater than the maximum power output of each diode. With a 50% duty cycle penetration of each diode gets cut in half. 4. JPM = Joules Per Minute 5. CPW = Cost Per Watt (Continuous Power Output)

Maximum power output per wavelength is one of the most important factors in favorable treatment outcome. With a dual wavelength laser, laser beam penetration is reduced by 50%; with a 50% duty cycle setting and dual wavelengths, laser penetration is equal ¼ of the stated power output of the laser.

With multiple-wavelength lasers (2-3) beam penetration is reduced even more significantly. If a 50% duty cycle setting is paired with a three-wavelength laser, beam penetration is equal to 1/6 of the stated laser power output. A 10W CW Diowave laser has a stronger maximum diode power output of any therapy laser currently produced.

HPLT —HDLT A New Trend in Pain Management
Profound anti-inflammatory and analgesic effects Pain relief typically immediate Non-invasive and no side effects Profound tissue regeneration of all tissue types Overall contraindications minimal

Evidence Based Medicine
The effects of HPLT can easily be documented Clinician’s can measure results using outcome assessment tools: Pressure Algometer Inclinometer , Goniometer Thermal Imaging and Doppler Studies VAS, PDQ – Pain Disability Questionnaire These tools are vital to document outcomes which ultimately lead to adequate reimbursement

Applications of Laser Therapy
Disc Pathologies, Spinal Stenosis, Radicular Pain, spondylolesthesis, and sacroiliac dysfunction Failed surgical back syndrome Accelerated Post Surgical, Soft and hard Tissue healing Arthritis (Degenerative Joint Disease) Foot Pain and Neuropathies Muscle, Ligament and Tendon Injuries Ulcerations and Open Wounds

What to Look For When Purchasing a Class IV Therapy Laser
Single wavelength laser True CW (Continuous Wave). Laser will operate all day on CW without issues Highest CW Power

Introducing the 2012 TMA Suite of Laser Platforms
A technological advancement in energy output and delivery The TMA suite of laser platforms offer the world’s most powerful and advanced therapeutic laser system ranging in power output from 10 – 60 watts or 10,000mw -60,000mw. As a veterinary based company we have treated or will know how to treat any condition you are confronted with, the ultimate result being a better outcome With the superior training and clinical support we provide veterinarians, the above goal will readily be achieved

Introducing the 2012 TMA Diowave Laser Platforms
Watt Laser Platform and 60 Watt Laser Platform

Marketing High Power Laser Therapy in Veterinary Medicine
Laser Therapy is by far the most exciting new clinical treatment to advance veterinary medicine in the 21st century It can also become one of your most significant profit centers in your practice All that’s need to be done to accomplish is to follow the Diowave Turnkey marketing plan that comes with every laser purchase For further information on bringing the a Diowave Laser into your practice you will find our contact information in the next page

In summary my recommendation is to bye the most powerful single continuous wavelength therapy laser you can afford over the next 5 years 15-30 watts for SA 30-60 watts for Equine or Mixed

Introducing the 2014 TMA-Diowave High Power – High Dose Lasers
10-15 Watt Laser Platform 20-30 and 60 Watt Laser Platform

For More Information Contact the Company by:
– Phone –

Better Outcomes Are Only a
Phone Call or Away

Introduction to New High Power High Dose Class IV Laser Therapy

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Introduction to New High Power High Dose Class IV Laser Therapy

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