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Heat Help

Laser Use

The approach to wound healing has undergone numerous changes in the past 25 years. One available modality to be considered is laser, or superluminous diode. Regardless of the approach, it is first and foremost important to assess the patient's medical, physiological and anatomical situation while assessing and evaluating the wound in question. It is important to remember that physical therapy modalities do not alone heal wounds, but rather they facilitate the normal process of healing that an individual may possess.

Over the last 10 to 20 years, laser therapy has been increasingly used in the practice of wound healing, and has proved to be effective in aiding the proliferation of essential cell activity necessary for healing.

When first evaluating a patient with a wound it is important to ask pertinent questions to find the cause and contributing factors to determine why the wound is in its present stage. A physical therapist must obtain and analyze the history and subjective reports to better obtain a clear picture of the patient. It is pertinent to know whether or not the patient has diabetes, peripheral vascular disease, hypertension or congestive heart failure.

It is also important to know what medications the patient is taking, and do they have any allergies? What, if any, treatment has the patient received for their present condition and what were the results? How did the wound occur (e.g., pressure wound, arterial or venous insufficiency, trauma)? These questions can assist a physical therapist with choosing the proper approach to assist the wound in healing.

Considering Treatment

Once a wound is assessed and properly diagnosed, it is time to facilitate healing. For example, if a wound is a result of venous insufficiency and the patient has a medical diagnosis of diabetes, then it is important to make the proper referral for addressing and gaining control of daily glucose levels, considering and reviewing the patient's A1C.

Diet and lifestyle (smoking, alcohol usage, exercise and activity levels) are large contributing factors to healing, and should be considered with appropriate counseling and education of the effects of these lifestyles. Blood work should be reviewed, with special consideration of albumen levels, and nutritional counseling should be considered accordingly.

After all these related systems are reviewed, and issues are addressed, the physical therapist may begin considering their treatment approach. A patient with venous insufficiency may respond well to a multitude of approaches, one of which being gradient compression hose for the assist of venous return.

Gradient compression socks or stockings provide pressure at the ankle that gradually decreases as it extends proximally, helping to assist the gastrocnemius to move blood back to the heart. This

Laser Heat

Laser application can provide a therapeutic tool for pain management and wound healing if used efficiently.

therapy reduces blood pooling that causes swelling, discomfort, skin changes and open wounds in the skin. In the event that an open wound occurs it is important to assess and determine the proper approach of treatment.

In order to progress a wound successfully through the three phases of healing, physical therapists have a few choices. One of these is a laser or super luminous diode. The laser light is designed to generate a light wavelength for a specific therapeutic window of 660-880 nm. The basic unit of light is the photon, which is the energy in any electromagnetic field made of discrete packets. Therefore when a therapist applies laser light to biological tissue, we are actually applying energy to the tissue. 

The specific therapeutic window of light or the photon is any wavelength between 600-1000 nm. At this wavelength, a photochemical reaction occurs and the tissue absorbs the light. The light photons are applied to the tissue, which is then absorbed by light absorbing structures within the mitochondria such as various chromophores (e.g., flavins, cytochromes, porphyrins). This energy is then stored as adenosine triphosphate, which causes an elevation of ATP, and then activates the metabolic process promoting cell proliferation. This begins the phases of wound healing.

Laser light has proven to be quite effective in the promotion of the three phases of wound healing. The series of events that takes place in the wound healing process is both complex and structured. These cellular events may take days or years to successfully complete.

Phase one of wound healing is called the acute or inflammatory phase and immediately begins after injury to the tissue. This phase lasts two to five days and begins with hemostasis where there is a vasoconstriction in the injured tissue. Platelet aggregation will then occur, which ultimately leads to the clotting of the blood in the effected tissue. As the light is applied to the biological tissue, the photon energy is absorbed in the mitochondria and promotes cell activity hence bringing the wound into the inflammatory phase of wound healing.

This activity is followed by vasodilation increasing the blood flow and beginning the process of phagocytosis. Phagocytosis begins with the release of neutrophils and macrophages, which are programmed to begin an enzymatic debridment of the pathogens that are harmful to healthy tissue. The neutrophils and macrophages are released and engulf the pathogen and enclose it within a phagocytic vesicle called a phagosome.

The phagosome is then fused with the lysosome to form phagolysosome for the ultimate destruction of these pathogens. We are brought to the second stage of wound healing called the proliferative phase. As we continue to facilitate wound healing, assuring we are facilitating a stable medical condition and an effective exercise program, the therapist continues to treat the wound with laser through the proliferative phase of wound healing.

In the proliferative phase the laser continues to promote healing through three weeks after the inflammatory phase. The photons in the laser activate the mitochondria and promote DNA and RNA synthesis, protein synthesis, mitosis and cell proliferation resulting in granulation tissue formation. Granulation is the proliferation of fibroblasts, which in turn lie down a new bed of collagen, and if intermittent pressure is applied during wound healing, elastin. The wound edges will contract and epithelialization occurs with cell migration across the biochemical correct wound bed.

As treatment progresses the wound enters the third stage of wound healing called the remodeling phase. In the remodeling phase the photons promote healing and will last up to two years. New collagen forms with elastin (providing there is intermittent pressure applied to the wound during the proliferative and remodeling phases) to provide for increased tensile strength with a flexible mobile intact epithelium. Studies have shown that scar tissue is only 80 percent as strong as the original tissue; however, with a proper collage and elastin tissue matrix, the scar will be less susceptible to re-injury secondary to its flexibility.

Wound Contraindications

When treating a wound with laser it is necessary to deem each patient appropriate for treatment with laser. Contraindications include: Cancer, treatment over an epiphyseal plate, patients with cardiac pacemakers, patients that have been pre-treated with one or more photo sensitizers, over a fetus or uterus during pregnancy, over the thyroid or endocrine glands, over the eyes, or on patients with idiopathic photophobia or abnormally high sensitivity to light.

The proper technique is as critical as choosing laser as a modality for treatment. The probe should be sanitized and placed over the wound with full contact during the treatment; however, with minimal pressure to avoid injury to the epithelialization process. A sanitized thin plastic film may be placed over the wound to prevent injury to the cells or cross contamination. The probe will only treat an area equal to its size, therefore, if the wound bed is larger than the probe, more than one treatment site is necessary. The probe should not be moved while administering the photons.

Treatment protocols vary from device to device and practitioner to practitioner. Laser light waves will penetrate the skin without heating or damage to the skin, and do not produce any side effects. The immunosuppressive and anti-inflammatory effects that laser light has on the cell optimizes the bodies immune response to injury. This biological stimulation aids in the acceleration of tissue repair, as well as provides for stronger more mobile tissue repair. Used in proper doses, laser or super luminous diode light therapy will have an analgesic effect on the wound. We found, however, that when laser is used every day on a wound, tissue continues to heal at a more rapid rate, but the subjective report of pain is increased.  

We have found in our clinic that utilizing super luminous diode or laser with a light cluster probe as an adjunct treatment, two to three times a week directly over a wound for 30 seconds at a dosage of 1-3 J/cm squared has a definitive positive effect on both controlling pain and promoting an environment for the wound to heal. Two to three treatments a week has proven most effective to allow collagen and elastin to mature and minimize pain.

I would stress the importance of performing a complete evaluation of all systems including blood work, review of past medical history, diabetes, cardiac condition, lifestyle (alcohol use, smoking, drugs, etc), activity level and diet. When the practitioner determines that all systems are reported stable by the patient's primary care physician or appropriate specialist he or she may begin to consider physical therapy intervention for wound healing.

For physical therapists to begin to facilitate wound healing, they must remember to properly assess the wound and determine what the cause is, address the root of the problem, then choose a modality to facilitate the healing. Of the modalities that a therapist has to choose from, laser is valid and effective in wound healing. Laser provides a therapeutic light or photon to the light absorbing structures within the mitochondria for the facilitation of wound healing. 

Gary Parker Jr. is the owner of Greene Physical Therapy in Greene, NY.