This is a snippet from our Photobiomodulation (Laser) Therapy for Animals CPD/CE.
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If you would like to read the transcript for this post then please click on the reference below.
Let’s think about the use of PBM specifically for osteoarthritis. I know this is a photobiomodulation course and we are obviously going to consider the specifics of that, but I would like you to really think outside the box with this one. OA can be considered as a special case because it’s not just about the joint – it’s about so much more than that. So we are going to have a look at the big picture and I just want you to consider how you can use PBM as part of your overall treatment plan. First of all, we need to think about whether we can get to the joints or not. We have already thought about depth of penetration for laser and we know that the skin is a slight hindrance for us there. We need to really think about some of these big joints, especially with horses. Are we going to be able to get there? We will discuss application in a moment for some little tricks and tips about how we can improve the depth of penetration with our application techniques, but we really do need to seriously think honestly about whether we are going to get into deep joints (like the sacroiliac on a horse with photobiomodulation) and I don’t really think that we are.
When you look at a joint like this which is a hock and it is swollen. You can see there is a fusion there (it’s not a very clear picture), but there is a fusion there of that hock joint. The joint itself (or the joint capsule in certain places) is actually quite close to the surface. It’s not that deep down, so you are not going to go through any of the bones to get to the joint on the other side.You are not going to necessarily go through huge areas of muscle depth to get deep down to a joint. However, when the joint is relatively close to the surface or in particular areas where it is close to the surface, you should be able to get there if you use clever application techniques.
We just need to think about how it’s not just the joints that we are considering. We need to think about the overall picture of OA and how it affects the animal as a whole. We can go in and target the joint and get some pain relief from that and modulation of inflammation which is great, but we need to consider the animal as a whole. I believe photobiomodulation becomes very useful when you use it as part of an overall treatment. The way I tend to look at any case with rehabilitation is initially, we need to go in there and reduce the pain. We need to help with the primary problem so that we can get the animal more comfortable and then we need to re-educate them to move better.
So with PBM, I think it fits in really nicely with this. We can come in and we can use it for the osteoarthritic joint and surrounding area to reduce the pain and to get some biological processes going and moving again. The overall effect that we are going to get is that the animal is in less pain and they are going to move a lot better. As soon as they start moving better, the joint will start to improve. With a joint (especially when we don’t have any of those shear forces on a joint) and if we have a nice stable movement, that will help it to cause some repair from osteoarthritis and some damage to the cartilage, etc.
What we do want to do is to get these animals moving. Even though we want to get them moving, we need to get them moving correctly otherwise shear forces on the joint are not a good thing, so it will need to be followed up with rehab. You can use photobiomodulation to reduce that pain and not just over the joint, but you need to think about the global picture. E.g. An osteoarthritic dog may have hip osteoarthritis, but they generally tend to have shifted all of their weight forward. They have a really sore neck and lack of range of movement in their elbows, neck and spine. Their posture and their core strength is gone. All of those things need to be addressed.
The very important point I am making here is that we can’t just go in there and say ‘We’re going to do PBM for the joint’. We can do that and it would help to a certain degree, but if you take it as part of the overall picture, you are going to get much more success. So let’s just think about application. The key thing is that we need to try and get into the joint and we do know that the skin is a significant barrier. There are some studies (which is a part of one of the other lessons) that show us that when the skin is removed, the penetration is much increased. We obviously can’t go in and peel off the skin and then treat the joint and then put the skin back across. I don’t suggest that as being a good technique. But what we do want to do is try to get into the joint as much as we can.
We need to think about the way in which we angle the photobiomodulation and where we actually get into the joint and where we can target the photobiomodulation to best get into the joint. We need to really think about that. When you look at a joint, this is where you need to absolutely know your anatomy. You need to know where the pockets and the areas are and where the joint capsule gets nearer to the surface. You really need to consider your anatomy and where you can attack the joint from and from which angle. And then we just want to think about contact. In the same study that I have just made reference to it also refers to contact or having the photobiomodulation head in contact really increases the depth of penetration and it will go on to increase the efficacy of the treatment.
We need to make sure we can get that treatment head in contact with the skin and even apply some pressure to that so that we can get deeper down (we have covered this in a different lesson). The issue is that if you have a painful joint, then contact or quite a firm contact with the head can cause pain going back and forward over that joint. That would be with a class 4 laser you would need to move back and forward over the joint. With a class 3B you wouldn’t need to, and you could move around. With those cases, you don’t have to press so hard. Whether you get that depth of penetration is the question and is something we are still not entirely sure about. We do need to think about the technique that we use and whether that contact is going to cause any pain. If it is, then we need to not use that amount of pressure and that will affect our dose. That is just something that we need to consider.
Also, when we are looking at osteoarthritis, specifically over bony areas, it can be uncomfortable. There is also another research paper (which we will cover as part of this lesson) where they treated osteoarthritic elbows and they couldn’t go in deep with the contact and the pressure because it was very bony around that area. It would be really uncomfortable and that is just something that we do need to consider.
Some therapists will suggest joint traction which is where (in basic terms) pull the joint apart so that you can get deeper into the joint line. I have not had much success with this myself. You can do it and you can give it a try and just gently sort of traction that joint so that you can angle the head more into the joint line and directly into the joint. I do find that if you have got an osteoarthritic joint, that joint traction can be quite uncomfortable. That is something that I don’t think is necessarily that effective. Although if you have worked on them for a bit and you can get that joint a little bit more traction on that joint, then that might be successful in some cases.
The other important point is that we need to take a 360 degree approach. So rather than just coming to the joint from one side like here, we have got this little chap laid on his back and we can get into the ventromedial hip area as shown here on the with the red mark. So you would do half of the dose on one side and half of the dose on the other side or even some caudal to that. So basically the best way to target the joint but to also use that 360 degree approach rather than just going in there on one side and keeping it all on one side will be much more effective. Again, we want to work with depth, so if we can catch a joint from one side and catch a joint from the other side, that is going to be better than just doing that on the one side and hoping that it’s going to go all the way through. There is normally less hair on the underside of their belly as well so that can be a good way to override the hair problem.
And then just finally, I just wanted to mention that posture breaks are sometimes essential. If they are standing for a long time or having to lay or move so that you can get into a particular joint or if you are using traction or any particular positions that might not be the most comfortable for the animal, then you might have to stop and give them some breaks. That is just something else to consider. So it’s just a different angle to look at osteoarthritis and PBM treatment. I hope you can see that really an overall approach would be better.