Cold Laser Equipment - 877-LASER-50 or 877-527-3750 (Anytime)

Introduction

Ground Rules and Safety

The most prevalent concern when using laser light treatment is that of eye exposure. The practitioner will typically have no problem understanding this but the patient may not. Eye protection is an absolute must during laser treatment. Use the recommended product rated to block the laser treatment wavelength in use. If your device uses lasers of multiple wavelengths be sure to have eye protection rated for all those wavelengths. Treating the face, especially near the eyes, presents a special challenge because of stray or reflected laser light that may cause eye exposure behind the protective glasses. You might have to get creative by adding solid ‘blinders’ made of cardboard or other opaque material to the sides of the protective glasses. Use of a hand (yours or the patients) can assist in blocking light as well. I do not use invisible light lasers near the face if at all possible. Typically, a red-light laser will work well on the shallow structures and a patient can tell you if the red light is visible behind the protective glasses. Invisible light would obviously never be detected and could unknowingly be damaging. Lastly, I have a sign posted on the door warning those who may unexpectedly attempt to enter the room during a laser treatment.

Your patients need to know that peeking around the glasses or just closing their eyes is never permitted during treatment. They have to be made keenly aware of the serious consequences that can result from eye exposure to laser light such as retinal damage and possible blindness. If you have any additional concerns regarding your patients’ understanding of this issue you may want to have them sign an informed consent including this information. Besides unwanted eye exposure there is also a maximum total body dose to be aware of. The recommended total dose of Cold Laser light daily is between 100 – 200 J. A Joule (J) is standard unit of measure when referring to laser energy exposure. See formulas under CALCULATIONS section for advice on determining exposure in Joules.

During the course of treatment the handheld laser device will possibly touch your patient. Therefore, infection control may be necessary. Because the equipment is electrically powered it cannot be simply washed. When I treat a patient the wand is typically a small, but defined, distance from the skin so contact is not really an issue. If necessary the housing can be cleansed with alcohol prep or other cold cleaning solution with the unit unplugged. Check with your manufacturer for advice. Use of a thin clear plastic bag around the laser wand can act as a disposable barrier. The smaller, single laser wands can be used with dental light curing covers. This is what your dentist uses to cover the dental composite filling curing light. I like to use these especially when there is an absolute possibility of contamination such as treating intra-orally or near open wounds.

Finally, you should not expose the area directly over the thyroid gland to Cold Laser light. It has been shown that laser energy can cause increased release of thyroid hormone which can result in an iatrogenic hyperthyroid condition. Remember that as people age the thyroid gland can have a more inferior position than in a younger person. Palpate carefully or avoid the region altogether!

Equipment

This guide references lasers marketed by Laser-Therapy.US. I started with the original desk top unit with two, single-element laser wands and moved to more powerful and multi functional equipment as it became available. You don’t have to get every piece of equipment just to get started. The lower powered, laser wands treat very well but take longer to treat commensurate with the lower wattage output. In any case all the equipment is reasonably priced so even a small practice can typically afford the advanced unit. Following is a summary and description of popular cold laser equipment listed at http://shop.coldlasers.com

There is one digital portable power supply currently available. You may see either the older style portable or desktop unit around but both have been replaced by the vastly superior digital programmable power supply. One of the limitations of the desk top unit is that it can only power the single-element lasers. It is functional but limited in use and not as easy to set-up as the portable type, or to use because it lacks a built in timer. The portable, programmable unit can power any Laser-Therapy wand including the newer units with multiple laser diodes. It has a built in timer that simplifies treatment. It has become my personal choice!

Power Wavelength Configuration Color of Light

5mw 635nm Single Laser Visible Red Light

50mw 650nm Single Laser Visible Red Light

150mw 808nm Single Laser Nearly Invisible

190 mw 635nm Nineteen Laser (19 x 10mw 635nm) Visible Red Light

315mw 635nm, 808nm Five Laser (3 x 5mw 635nm + 2 x 150mw 808nm)

Exposure and Dosage

There are some generalities that will help you to choose the correct wand. Red light lasers in the 635nm and 650 nm range are shallow-use lasers (< 1”). The 808nm (near invisible) wavelength light can penetrate much deeper (>1” – 1.5” in some instances). Think about a red light meaning STOP, and something invisible can go further undetected, as a memory aide. What really happens is that the red light is scattered and absorbed more by the color and density of the body so the light penetration is limited. The ‘invisible’ nature of 808nm wavelength light allows it to pass through tissue with less of the obstructive limitations that red light can face.

When I use the laser I hold it so that the red light is in focus and will appear as a pinpoint. This is how I keep my treatment consistent. Some will argue that I lose power this way but it really gives me latitude to adjust power and depth of treatment. If I want more power concentrated a little deeper I move the wand closer to the patient; and for less power over a wider area I move away. As you use this new form of treatment you will develop a feel for it and will know where you need to be. Of course, for nearly invisible laser light you have to find the focal point a different way because the point of light cannot be seen during treatment. While wearing protective glasses turn on the 808nm laser and aim it at the test card provided. You will easily be able to see the focal point because the test card allows the light to be visualized even through the glasses. You will have to remember what this distance is in your mind. However, you will become comfortable with positioning the laser very quickly.

Calculating dosage and remembering the power output of the different laser wands can be daunting for some; for others, easy. I suggest writing down the average recommended power settings and exposure times until you are comfortable with the protocols. You will quickly find what works in certain situations and will adjust your settings and notes accordingly. Eventually, the treatment process will become nearly second-nature and you will need to reference the settings for only the most infrequently treated areas. Others have reported using a line drawing of a human with dosage and settings noted on treatment areas.

Calculations

A Joule is one watt of energy delivered over one second of time. (watt/second)

A milliwatt is one thousandth of a watt. (1000mw = 1 watt)

Therefore you need to use the equivalent of 1000mw/second to deliver one Joule.

Treatment parameters are typically given by stating the energy in Joules delivered over a specific area. The common nomenclature used is Joules per centimeter squared or J/cm². A treatment point is considered to be one square centimeter in area. See the following examples and table showing the calculations for each laser wand.

Generic Equation for Calculation of Total Delivered Energy:

(Laser Power in mw) x (treatment time in seconds) / 1000 = total delivered energy in Joules. If you divide the total energy delivered by the area (cm²) you get the average energy delivered to each point.

Example: (150mw) x (20 sec.)/1000 = (3000 mw/s)/1000 = 3w/s or 3 Joules of energy.

If you evenly provided this energy over 3 cm² you delivered 1J/ cm²

The laser wavelength does not affect the power calculation.

Remember that all your combined totals need to be less than the maximum daily dose!

Wand Power Rating J/minute Time in Seconds to deliver 1Joule

5mw 0.3J 200

50mw 3J 20

150mw 9J ~6.6

190mw 11.4J ~5.2

315mw 18.9J ~3.2

These are calculations of energy delivery in a perfect world. However, there are many factors that can affect the actual delivered energy. Some you can control and others you cannot.

Factors That Can Adversely Affect Treatment

Incorrect rate of travel over treatment area: Use slow deliberate movement across the treatment area to evenly expose it. Don’t ‘scribble’ with light… instead paint with it.

Is the problem local or remote? This is commonly seen with such maladies as carpal tunnel syndrome. As an example the chief complaint might be “I have carpal tunnel syndrome”. However, the patient may really have cervical radiculopathy. Use your ability to test and diagnose so the appropriate area is treated instead of just pointing your laser towards the complaint. You still have to be a diagnostician!

Depth of target structure: The deeper the structure the more accurate you need to be in your aim. This is due to increased light scatter, absorption and reflectance from increased tissue density. Adjust your dosage based on whether the area is thicker or thinner than ‘average’, skin color and anatomical barriers.

Poor aim or treatment angle: Generally you should aim at a right angle to the target area. However, sometimes holding the laser at a lesser angle is advantageous especially to avoid having the light strike an anatomical obstruction. Treatment time may be extended due to the indirect path of light.

Incorrect laser wavelength: Generally higher wavelengths (non-visible) penetrate deeper. Visible light like the red laser treats shallow regions better. You can ‘overshoot’ just as easily as under treat. If I can lightly palpate and easily feel the area I need to treat; a red-light laser of 635nm or 650nm will work most times.

Obstructing anatomy: Any anatomical structure, especially bone, will impede your treatment efforts so adjust your angle and treatment times accordingly.

Skin type and color: Thin or lighter colored skin will be less of a photo-barrier than darker, thicker skin. Calluses and other benign skin lesion can decrease light energy, too. Adjust you treatment accordingly. You can reduce your treatment power by 3050% for the lighter/thinner skinned person and work up. This is also true when the treatment area is markedly inflamed or exquisitely tender i.e. Fibromyalgia. Darker individuals may need maximum treatment times or more treatments because of the reduction of light exposure due to skin pigment.

Jewelry or clothing: Anything that reflects or blocks light can reduce treatment effectiveness. Have the patient remove the jewelry and store in a safe place. A patient gown may be necessary when clothing is removed.

Light sensitivity: Examples of conditions which can involve light sensitivity include Lupus, and Porphyria. Use of certain medications such as antibiotics (i.e. Tetracycline) and some antihistamines increase light-sensitivity, too. When in doubt, consult with a dermatologist or other specialist involved in the care of the patient who may have made the initial diagnosis. You may need to use an alternate method of treatment. I also avoid areas that appear infected or are suspected of being cancerous.

Hair: Hair is an anatomical obstruction that can directly block or absorb light. Use a thin, single element wand to go between hair strands when treating the head. Other hairy bodily areas will require adjustment of treatment dose accordingly. You should cover your laser to keep it clean.

Skin applications (makeup, oils, sun block): This one should be an easy fix. Clean off the offending agent and remind your patient not to apply these items before treatment. Even makeup remover can pose a problem. Anything that physically blocks or reflects light will hamper your treatment efforts. I clean treatment areas with 70% rubbing alcohol diluted equally with water in a spray bottle, as tolerated by the patient. Other practitioners have found alcohol prep pads to be more convenient. If a chemical peel has been applied or inflammation is present I would not treat with laser until the face has completely healed.

Treatment Procedure

Choose your treatment exposure based on W.A.L.T. treatment suggestions initially and then as your own experience leads you; staying within the safe limits of maximum exposure. Everyone in the room needs to have appropriate eye protection. Turn on the laser and aim the beam at the target area moving it slowly to evenly expose the treatment area for the specified time. You should move over the area several times averaging the exposure based on your J/cm² calculation. Reevaluate!

Treatment Goals

Treatment goals will be different based on the patient’s condition. In general you would like complete resolution of the malady but that is not always possible. You can be looking for a decrease in inflammation or pain, improved range of motion, circulation or neurologic function. Whatever your goal is, it is important to compare the result to the original complaint.

Once in a while a patient will say there is little, if any, improvement when really there has been a major change albeit only one. This may be due to the invisibility of, and inability to, feel a Cold Laser treatment. Therefore, your patient may believe nothing has happened! Sometimes, there may be such an improvement in function that the patient starts to over-use the treated body part unconsciously. They might say that the area in question still fatigues easily or has pain after activity. Reminding them that they could do little or were inactive before treatment can provide the reality check necessary to show there has been improvement. Educate your patients on posture, ergonomics, use of assistive devices, or whatever is necessary to prevent injury exacerbation or additional injury. Also, partial resolution of dysfunction is always better than no improvement at all. This is especially true in chronic situations. Use of a pain scale or other objective form of rating function can be invaluable.

Tips, Tricks and Troubleshooting

Even though there may be complete resolution of dysfunction from the first treatment your work may not be finished. Often there will be improvement followed by the same complaint from the patient within a short period of time. Likewise, there may be a time where there is absolutely no improvement. For both these reasons you should treat at least three times. This will provide completeness for the issue that resolved and additional effort for the recalcitrant dysfunction. Maintenance treatments can be given weekly as needed. Chronic complaints may require treatment as often as every day, at least initially. Be sure to evaluate why the treatment may not be working as planned by consulting the ‘Common Factors Affecting Treatment’ listed above.

Patient position is an important consideration as is your own comfort. Be sure to position the patient such that you can effectively treat the area(s) in question. This means you should be comfortable for an extended period of time while able to move the target area through a range of motion as necessary for anatomical access.

You need to know what power you are delivering to the target area, what area you are covering and what settings to use. If you provide too little or too much light to a given area the treatment effect can be equally inadequate. Resist the temptation to ‘just give a little more’ unless you are sure that a low-dose is really the problem. My grandmother always said “too much is like not enough”! That is so true when treating with Cold Laser.

I don’t believe there are many practitioners who can accurately estimate treatment area in square centimeters. This is an important skill so while you are getting used to treating with a laser, apply a paper ruler marked in cm to the laser wand. I did this by copying a small pharmaceutical information card with a ruler printed on it. Then I cut out the ruler part so it would fit on the wand and affixed it with tape for an easy size reference.

If you use the five element laser it is a good idea to know where the 808nm150mw diodes are positioned in relation to the 635nm-5mw diodes. I made small marks with white nail polish on the side of the wand denoting the position of the two most powerful lasers in the array since they will do the lion’s share of the work. Another colored mark half-way between the white marks, helps me to quickly orient the same two lasers horizontally. You will get used to seeing the other three red lasers in a certain pattern which also can also help you with orientation. Flash cards or labels can help to remind you of certain settings and power outputs for each wand. Keep them with the laser.

For the most part you will use the factory established pulse setting of 12Hz. The laser is designed to pulse because the impulse is greater when a laser is first energized so each pulse is stronger than when on continuously. I have found it beneficial to occasionally set the pulse rate to 20Hz especially with the 808nm laser wand and a deep target zone. Tough to treat areas under thickened skin or edematous regions may respond better with this pulse setting.

Be sure that your laser is operating properly. This is especially true when using lasers that are essentially invisible because you cannot be sure if there is light being emitted. Use the test card supplied with your laser to ‘prove’ it is emitting light. If your laser is powered by a battery, charge it often even if it has only been lightly used. Refer to the manufacturer’s recommendations. Some lasers use adapters to retrofit older wands to newer power supplies. Be sure you have the correct adapter in place and consult the manufacturer as necessary.

Summary

Cold Laser Treatment is an exciting modality that I cannot be more pleased to have added to my practice regimen. This guide is extensive and, as such, may make Cold Laser treatment appear too complicated. The information is meant to be as complete as possible to help you through some of the possible pitfalls. However, pitfalls are rare and I believe you will find it is relatively easy to get started and obtain satisfactory results. Soon you will have no trouble developing a gestalt of the patients’ complaints as you have done many times before; only this time with Cold Laser in mind. A Cold Laser treatment plan, if indicated, will be as easy to formulate as it was to decide what pain medication to prescribe. Treating without medication, when possible, is an experience that is rewarding for both you and your patient. Only when you run into the occasional difficulty will you have to look to this guide for detailed advice. With enough experience this will become a thing of the past. Start slowly and do not try to cram all the settings into your head all at once. Use the W.A.L.T. table found at this link: http://www.walt.nu/images/stories/files/dosage-table-780-860nm.pdf to get you started with settings and treatment times. The W.A.L.T table concentrates on common musculoskeletal disorders. This is how I started and had a successful treatment the very first time I used my new laser! Adjust your settings as necessary based on the suggestions made above as well as your own experience. As with anything new you will wonder if you are doing the treatment correctly. Positive results will be realized very soon and you will know you are on your way to using this form of treatment for a very long time.

Finally, continue to enrich your laser therapy knowledge base by joining the World Association for Laser Therapy. You will have members from around the world to assist you. You can draw from their experience as well as referencing W.A.L.T.’s amazingly information-dense scientific journal: Photomedicine and laser Surgery.

May you find the health within your patients!

JOHN B. CARAMAGNA, D.O., PLLC

Important Disclaimer & Additional Information

The use of Cold Laser is considered the practice of medicine by certain entities. While a safe approach to treatment it is not completely innocuous and, as such, one should have a thorough understanding of safe practices and techniques involved in the use of laser equipment. This guide should not be considered medical advice and it does not guarantee specific results. The information provided is strictly for informational purposes only and not for the diagnosis, treatment, cure, mitigation or prevention of disease. Also, you must be properly authorized to use laser equipment and comply with local laws of practice. This guide cannot be all-inclusive and is not meant to be fully educational or replace common medical practice. Considering the type of equipment used and your methods of using it cannot be controlled or monitored, the operator of such laser equipment bears full responsibility for its use and results of that use.