A Step-by-Step Guide to Optimising Laser Therapy Treatments for Arthritis
TABLE OF CONTENTS
3
Introduction to laser therapy for arthritis
4
Early interventions strategies for arthritic patients
6
A multimodal approach to arthritis treatment
8
Optimising laser therapy dosing A randomized blind placebo-controlled trial investigating the effects of photobiomodulation therapy (PBMT) on canine elbow osteoarthritis A randomized double-blind controlled trial on the effects of photobiomodulation therapy in dogs with osteoarthritis
Arthritis case studies Additional resources
18
About Companion Animal Health
INTRODUCTION TO LASER THERAPY FOR ARTHRITIS Arthritis is one of the most common conditions veterinarians see. According to Canine Arthritis Management arthritis is the most common cause of chronic pain in dogs, impacting 80% of dogs over the age of 8. 1
The statistics for cats are even more startling. According to research, 90% of cats over the age of 12 have radiographic evidence of arthritis. 2
In this eBook, we’ll share how to leverage early lameness screening tools, platelet-rich plasma, and laser therapy as part of your arthritis pain management protocols. There are several key factors to achieving therapeutic outcomes for arthritis patients: Early Intervention Detecting joint changes earlier allows for medical management before symptoms negatively impact the patient’s quality of life. Multimodal Care Most pets benefit from a plan of care that includes multiple treatments. These may include supplements, NSAIDs, platelet-rich plasma injections, laser therapy, exercise, and dietary changes. 3 Optimising Laser Therapy Dosing Laser therapy is an effective pain management treatment for patients with arthritis when the appropriate dose is administered. In this eBook, we’ll review the research behind the most effective dosing strategies for arthritis.
Watch a Deep Dive Webinar Laser Therapy Dosing Advances: Photobiomodulation Updates www.companionanimalhealth.com/webinar/laser-therapy-dosing-advances- photobiomodulation-upda/false
EARLY INTERVENTION STRATEGIES FOR ARTHRITIC PATIENTS
The best intervention is early intervention. Here are a few ways to detect arthritis earlier.
ARTHRITIS INTAKE QUESTIONS Add questions to your standard wellness pet registration forms to screen for potential arthritis symptoms.
FOR EXAMPLE:
•
Does your pet have difficulty getting up?
• Does your pet have trouble climbing or jumping? • Have you noticed any behavioural changes? • Has your pet’s interest in physical activity changed? • Have you noticed any trembling in your pet’s limbs while walking or standing?
The answers to these questions can help identify patients who warrant further diagnostics such as radiographs.
Check out more tools to help identify pain earlier from Canine Arthritis Management at caninearthritis.co.uk/what-is-arthritis/identifying-the-signs/
EARLY INTERVENTION STRATEGIES FOR ARTHRITIC PATIENTS
Physical Exam Include a thorough palpation of joints and common areas impacted by arthritis during all wellness exams.
Visual Gait Observation Collect videos of patients walking at each visit. This will allow you to slow the videos down, and compare them to previous visits to detect gait changes.
Stance Analysis Analysing a pet’s stance allows you to objectively measure abnormal weight bearing. A recent study of 50 police working dogs revealed the weight-bearing redistribution in dogs with bilateral hip arthritis. The study showed that the Stance Analyzer weight distribution platform can be used to evaluate patients at initial presentation, and during the assessment of response to treatment. 4
[Study] Characterization of Weight-Bearing Compensation in Dogs with Bilateral Hip Osteoarthritis www.sciencedirect.com/science/article/abs/pii/S1938973622000320?via%3Dihub
A MULTIMODAL APPROACH TO ARTHRITIS TREATMENT
Managing arthritic pain takes a multimodal approach that may change over time as the patient’s condition evolves. Arthritis management also takes a team approach that extends outside of the clinic walls. Educating pet owners and getting them actively involved in care is key to maintaining a high quality of life for arthritic patients. Here are a few modalities to consider in your treatment plans:
Hydrotherapy Hydrotherapy is a great option for patients who are too painful to exercise on land or whose mobility restrictions get in the way of weight loss programs.
Medications Pain medication is commonly prescribed as part of a multimodal plan of care. As other treatments prove effective, medication intake can be adjusted to meet patient needs.
Nutrition Overweight pets feel the strain of arthritis pain more than pets of a healthy weight. Getting pet owners on board with a nutrition plan can provide significant pain relief.
LASER THERAPY GOES HEAD-TO-HEAD WITH MELOXICAM IN CANINE ARTHRITIS STUDY The study found that PBMT reduced pain levels and improved clinical findings (including functional scores) in dogs with moderate to severe hip osteoarthritis. The mean number of days that joints in the PBMT group took to return to baseline values was significantly higher than in CG (meloxicam) and also showed improvements in joint range of motion, sometimes out to +90 days after discontinuing treatment.
Read more at avmajournals.avma.org/view/journals/ajvr/83/8/ajvr.22.03.0036.xml
Supplements Joint supplements containing ingredients such as glucosamine, chondroitin, and omega-3 fatty acids can support joint health.
A MULTIMODAL APPROACH TO ARTHRITIS TREATMENT CONTINUED...
Platelet-Rich Plasma (PRP) PRP injections leverage the body’s natural healing powers to improve joint health by improving the joint environment in a targeted way, not just systemically masking pain. These long-lasting injections can provide relief for months. New research, Platelet-Rich Plasma Therapy in Dogs with Bilateral Hip Osteoarthritis, showed that PRP can improve pain and functional scores in police working dogs with bilateral moderate to severe hip OA, compared with a control group. Effects lasted for up to 6 months.
Read more at bmcvetres.biomedcentral.com/articles/10.1186/s12917-021-02913-x
See How a Multimodal Approach Helped Cabela Cabela, a five-year-old Labrador Retriever benefitted from early arthritis intervention as a result of the findings of her stance analysis. She then received laser therapy, PRP treatments, and began a weight loss program to manage her condition. Watch now at www.youtube.com/watch?v=ZtqtaYb9gCk
Laser Therapy Laser therapy (also known as photobiomodulation) treatments target the mitochondria in damaged cells to increase blood flow, accelerate tissue repair, and decrease pain. Treatments are non-invasive, painless, and non-pharmacological .
INNOVATIONS IN COMBINATION CARE New research reveals that combination laser therapy and PRP treatment can achieve better results than either modality on their own. 3 This study, A Preliminary Report on the Combined Effect of Intra-Articular Platelet-Rich Plasma Injections and Photobiomodulation in Canine Osteoarthritis, found that combining these two therapies produced greater, longer-lasting improvements. Read the full report at pubmed.ncbi.nlm.nih.gov/37893971/.
OPTIMISING LASER THERAPY DOSING
The key to achieving reproducible outcomes with laser therapy for arthritis patients is dosing. In this section, we’ll review key dosing parameters to treat chronic pain associated with arthritis.
FIRST, HERE ARE A FEW TERMS TO KEEP IN MIND WHEN WE DISCUSS DOSING:
Joule (J) A Joule (J) is the international system unit of energy
Therefore: A 10W laser will deliver 10 J/s Over a period of one minute: 10 J/s x 60 s/Minute = 600 J/Minute Irradiance Irradiance = Watts per unit area (W/cm 2 ) This is the brightness or “how much light energy (J) is passing through a given area (cm 2 ) per seconds (s).
Power Power = Energy/ Time
Watt (W) 1 Watt (W) = 1 Joule/ Second
EXPRESSING DOSAGE FOR PHOTOBIOMODULATION Laser therapy dosage is described in the literature in terms of the amount of total energy that is applied to a given area measured in cm 2 .
Dosage Dosage = Energy/ Area Joules (J)/cm 2
For medical records, record total joules administered to a specific anatomical area for example, 600 total J administered to the right ear.
ESTABLISHED THERAPEUTIC DOSES
• Superficial conditions: 4-6 Joules/cm 2 • Deep tissue conditions: 8-20 Joules/cm 2
Therefore, to effectively treat arthritis we need to deliver 8-20 Joules/cm 2 . Recent research, A randomized blind placebo-controlled trial investigating the effects of photobiomodulation therapy (PBMT) on canine elbow osteoarthritis, found that regularly scheduled PBMT at 10-20 J/cm 2 per joint for 6 weeks was successful in improving lameness and pain scores, and in lowering NSAID requirement in canine osteoarthritis patients. 5 Read more at pubmed.ncbi.nlm.nih.gov/30197438/
DOSE CALCULATION TIP:
Therefore, to achieve a target dose of 8-10 J/cm 2 (Energy density = fluence)
You need to deliver 800- 1,000 J total in the CD/ DVD sized area
The area of a CD/DVD is approximately 100 cm 2
SMARTCOAT PLUS SOFTWARE SIMPLIFIES DOSING Companion’s SmartCoat Plus software simplifies dosing calculations. Simply select your patient’s characteristics, condition, and anatomical area and the software will calculate your dose and prescribe a treatment attachment to use to optimise outcomes. Doses are developed to provide enough energy to treat 360 degrees around the entire affected joint to ensure uniform dosing in the entire injured area.
DOSE EXAMPLE LASER THERAPY OF THE HIP JOINT IN A LARGE BREED DOG
• Target energy density for deep tissue conditions, including arthritis = 8-10 J/cm 2 • 75 lb. dog hip area = ~250 cm 2 • 10 J/cm 2 x 250 cm 2 = 2,500 J Total dose over the hip area
Class IV 12W Class IV 6W Class IV 1W Class III 0.5W With class IV laser
With class IV laser therapy at 6W power (CW), treatment time = 6 minutes, 56 seconds
With class IV laser therapy at 1W power (CW), treatment time = 41 minutes, 40 seconds
With Class III laser therapy at 0.5W (500mW) power, treatment time = 83 minutes, 20 seconds
therapy at 12W power (CW), treatment time = 3 minutes, 28 seconds
[FAQ] CAN LOW POWERED LASERS ACHIEVE THE SAME RESULTS FOR ARTHRITIS AS HIGH-POWERED LASERS IF YOU TREAT LONG ENOUGH? We used to believe lower-power lasers could treat deep tissue conditions with longer treatment times. However, because we now understand that to have enough concentration (brightness) of light energy left in deep tissue to be effective, longer treatment times with low power do not deliver the same results. 6
REACHING TARGET TISSUE
The key to achieving success in arthritis is ensuring a sufficient amount of light (number of photons) reaches the target tissue. Simply, deeper tissue structures require a higher dose of light energy delivered at the surface of the skin.
Depth of penetration depends upon the power (W) delivered at the skin’s surface and the size of the area being treated (irradiance= W/cm 2 )
The distance from the skin’s surface at which the light is delivered also impacts the penetration depth. Therefore, delivering light directly in contact with the skin is the most efficient way to maximise light transmission to target tissue.
[eBook] A Beginner’s Guide to Veterinary Laser Therapy Download this eBook for a deep-dive on the foundational science behind laser therapy at info.companionanimalhealth.com/a-beginners-guide-to-veterinary-laser-therapy-uk
A RANDOMIZED BLIND PLACEBO-CONTROLLED TRIAL INVESTIGATING THE EFFECTS OF PHOTOBIOMODULATION THERAPY (PBMT) ON CANINE ELBOW OSTEOARTHRITIS
Andrea Looney 1 , Janice Huntingford 2 , Lauren Blaeser 3 , Sabine Mann 4 1 Ethos Veterinary Health, Massachusetts Veterinary Referral Hospital, 20 Cabot Road, Woburn, Massachusetts 01801, USA (Looney); 2 Essex Animal Hospital, 355 Talbot Street North, Essex, Ontario N8M 2W3 (Huntingford); 3 Ethos Veterinary Health,Bulger Veterinary Hospital, 247 Chickering Road, Andover, Massachusetts 01845, USA (Blaeser); 4 Department of Population Medicine and Diagnostic Sciences, College of Veterinary Medicine, Cornell University, Ithaca, New York 14853, USA (Mann).
Materials/Methods: Dogs (n = 20) were randomly assigned to receive either PBMT (group PBMT; n = 11) 10 to 20 J/cm 2 or a placebo treatment (sham light group S; n = 9) treatment 0 J/cm 2 , to both elbows for 6 weeks. Clinician Lameness score, Helsinki Chronic Pain Index scoring by blinded owner, and NSAID dose were recorded before and 7 to 10 days after last treatment by blinded study personnel. Results: Reduction in NSAID dose occurred in 9/11 dogs in the PBMT group, and in 0/9 of group S dogs (P = 0.0003). There was greater improvement in lameness score in the PBMT group compared to S group (P = 0.001). A greater reduction in pain score was detected in 9/11 parameters/daily life functions in group PBMT compared to group S (P < 0.05), with the exception of mood (P=0.2) and vocal score (P=0.35) which did not differ between groups before and after treatment. Discussion/Conclusion: Regularly scheduled PBMT at 10 to 20 J/cm 2 per joint for 6 weeks was successful in improving lameness and pain scores, and in lowering NSAID requirement in canine elbow osteoarthritis patients.
Acknowledgment: This study was funded by a grant from the Waltham Foundation. Equipment was provided by Companion Animal Health. Neither supporter played a role in study design, data collection or analysis, and manuscript submission or publication.
A RANDOMIZED DOUBLE-BLIND CONTROLLED TRIAL ON THE EFFECTS OF PHOTOBIOMODULATION THERAPY IN DOGS WITH OSTEOARTHRITIS
Published: American Journal of Veterinary Research, Volume 83: Issue 8 Author(s): João C. Alves, DVM, MSc, PhD; Ana Santos, DVM, MSc; Patrícia Jorge, DVM; L. Miguel Carreira, DVM, PhD
Objective: To evaluate photobiomodulation (PBM) therapy in dogs with bilateral moderate to severe hip osteoarthritis. Methods: Forty joints were assigned to a control group (CG, n=20) or treatment group (PBMT, n=20). CG received a 21-day course of meloxicam, and PBMT received treatment 14-20 J/cm 2 with a Class IV therapeutic laser over three weeks. Joint range of motion, thigh girth, the Canine Brief Pain Inventory (CBPI, divided into pain interference score - PIS and Pain Severity Score - PSS), Hudson Visual Analogue Scale (HVAS), Liverpool Osteoarthritis in Dogs (LOAD), Canine Orthopedic Index (COI, divided into function, gait, stiffness, and quality of life), and digital thermography evaluation of the hip joint were evaluated before treatment, +8, +15, +30, +60 and +90 days after initial treatment. Results were analyzed with repeated measures ANOVA or Wilcoxon signed ranks test, p<0.05. Kaplan-Meier estimators were compared with the Breslow test. Results: Patients had a mean age of 8.3±1.9 years and bodyweight of 65.7±12.1lb. Osteoarthritis was classified as moderate (n=26) and severe (n=14). No differences were found at T0. Better results were observed in PBMT at +8d (p=0.01 for PSS, p=0.04 for function and COI), +15d (p=0.01 for PSS and function, p=0.02 for PIS and function, p=0.03 for COI and p=0.04 for LOAD) and +30d (p=0.01 for function and gait, p=0.02 for COI, and p=0.04 for PIS, PSS and LOAD). Joint range of motion improved in PBMT from +15d- to 90d. Lower values were recorded in both thermographic views of joints in the PBMT during the treatment period. Kaplan-Meier estimators showed that PBMT produced longer periods with better results. Conclusions: PBMT reduced pain levels and improved clinical findings (including functional scores) in dogs with moderate to severe hip osteoarthritis. The mean number of days that joints in the PBMT group took to return to baseline values was significantly higher than in CG (meloxicam) and also showed improvements in joint ROM sometimes out to +90 days after discontinuing treatment.
ARTHRITIS CASE STUDIES Osteoarthritis, Labrador Retriever Author(s): “Chambersburg Animal Hospital, Chambersburg, PA”
Scan the QR code to see Willow’s before and after video youtu.be/sPh_QS0nXzg?si=ocRQTarZRG476wb4
Signalment: 11 year old, F/S Labrador Retriever, “Willow” History: Chronic history of right forelimb lameness and difficulty “getting up and down” but owner presented dog for acute left forelimb lameness Ortho Exam: Grade 4/5 lameness left forelimb; left elbow joint capsule palpated thickened; decreased ROM and evidence of osteoarthritis in multiple joints Initial Diagnostics: Radiographs showed evidence of severe OA in left elbow joint • Laser Therapy: All between 8-12 W CW • 2000 Total Joules to each elbow • 2000 Total Joules to left shoulder • 2800 Total Joules to each stifle, hip(s) • 2800 Total Joules to lumbar spine Treatment Frequency: Twice weekly for 6 weeks Other Treatments: Adequan injectable; Tramadol. *Patient had previously been treated with Rimadyl but resulted in no improvement per owner, since patient was taking Temaril-P chronically for allergies, no NSAID was prescribed.
SEVERE BURSITIS AND OSTEOARTHRITIS, AMERICAN QUARTER HORSE GELDING Author(s): “Lisa Miller, DVM, CCRT”
Signalment: 26 year old American Quarter Horse Gelding, “Rio” Patient Symptoms: Severe bursitis and osteoarthritis of the elbow
Medical History: 2 IA injections of steroid + Hyaluronic Acid, systemic NSAID’s and chiropractic, joint support supplement in feed – No improvement noted (All treatments tried over a period of 8-12 weeks) Laser Treatment: 7,500 Joules each applied to the left elbow and left shoulder (15,000 Total Joules). (Palpated secondary soreness and swelling d/t weight shifting from lameness), beginning three times weekly, then weaning frequency as the patient improved. Patient Updates: After June 2013 Rio received maintenance laser treatments once weekly to his elbow 4-8 weeks for the following year and then only on an “as needed” basis. He is not on any systemic medications, just a chondroprotectant supplement in his feed daily.
WATCH THE BEFORE AND AFTER CASE VIDEO companionanimalhealth.com/publication/severe-bursitis-and-osteoarthritis,-american-quart
ADDITIONAL RESOURCES
[White Paper] THE ROLE OF PHOTOBIOMODULATION IN OSTEOARTHRITIS PATIENTS João C. Alves, DVM, MSc, PhD 6858913.fs1.hubspotusercontent-na1.net/hubfs/6858913/White%20Paper_Presentation%20PBMT%20OA_Eng.pdf
[Webinar] PLATELET-RICH PLASMA (PRP) AS PART OF A MULTIMODAL APPROACH TO OSTEOARTHRITIS MANAGEMENT Jeff Denny, DVM, CCRP, CVPP companionanimalhealth.com/webinar/platelet-rich-plasma-(prp)-as-part-of-a-multimodal/true
[Webinar] ELBOW ARTHRITIS - MEDICAL MANAGEMENT & LASER THERAPY Andrea Looney, DVM, DACVAA, CCRP, DACVSMR companionanimalhealth.com/webinar/elbow-arthritis---medical-management-&-laser-therapy/true
[Webinar] WHEN OSTEOARTHRITIS PATIENTS DON’T RESPOND TO TREATMENT Michael Petty, DVM, DAAPM, CVPP, CCRP, CVMA companionanimalhealth.com/webinar/when-osteoarthritis-patients-don%27t-respond-to-treatme/true
[Fireside Chat] OSTEOARTHRITIS FIRESIDE CHAT Andi Looney, DVM, DACVAA, CCRP, DACVSMR, Janice Huntingford, DVM, DACVSMR, CVA, CVPP, CCRT, CAVCA, Cara Blake, DVM, DACVS, CCRT, Candidate DACVSMR, Jill Bruno, CVT, CCRP, Lisa Miller, DVM, CCRT, CVA companionanimalhealth.com/webinar/osteoarthritis-fireside-chat/true
[Webinar] IDENTIFYING EARLY LAMENESS AND OSTEOARTHRITIS IN DOGS João C. Alves, DVM, MSc, PhD companionanimalhealth.com/webinar/identifying-early-lameness-and-osteoarthritis-in-dogs/true
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Companion’s products are backed by evidence, supported by education, and successfully implemented through Companion’s industry-leading commitment to long-term partnership.
References
1. Arthritis – the basics - Canine Arthritis Management. (n.d.). Canine Arthritis Management. https://caninearthritis.co.uk/ what-is-arthritis/arthritis-the-basics 2. Hardie, E. M., Roe, S. C., & Martin, F. R. (2002). Radiographic evidence of degenerative joint disease in geriatric cats: 100 cases (1994–1997). Javma-journal of the American Veterinary Medical Association, 220(5), 628–632. https://doi. org/10.2460/javma.2002.220.628 3. Alves, J. C., Santos, A., & Carreira, L. M. (2023). A preliminary report on the combined effect of Intra-Articular Platelet- Rich plasma injections and photobiomodulation in canine osteoarthritis. Animals, 13(20), 3247. https://doi.org/10.3390/ ani13203247 4. Alves, J. C., Santos, A., Jorge, P., Lavrador, C., & Carreira, L. M. (2022). Characterization of weight-bearing compensation in dogs with bilateral hip osteoarthritis. Topics in Companion Animal Medicine, 49, 100655. https://doi.org/10.1016/j. tcam.2022.100655 5. A randomized blind placebo-controlled trial investigating the effects of photobiomodulation therapy (PBMT) on canine elbow osteoarthritis. (2018, September 1). PubMed. https://pubmed.ncbi.nlm.nih.gov/30197438/ 6. Zein, R. E., Selting, W. J., & Hamblin, M. R. (2018b). Review of light parameters and photobiomodulation efficacy: dive into complexity. Journal of Biomedical Optics, 23(12), 1. https://doi.org/10.1117/1.jbo.23.12.120901
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