Dr. Robert G. Silverman DC, DACBN, MS, CNS, CCN, CSCS, CIISN, CKTP, CES, DCBCN, HKC,

SFMA

www.DrRobertSilverman.cominfo@drrobertsilverman.com

Musculoskeletal Laser Therapy: Integrated Clinical Protocols

Quote“Let there be

light”.

Pathogenesis of the cumulative trauma disorder

RecoveryCycle

Injury Cycle

Frequency of Insult

Amou

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f Tiss

ue In

sult

SymptomaticInjury Threshold

Pathogenesis of the cumulative trauma disorder

Injury Cycle

Frequency of Insult

Amou

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f Tiss

ue In

sult

Insufficient Tissue Recovery Between

Injury Cycles

Tissue Damage Accumulates

Copyright Jerome M. True, DC

Integrating Laser into Practice“The most versatile

healthcare tool of the 21st century”.

Dr. Rob, January 2013

“No-pill pain buster”.Dr. Oz, January 2013

Blue Print• Find the cause• Explain the source• Determine effective treatment• Shorten treatment time

What Comes First?

Injury Pain

Altered Motor Control

We should diagnose this

FUNDAMENTAL QUESTION?

AbdominalsGluteus maximus

For Your Pain“Immediate pain reduction can be achieved by altering muscle activation and movement patterns”

Spine, 8-6-2012. S. McGill, D. Ikede

Kinetic Chain = Functional Anatomy

Muscles act in synergy not in

isolation

Muscular strain is applied along

traceable “Myofascial Lines”

Movement, not muscles

The Search Is On

Laser Focus• Laser: Light Amplification by Stimulated Emission of

Radiation• A focused beam of light that emits photon energy• All photons travelling same direction at same

wavelength = coherent light

Laser Focus“The cell is a machine driven by energy…in every medical tradition before ours, healing was accomplished by moving energy”.

Albert von Szent-Gyorgi, 1967

Well, the answer is best explained using the basic principles of

photochemistry

How Does it work?

Branched Chain Effect…• A single photon can trigger a

reaction in one cell that causes emission of several photons

• These then trigger photon emissions in other cells like a chain reaction

• This accounts for the fact that a tiny signal can be multiplied to cause a rapid and regenerating flow of energy through a bio systemJames Oschman, PhD. 2006

How It Works• LLLT stimulates cell activation processes which, in turn, intensifies

physiologic activity• Healing is essentially a cellular process• Light energy initiates a cascade of reactions• From cell membrane – cytoplasm – nucleus – DNA• Cellular amplification

How can this “Star Trek” medicine benefit my patients?

Photobiostimulation results in 2 basic responses:

Increased Cellular Regeneration

Increased Cellular Communication

ATP Production

Nervous systemLiving matrix

Phospholipid cell membraneHydration

Due to

Due to

Cell RegenerationLaser Therapy Causes Increased ATP Production, a Precursor to Cell Division

Photons Absorbed by Chromophores on Cell

Membrane

Absorption into Molecules Leads to an Acceleration of Electron Transfer Reactions

and ATP Production

Cell CommunicationIntegrins: Receptors on Cell Surface Linking Cell to Surrounding Environment

Unique Bidirectional Transmembrane Signal Transduction

Photons are Absorbed and the

Integrin System Aids in Transduction

Olsen, I.M. and French Constant, 2005, BMC Biology 3:25

Laser Therapy 3 components integral to beneficial outcome

LASER

1) Active ingredient

2) Dosage

3) Delivery Mechanism

Specific wavelength (color) is component responsible for influencing biochemical cascades

Intensity (power of light) determines a response. Too little limits response. Too much produces adverse effect

Manner in which light is delivered determines proper tissue response and depth of penetration. Coherent, focused light insures deep tissue stimulation

Wavelengths• Expressed in terms of color. Each wavelength has different properties:

• 635 NM is the frequency of a healthy cell• 635 NM is the absorbable dose• 635 NM is visible light• 635 NM is where DNA replication occurs (photobiostimulation)• 20 times more effective than longer wavelengths

Power and Wavelength• LLLT accelerates tension healing, increasing fibroblast proliferation and

collagen synthesis• LLLT effective at reducing post-injury inflammation and accelerated soft-

tissue healing• LLLT increases ATP…stimulating DNA synthesis and cell proliferation• 632.5-nm laser “produced a higher deposition of collagen, increasing the

tensile strength of completely severed and surgically repaired rat tendons

Comparative Study Using 685-nm & 830-nm Lasers in the Tissue Repair of Tenotomized Tendons in the Mouse, Photomedicine and Laser Surgery, Dec. 2006, vol.24(6), p.754-758

KEY• Wavelength (in NM) or color of the light should maximize

cytochrome-C-oxidase (CCO) absorption

KEY• CCO – terminal enzyme of the mitochondrial respiratory chain,

catalyzing the transfer of electrons from reduced cytochrome c to molecular oxygen

• CCO may be considered to be a mitochondrial photo-acceptor• LLT at 635nm has ability to influence mitochondrial enzyme activity, in

particular CCO, leading to mitochondrial activity and ATP synthesis

Frequency• Frequency is the blinking quality of the red line• Frequency (in Hz) – the number of light flashes per second. Allows for

modulation of the light which can overcome clinical plateaus in patients

• Frequency of 30 or less is visible to the naked eye• Over 30 – the pulse/blink is too fast to see and it appears as a

continuous line

Dr. Rob’s Fab 5Joint dysfunction

EC Matrix

Exercise/ergonomics/proprioception

Laser therapy

Nutrition: a) Diet b) Supplements

Laser/Pain ManagementDr. Rob’s take:• By applying laser energy to affected areas, the frequency sensory

nerve firing is increased, which subsequently increases the frequency of stimuli to the spinal cord, brainstem, and brain, in turn inhibiting pain at the spinal cord and brain stem levels

Don’t you need a lot of power for the light to penetrate?

Too much power – not low-level laser

Low level laser therapy effect are biochemical and not dermal and cannot cause heating and thereby damage to living tissue

Low level laser therapy

Arndt-Schulz Law• “Weak stimuli excite physiological activity, moderately strong ones

favor it, strong ones retard it, and very strong ones arrest it.” • Biomodulation

Restoring the cell back to its natural frequency

IT’S ALL CONNECTED

“Spontaneous healing…all the circuitry and

machinery is there; the problem is simply to

discover how to turn on the right switches to

activate the process”.Spontaneous Healing

Andrew Weil

Using laser light to “turn on the right switches”

Muscle Test – Upper Body• C1 – Flex/extension• C2 – Flex/extension• C3 – lateral flexion• C4 – rotation• C5 – deltoid• C6 – bicep• C7 – tricep• C8 – finger flexors• T1 – finger abductors

Low Back and Pelvis

MyotomesMuscles

L1-3 Iliopsoas

L2-4 Quadriceps

L3 Sartorius

L4,5 S1-3 Hamstrings

L4 TibialisAnterior

L5 Toe Extensors

L5 Glute Medius

S1 Peroneus L. & B.

S1 Glut Max/TFL

Laser Muscles• SCM• Scalenes• Levator scap• Trapezius• Supraspinatus• Lat dorsi• Psoas• Glute max• Piriformis• Erector spinae

Laser “Locomotor Lock-In”• Resets NMS in 3D motion• 4, 9, 33, 60• Facilitated bodies global integration• 5 sec.eyes open, 5 sec. eyes closed• Cross-crawl: right arm – left leg, left arm – right leg• Aim posterior midline-spine• Repeat pointing at brain.

Core Lock-In

4, 9, 33, 6030 sec. each side

Dr. Rob’s Magnificent 71) Posture/pain

2) Overhead squat3) 1-legged squat

4) Trunk stability push-up5) Valgus jump test

6) Upper/lower muscle firing patterns7) Push-up

Functional Movement

Assessment

Functional Movement Assessment (FMA)• FMA will make the invisible visible very quickly• Movement never lies• It tells the unique story of each individual’s history,

compensations and adaptations• Dysfunctional movement patterns lead to:

• Poor performance• Increased injury• Decreased durability and pain

Movement

Adhesions limit movementlimited movement creates

compensationsCompensations create stress

Chronic stress creates adhesions

Key Laser therapy Protocols for Musculoskeletal Injuries

Carpal Tunnel Treatment Protocol• Laser at point/points of involvement (9,16,21,36) – 3

to 5 mins. max• Laser during movement – 30-60 sec.• Laser “locomotor lock-in”• Nerve floss• Corrective exercise• Nutritional protocol: B vitamins (B5, B6), omega-3

fatty acids• Mobilize, manipulate joint restrictions• Myofascial release

Carpal Tunnel

Rotator Cuff Injury Treatment Protocol• Laser at point/points of involvement:

• Muscle/joint/scapular (9,16,42,53)

• Laser during movement – 30-60 sec.• Laser “locomotor lock-in”• Corrective exercise• Nutritional protocol: see 3 Phases of Care• Mobilize, manipulate joint restrictions• Myofascial release

Exercise and LLLT for Subacromial Impingement• Conclusion: This double-blind, randomized control trial showed that

LLT and exercise therapy is more effective than exercise therapy alone for the purposes of improving pain and active/passive ROM in patients with subacromial syndrome

Clinical Rheumatology 2011; 30: p1341-46

Supraspinatus

Intervertebral Disc Tx Protocol (cont’d)• Core “lock-in”• Nutritional protocol:

• Glucosamine chondroitin MSM complex• Omega-3 fatty acids• Turmeric, ginger, boswelia• Mg/calcium• Outer annulus – ca, mg, vit. D, boron, horsetail aerial parts, silica

• Myofascial release• Mobilize, manipulate, flx/distraction, joint restrictions

Intervertebral disc

Lat/Medial Epicondylopathy Tx Protocol• Laser at point/points of involvement: (9,16,42,53)• Laser during movement: 30-60 sec.• Laser “locomotor lock-in”• Corrective exercise• Core “lock-in”• Nutrition protocol• Myofascial release• Mobilize, manipulation, joint restrictions

Lateral Epicondylopat

hy:Laser Protocol

Medial Epicondylopat

hy:Laser Protocol

Non Surgical Interventions for Rheumatoid ArthritisChristie et alPT Journal December 2007

• LLLT reduces Pain and improves function!!• Higher Quality of evidence than US, TNS, Heat,

Exercise, ES, Acupuncture.

The low-level laser therapy application improves the healing process of the Achilles tendon of rats

Conclusion: the laser treatment is effective during the healing process in tendons since there is more presence of gags and collagen types I and III in tendons submitted to low-level laser than in tendons without treatment. With respect to the active isoform of MMP-2, the low-level laser with a pulsed emission is more effective than low-level laser continuous

2012 Fascial congress abstract. FR Guerra, CP, Vieira AA Aro, EP Pimentel

Effects of LLLT in the development of exercise-induced skeletal muscle fatigue and changes in biochemical markers related to post-exercise recoveryConclusion: pre-exercise irradiation of the biceps with an LLLT dose of 6 J per application location, applied in 2 locations, increased endurance for repeated elbow flexion against resistance and decreased post-exercise levels of blood lactate, creatine kinase, and C-reactive protein

J Orthop Sports Phys Ther, 2010 Aug;40(8):524-32

Low-Level Laser Therapy for Sports Injuries

Conclusion: LLLT is an effective treatment for sports injuries, particularly jumper’s knee, tennis elbow, and Achilles tendinitis

Y. Morimoto, A. Saito, Y. Tokuhashi, Low level laser therapy for sports injuries. Laser Ther. 2013; 22(1):17-20

Getting Athletes Back in The Game: Low-Level Laser Therapy For Sports Injuries“Most athletes with chronic ankle sprains have a proprioceptive deficit

in that injured ankle. Proper proprioceptive exercises coupled with laser therapy have enabled many of my athletes to avoid the

recurrence so commonly seen with the injury.”

Dr. Robert SilvermanDynamic Chiropractic, Aug. 1, 2014

Low level laser therapy (LLLT) in the management of neck pain

Conclusion: LLLT reduces pain immediately after treatment in acute neck pain and up to 22 weeks after completion of treatment in patients with chronic neck pain

Lancet, Nov. 13, 2009

LLLT Effectiveness• The International Association for the study of pain found “strong

evidence” for LLLT on myofascial pain syndrome

A meta-analysis of the efficacy of laser phototherapy on pain relief

Conclusion: These findings warrant the conclusion that laser phototherapy effectively relieves pain of various etiologies; making it a valuable addition to contemporary pain management

Fulop AM, Dhimmer S., et al. Clin J Pain. 2010 Oct; 26(8):729-36

Frozen Shoulder: The Effectiveness of Conservative and Surgical Interventions

Conclusion: Strong evidence for the effectiveness of laser therapy

British Journal of Medicine 2011, Jan. 45(1), p.49-58

Treating TMJ Pain with Low-Level LaserPatients with functional TMJ pain reported significantly reduced pain scores (pain Visual Analog Scale) following five treatments with low-level laser therapy

0 5 10 15 20 25 30

Before laser therapy

After laser therapy

27.5

4.16

Dostalova T, et al. Effectiveness of physiotherapy and GaA/As laser in the management of temporomandibular joint disorders. Photomed Laser Surg, 2012;30(5):275-80

Low-level light stirs in vivo stem cells to regenerate tissue• Researches have demonstrated for the first time that non-invasive,

low-power light therapy can prompt stem cells inside the body to reconstruct tissue

• Research promises a broad range of clinical applications in wound healing and bone growth

• Led by Dr. David Mooney of Harvard University – the team used a low-power laser to trigger human dental stem cell to form dentin (hard tissue that is similar to bone and makes up bulk of teeth)

P.R. Arany, Sci. Trans Med 6, 238 (2014)

Low-level light stirs in vivo stem cells to regenerate tissue (cont’d)• They outlined the precise molecular mechanism involved and

demonstrated its abilities using multiple laboratory and animal models

P.R. Arany, Sci. Trans Med 6, 238 (2014)

Neurodynamic test – Lower Extremity

• Sciatic: slump or add neck flexion (SLR) – piriformis

• Tibial: df/ev/SLR - posterior to the knee

• Peroneal: pf/in/SLR – head of fibula/medial to b. femoris

• Sural: df/in/SLR – bottom of calve

• Femoral: prone knee bent – inguinal ligament

Laser Nerves• Brachial plexus – scalenes• Median – pronator teres, flexor retinaculum• Ulnar – olecranon and medial epicondyle• Radial – triangular space between T minor, LH triceps and humerus• Sciatic – piriformis muscle• Femoral – psoas• Tibial – posterior to knee• Peroneal – medial biceps femoris/head of fibula• Sural – calve region• Tarsal tunnel –at tunnel

Cell membrane Health

Alpha-Linolenic Acid (ALA)(e.g., green vegetables, flaxseed oil)

Steridonic Acid

Eicosatraenoic Acid

delta-5 desaturase

EPA/DHA(e.g., fish oils)

Cyclooxygenase LipoxygenaseDelta-4 desaturase

(DHA critical)

PGE3 LTB5(anti-inflammatory) (anti-inflammatory)

Linoleic Acid (LA)(e.g., corn, safflower, sunflower oil, grains)

Gamma-Linolenic Acid (GLA)(e.g., evening primrose, borage, black currant seed oils)

Dihomo-Gamma-Linolenic Acid (DGLA)

delta-5 desaturase

Arachidonic Acid (ArA)(e.g., grain-fed meat)

Cyclooxygenase Lipoxygenase

PGE2 LTB4 (pro-inflammatory) (pro-

inflammatory)

Competing

Delta-6 desaturase

Blocked by insulin, trans fats, alcohol,

Stress

OMEGA-3 EFA

PGE1(anti-inflammatory)

OMEGA-6 FA

Competing

B3, B6, C, zinc, mg. (nutrient co-enzyme)

Ginger, turmeric,

bioflavonoids, boswelia (co-

enzyme)Cell membrane

Laser directed to affected sitePhoton Enters Tissue

Alters Cell Permeability

Cellular Photochemical ReactionAbsorbed into Mitochondria ATP+

Resulting EffectsRapid Cell Growth Increased Metabolic Activity

Increased Angiogenesis Vascular ActivitySuppression of COX-2 Pathway Decreased Inflammation

Simple strategies first!

Choosing Your Next Laser• Regulating considerations – FDA-cleared• Therapeutic factor – laser light parameters:

• Dose and frequency• Wavelength• Power• Modulation (pulsing) of light

• Non-therapeutic factors:• Portability• Size and weight• Corded or cordless operation

What does the low-level laser do• Laser therapy – stimulates both the nervous system

and site of tissue injury• Clinically proven to:

• suppress inflammation• Increase oxygen and blood flow• Promote muscle calcium update• Increase neurotransmitter release

• Key – by addressing the injury with a diverse tool it is possible to resolve the condition more effectively by suppressing not one but all contributors

Dr. Rob’s Sexy Six1) Laser delivers light energy2) Lasers can stimulate cell activity 3) Laser is classified based on its power supply4) Wavelength (color) is the length of the wave of the light energy5) The kind of tissues treated depends on wavelength and power

supply6) Laser companies do not always agree

Quote

“A mind once stretched by a new idea never regains its original dimensions”

Oliver Wendell Holmes

Q & A