Phototherapy Treatment Guidelines

Phototherapy Treatment Guidelines P/N 000-155

Treatment Guidelines An Introduction to the RICH-MAR Phototherapy System Having chosen RICH-MAR Phototherapy (Laser and Light Therapy) we hope you'll come to think of this little blue hand book as a companion and guide A resource informed by 35 years of world-wide research, thousands of published papers and more than a decade of design, development, manufacture, research and, best of all, direct clinical experience The RICH-MAR s Treatment Manual s highly effective protocols were developed exclusively for the use of RICH-MAR Phototherapy devices which incorporate the use of Super Luminous Diode (SLD) and Low Level Laser Therapy (LLLT)* VER 13 RICH-MAR 2009 The RICH-MAR Treatment Manual is organized into 5 "Chapters", "head to foot" anatomical zones These detailed protocols demonstrate specific treatments for more than sixty five common conditions The balance of this chapter briefly outlines the science, how to follow the guidelines, treatment principles and references used For a complete profile of RICH-MAR products and more visit us at: wwwrichmarwebcom Should you have any questions, do not hesitate to contact us at: info@richmarwebcom 1 8885494945 * variously referred to as cold laser, low intensity laser or therapeutic laser

Treatment Guidelines Mechanism of Action Phototherapy is a physical therapy modality using photons (light) in very specific regions of the electromagnetic spectrum Photons of near infrared wavelengths 1 and visible red 2 used in RICH-MAR devices penetrate the skin stimulating a cascade of clinical benefits 2 Light energy, absorbed by elements in mitochondria, cell membrane and other proteins, is converted into biological energy, inducing the processes detailed in the accompanying diagram Understanding these Mechanisms of Action can assist in significantly enhancing your patient's outcomes Phototherapy is both an art and science The relevant research as well as your own clinical observations helps to inform best practice See the excellent resources listed at the end of this section It is the special combination of RICH-MAR LLLT and SLD that provides the balanced distribution of light energy needed to initiate these Mechanisms of Action, enhancing the body's ability to heal itself The coherent, focused near infrared laser energy penetrates deeply to treat deeper target tissue The SLD delivers a non-coherent, broader, evenly distributed visible red and infrared energy over a much larger area for local and regional effects This combinaton of deeper and broader treatment areas enhances healing, decreases pain and normalizes cell function VER 13 RICH-MAR 2009 It is this balanced approach to treatment that is detailed in the illustrated RICH-MAR Guidelines which follow 1 785nm, 808nm and 870nm 2 633nm

3 Phototherapy Mechanism of Action L A S E R L I G H T, P H O T O N E N E R G Y Diffuse scattering of laser light in tissue produces interference and speckle formation P R I M A R Y Volumes of partially polarized light are formed Absorption of polarized light in cytochrome molecules (eg porphyrines) stimulates the creation of singlet oxygen Points of high laser light intensity appear In points of high intensity the probability is higher for multiphoton effects The electrical field across the cell membrane creates a dipole moment on the bar-shaped lipids Areas of high difference in light intensity levels Local differences in intensity create temperature and pressure gradients across cell membranes VER 13 RICH-MAR 2009 I N F L U E N C E S S E C O N D A R Y M E C H A N I S M S Increases of ATP-ase Activation of camp and ENZYMES Triggers IMMUNE RESPONSE Increase of PROCOLLAGEN SYNTHESIS in FIBROBLASTS Increases ENDOTHELIAL CELLS and KERATINOCYTES Enhancement of SRF Activates MACROPHAGES Increases number of MAST CELLS Influences the permeability of CELL MEMBRANES, which effects Ca2+, Na+, and K+ as well as the proton gradient over the mitochondria membranes Increases SEROTONIN SYNTHESIS Enhancement of SOD Increased RECEPTOR ACTIVITY on cell membranes Enhances ENDORPHIN SYNTHESIS Decreases C-FIBER ACTIVITY Increases NERVE CELL ACTION POTENTIAL RESTORES HOMEOSTASIS Increased local microcirculation, accelerated tissue repair, reduced pain, decreased inflammation/edema, enhanced immune response and angiogenesis Decreases BRADYKININE W O U N D H E A L I N G ACCELERATED P A I N I N F L U E N C E INFLAMMATORY PROCESS This chart has been modified from "The Laser Therapy:Handbook, 2004, with permission of Jan Tunér and Lars Hode

Treatment Guidelines Headache Guidelines Explanation 4 MENT SCHEDULE MIGRAINE TENSION CERVIOCOGENIC X per WEEK # of WEEKS daily PRN 2-3 4-6 2-3 4-6 BILATERAL MENT Below mastoid process, semispinalis, upper trapezius and sternocleidomastoid muscles VER 13 RICH-MAR 2009 10-16 10-16 Pulsed @ low 0100-0160 0101-0161 JOULES dose PULSING joules mode CONSOLE SETTING 8-14 8-14 Pulsed @ low 0080-0140 0081-0141 Select 4-6 sites based upon pathology Trigger points; semispinalis, upper trapezius, sternocleidomastoid muscles and points of tenderness For retro-orbital headaches treat Liv 3 and LI 4 acupuncture points

Treatment Guidelines 5 Guideline Explanation ABLE CONDITIONS Related clinical conditions are clustered and treated with a similar protocol The selection of treatment sites vary based upon the assessment, diagnosis and outcomes MENT SCHEDULE Generally, for the first week: Treat up to 5 x per week then to the lower range by week 2 Acute conditions can be treated 1-2 x daily as warranted Chronic conditions: Longer duration and less frequent treatments (2-3x weekly) LASER, SLD, LASER + SLD ICONS Use treatment sites for both Laser and SLD, providing a comprehensive approach Based on the pathology select the most appropriate treatment sites Also refer to Treatment Notes at bottom of the protocol page BILATERAL MENT For purposes of clarity, treatment sites for Laser and SLD have been illustrated on one side of the body only Treat bilaterally as required Additional information to assist with using the specific treatment guideline VER 13 RICH-MAR 2009 JOULES A joule is a unit of energy One joule is the equivalent of one watt of power radiated or dissipated for one second (eg 200mw Laser Cluster delivers one joule per 5 seconds 500mW SLD Cluster delivers one joule/cm 2 per 45 seconds) Time is automatically set with dose selection PULSING Photon energy can be delivered in a continuous stream or pulsed (bursts of energy per second) Guidelines provide both continuous (black) and pulsed settings (grey) for treatment See following pages for further treatment details RICH-MAR pulsed settings: 1 - Low = 8 pulses / second, 2 - Medium = 146 pulses / second and 3 - High = 1000 pulses / second Pulsed mode and continuous mode can be alternated between sessions DEVICE SETTINGS Consult your RICH-MAR Operation Guide for full operational details for the specific RICH-MAR devices For the RICH-MAR Console setup, the numerical sequence listed is a rapid method of programming the treatment console settings and must be used under the "Manual" 'O' category Example: 0 10 0 Manual Setting Joules or Pulsed (1-3) Note: For the Portable Laser once dose is selected, it delivers the dose then automatically shuts off Each audible beep indicates one joule has been delivered and three rapid beeps indicate the treatment cycle is complete

Treatment Guidelines Treatment Principles The delivery of light energy and the dose required to treat target tissue is influenced by a number of factors Consult the RICH-MAR Treatment Manual as a starting point for a range of suggested doses 6 Starting with the smallest dose in the protocol add additional joules of energy based upon the following parameters: Age - small children & frailty (eg dehydrated older patients), use smallest dose in the protocol Size of treatment area - larger areas require combined SLD & Laser treatment for beneficial local and regional effects Pigmentation - melanin in darker skin absorbs more energy at the surface, requiring a larger dose for deeper target tissue Depth of target tissue - deeper target tissue requires more energy to deliver therapeutic dose (gentle pressure = greater penetration) Type of tissue - Adipose tissue (less vascular) requires less energy than muscle mass (more vascular) for energy penetration to target tissue vs Pulsed Wave Mode Use continuous mode for acute conditions Generally use 1 - Low setting for chronic conditions Change from continuous to pulsing (or vice versa) when: a) there is no treatment response after a few treatments or b) positive progression hits a plateau Based on the literature, the following pulsed settings have been programmed into the RICH-MAR Console System: VER 13 RICH-MAR 2009 Option 1 = 8 Hz Pain, Neuralgia Option 2 = 146 Hz General Stimulation, Trigger points Option 3 = 1000 Hz Edema, Inflammation

Treatment Guidelines 7 Comprehensive Treatment A comprehensive treatment approach results in more rapid, successful outcomes (Generally a minimum of 2 approaches should be used) Assessment, diagnosis and testing results will determine which of the following areas require treatment: Entire injured or affected area Nerve root or superficial nerve trunks Motor or trigger points Referred areas of pain Acupuncture and / or auricular points For extensive edema, treat proximal (centrally) to distal (towards extremities), to open up the lymphatic pathway to enhance drainage VER 13 RICH-MAR 2009 Treatment Steps Degrease skin by cleansing with soap and water or alcohol Broken skin, cover cluster or area with clear plastic wrap for barrier Position patient for most direct access to target tissue Use protective goggles when using the laser, not required with SLD treatment Position laser or SLD in direct, firm skin contact, directing energy towards target tissue Do not move device during treatment, keep in one position until completed Treatment Schedule Acute Conditions - Treat daily to 3 times weekly until significant symptom relief is achieved, especially for patients with trauma, herniated discs and acute back pain Treatment may last 1-3 weeks with 6-15 treatments With competitive athletes, treatment may be delivered 2-3 times per day with a minimum of 2-4 hours between sessions, for rapid response Once sufficient improvement or pain relief is achieved, treat 2-3 times per week and decrease dosage for healing until achieving significant improvement or full resolution

Treatment Guidelines Treatment Schedule (cont d) Chronic Conditions - Treat 2-3 times weekly, up to 15-25 treatments Maintenance treatment may be required for chronic degenerative conditions Consistent schedule of treatments augment the accumulative effects enhancing outcomes 8 Occasionally, pain can increase following the first few treatments, (2-4 hours post treatment until the next day) This is referred to as a 'treatment reaction', an indication that the light energy may have "pushed" the chronic condition into a sub-acute phase of healing Forewarn patients so ice or analgesics can be used Once this pain subsides, pain levels are generally less than pre-treatment ratings Next session, decrease treatment dose by 50% and gradually increase over time Frail individuals, small children and patients with degenerative rheumatoid arthritis, fibromyalgia or other autoimmune conditions, should be treated initially with smaller doses Gradually work up to full dosage Patients may initially state they feel "fatigued" by treatment Constant re-testing and clinical outcomes dictate when patients are discharged Use of Other Modalities Other modalities may be unnecessary with phototherapy If combining modalities, treatment sequence is important: VER 13 RICH-MAR 2009 If icing, use before phototherapy (vasoconstriction decreases blood flow, improving light penetration) If massage or heat generating therapy (eg ultrasound, e-stim) is used, apply after phototherapy (vasodilation increases blood flow, diminishing penetration of light)

Treatment Guidelines 9 Contraindications Do not treat: Directly into the eyes (retinal exposure to Class 3B laser, may cause eye damage) (Does not apply to SLD) Over a pregnant uterus Over any suspicious lesion or active cancer Over thyroid gland Over an area injected with steroids or other anti-inflammatory medication within the past 72 hours References Baxter D, Therapeutic Lasers: Theory & Practice, 1994 Kert J & Rose L, Clinical Laser Therapy, 1989 VER 13 RICH-MAR 2009 Oshiro T & Calderhead R, Low Level Laser Therapy, 1988 Pöntinen P, Low Level Laser Therapy as a Medical Treatment Modality, 1992 Tunér J & Hode L, The Laser Therapy Handbook, 2004 Siminovic Z, Lasers in Medicine and Dentistry, 2000 Websites wwwlasernu wwwnaaltorg wwwwaltorg wwwnasagov wwwdarpamil wwwrichmarwebcom RICH-MAR wwwrichmarwebcom 4120 South Creek Road, Chattanooga, TN 37406 info@richmarwebcom 8885494945 service@richmarwebcom These Treatment Guidelines have been prepared for international use Each clinician must ensure that the particular treatments employed comply with any restrictions as specified by local, professional and regulatory agencies

Copyright 2009 RICH-MAR Inc All rights reserved This book is protected by copyright No part of this book may be reproduced in any form or by any means, including photocopying, or utilized by any information storage and retrieval system without written permission from the copyright owner The publisher is not responsible (as a matter of product liability, negligence or otherwise) for any injury resulting from any material contained herein This publication contains information relating to general principles of medical care which should not be construed as specific instructions for individual patients Manufacturers' product information and package inserts should be reviewed for current information, including contraindications, dosages and precautions First Edition 2009 P/N 000-155 Credits Anita Saltmarche RN, BScN, MHSc HealthCare Associates Toronto Dr Nimet Meghji Optimum Health Centre Toronto David Saltmarche Design Toronto Guideline Research and Development Clinical Consultant Design, Illustration, Digitals

Head & Neck Cervical Spine Facial Pain Headache Temporomandibular Joint Dysfunction Sinusitis HerpesSimplex Shoulder & Arm Shoulder Elbow Hand Carpal Tunnel Syndrome Spine & Hip Thoracic Spine Lumbosacral Hip Herpes Zoster Leg & Foot Knee Ankle & Foot Plantar Fasciitis Other Fibromyalgia Wounds Charts of Acupuncture Points

Head & Neck SLD Laser SLD and Laser

Cervical Spine MENT SCHEDULE TORTICOLLIS WHIPLASH INJURIES FACET JOINT SYNDROME CERVICAL RADICULOPATHY HERNIATED DISC OSTEOARTHRITIS REFLEX SYMPATHETIC DYSTROPHY X per WEEK # of WEEKS daily PRN 3 4-8 2-3 2-4 2-3 4-6 2-3 4-6 2-3 4-8 2-3 4-6 VER 13 RICH-MAR 2009 BILATERAL MENT Areas of pathology: including para-cervical muscles from C1-T2 Select appropriate SLD cluster positions Treat bilaterally or unilaterally based on symptoms 12-18 12-18 JOULES dose Pulsed @ me PULSING 0120-0180 0122-0182 joules mode CONSOLE SETTING CONSOLE code SETTING 10-18 10-18 Pulsed @ me 0100-0180 0102-0182 Areas of pathology and pain: including para-cervical nerve roots from C1-C7 Trigger points or tender points: mastoid process, semispinalis, upper trapezius and along the posterior margin of the SCM muscles Additional acupuncture points: LI 4 and Si 3

Facial Pain MENT SCHEDULE BELL'S PALSY ATYPICAL FACIAL PAIN TRIGEMINAL NEURALGIA (V1, V2, V3) POST HERPETIC NEURALGIA X per WEEK # of WEEKS 3 3-6 2-3 3-6 3 3-6 3-5 2-4 V1,2 V3 V2 V1 V1 V3 V2 V3 VER 13 RICH-MAR 2009 Over TMJ and masseter muscle Treat bilaterally 6-20 6-20 JOULES dose 6-16 6-16 Pulsed @ low PULSING Pulsed @ low 0060-0200 0061-0201 joules mode CONSOLE SETTING 0100-0160 0061-0161 Trigger/acupuncture points Select 4-6 points based on symptoms

Headache MENT SCHEDULE MIGRAINE TENSION CERVIOCOGENIC X per WEEK # of WEEKS daily PRN 2-3 4-6 2-3 4-6 VER 13 RICH-MAR 2009 BILATERAL MENT Below mastoid process, semispinalis, upper trapezius and sternocleidomastoid muscles 10-16 10-16 Pulsed @ low 0100-0160 0101-0161 JOULES dose 8-14 8-14 PULSING Pulsed @ low joules mode CONSOLE SETTING 0080-0140 0081-0141 Select 4-6 sites based upon pathology Trigger points: semispinalis, upper trapezius, sternocleidomastoid muscles and points of tenderness For retro-orbital headaches treat Liv 3 acupuncture point

MENT SCHEDULE Temporomandibular Joint Dysfunction (TMJ) X PER WEEK # WEEKS 2-3 4-6 VER 13 RICH-MAR 2009 TMJ, masseter and temporalis muscles, bilaterally Select cluster sites appropriate to pathology 10-20 10-20 Pulsed @ me 0100-0200 0102-0202 JOULES dose 6-12 6-12 PULSING Pulsed @ me joules mode CONSOLE SETTING 0060-0120 0062-0122 TMJ (mouth closed) and posterior aspect of joint (mouth open) Trigger points: masseter and temporalis muscles Treat bilaterally

Sinusitis MENT SCHEDULE ALLERGIC SINUSITIS MAXILLARY SINUSITIS X per WEEK # of WEEKS 1-2x daily as required VER 13 RICH-MAR 2009 JOULES dose 6-8 6-8 PULSING Pulsed @ low joules mode CONSOLE SETTING 0060-0080 0061-0081 Over the maxillary and frontal sinuses bilaterally, as indicated

Herpes Simplex MENT SCHEDULE X per WEEK # of WEEKS 1-2x daily until resolved VER 13 RICH-MAR 2009 Lesion using direct contact Cover SLD cluster with clear plastic wrap 6 0060 JOULES dose PULSING joules mode CONSOLE SETTING 6 0060 Treat tender lymph nodes

Shoulder & Arm SLD Laser SLD and Laser

Shoulder MENT SCHEDULE ARTHRITIS DELTOID TENDONITIS SUBDELTOID BURSITIS BICIPITAL TENDONITIS IMPINGEMENT SYNDROME ROTATOR CUFF SYNDROME SUPRASPINATIS TENDONITIS ADHESIVE CAPSULITIS (FROZEN SHOULDER) X PER WEEK # WEEKS 2-3 4-8 2-3 3-6 2-3 3-6 2-3 3-6 2-3 3-6 2-3 3-6 2-3 3-6 2-3 3-6 VER 13 RICH-MAR 2009 Surround area of pathology, potentially including trapezius muscle, insertion sites and trigger points for supraspinatus, infraspinatus, teres major, anterior and posterior joint capsule 10-20 10-20 JOULES dose 10-20 10-20 Pulsed @ me PULSING Pulsed @ me 0100-0200 0102-0202 joules mode CONSOLE SETTING 0100-0200 0102-0202 Over area of pathology Acupuncture points Li 14, 15, 16, TW 14 and Si 11

Elbow MENT SCHEDULE MEDIAL EPICONDYLITIS LATERAL EPICONDYLITIS OLECRANON BURSITIS X per WEEK # of WEEKS 3 3-6 3 3-6 3 2-4 MEDIAL LATERAL VER 13 RICH-MAR 2009 Over area of pathology, medial or lateral epicondyle or bursa If pain radiates, treat along the involved muscle 10-16 10-16 Pulsed @ high 0100-0160 0103-0163 JOULES dose 8-16 8-16 PULSING Pulsed @ high joules mode CONSOLE SETTING 0080-0160 0083-0163 Medial epicondyle and flexors Lateral epicondyle and extensors If pain is present on palpation, repeat treatment up to 3 times Lateral may require larger treatment doses

Hand MENT SCHEDULE FRACTURES OSTEOARTHRITIS RHEUMATOID ARTHRITIS DE QUERVAIN'S TENOSYNOVITIS X per WEEK # of WEEKS 3-5 2-4 2-3 4-8 2-3 4-6 2-3 4-6 VER 13 RICH-MAR 2009 Dorsal and palmar aspects of affected areas 10-14 10-14 JOULES dose 8-14 8-14 Pulsed @ me PULSING Pulsed @ me 0100-0140 0102-0142 joules mode CONSOLE SETTING 0080-0140 0082-0142 Dorsal and palmar side of site(s) including trigger point on thenar muscle * Additional acupuncture points: SP 6 (immune point for RA)

Carpal Tunnel Syndrome MENT SCHEDULE X per WEEK # of WEEKS PERIPHERAL NERVE COMPRESSION 3 4-8 BILATERAL MENT VER 13 RICH-MAR 2009 Over transverse carpal ligament and thenar muscle Follow the course of the median nerve based upon symptoms Also treat C5-T1 10-14 10-14 Pulsed @ me 0100-0140 0102-0142 JOULES dose 8-14 8-14 PULSING Pulsed @ me joules mode CONSOLE SETTING 0080-0140 0082-0142 Over area proximal to flexor retinaculum to mid palm following the course of the median nerve If pain radiates up arm, follow along median nerve Also treat para-cervical region and tender points along SCM muscle Additional acupuncture point Li 4

Spine & Hip SLD Laser SLD and Laser

Thoracic Spine MENT SCHEDULE MYOFASCIITIS COSTOCHONDRITIS COMPRESSION FRACTURE X per WEEK # of WEEKS 2-3 4-6 2-3 2-4 3-5 2-4 VER 13 RICH-MAR 2009 BILATERAL MENT Select one or more SLD cluster positions as indicated by pathology Repeat until affected area is covered 12-20 12-20 Pulsed @ me 0120-0200 0122-0202 JOULES dose 10-20 10-20 PULSING Pulsed @ me joules mode CONSOLE SETTING 0100-0200 0102-0202 Trigger points, below mastoid process, semispinalis, trapezius and rhomboid muscles

Lumbosacral MENT SCHEDULE DISC HERNIATION SCIATIC NEURALGIA LUMBAR FACET SYNDROME LUMBOSACRAL STRAIN/SPRAIN SACROILIAC JOINT DYSFUNCTION OSTEOARTHRITIS + - FORAMINAL STENOSIS X per WEEK # of WEEKS 3-5 4-8 2-5 4-8 2-3 2-4 2-3 2-4 2-3 2-4 2-3 4-8 VER 13 RICH-MAR 2009 BILATERAL MENT Treat bilaterally or unilaterally based upon pathology Select appropriate SLD cluster sites Apply over SI joint if involved If required, increase pulsing to high 14-20 14-20 Pulsed @ high 0140-0200 0143-0203 JOULES dose 6-20 6-20 PULSING Pulsed @ high joules mode CONSOLE SETTING 0060-0200 0063-0203 Over SI joint and a total of 4-6 points based upon pathology Acupuncture points: GB 34, GB 30, ST 36, BL 57, BL 60 and SP 6

Hip MENT SCHEDULE OSTEOARTHRITIS CAPSULITIS TROCHANTERIC BURSITIS X per WEEK # of WEEKS 2-3 4-8 2-3 3-6 2-3 3-6 VER 13 RICH-MAR 2009 BILATERAL MENT Anterior and posterior hip Repeat over lateral hip At least one pulsed setting should be used 10-20 10-20 Pulsed @ high 0100-0200 0103-0203 JOULES dose 10-20 10-20 PULSING Pulsed @ high joules mode CONSOLE SETTING 0100-0200 0103-0203 Anterior, posterior and lateral hip can be treated with both SLD and Laser simultaneously

Herpes Zoster (Shingles) MENT SCHEDULE Initially Follow-up X per WEEK # of WEEKS 2-4 3 4-8 VER 13 RICH-MAR 2009 Cover cluster with clear plastic wrap prior to treatment Treat involved nerve root(s) and dermatomes Initially hold cluster 5-1 inch above lesions until sufficient pain control achieved When possible, use direct skin contact 10-14 10-14 JOULES dose 8-12 8-12 Pulsed @ me PULSING Pulsed @ me 0100-0140 0102-0142 joules mode CONSOLE SETTING 0080-0120 0082-0122 Cover Laser with clear plastic wrap prior to treatment Treat the involved nerve root(s) and dermatomes Initially treat 5-1 inch above lesions until sufficient pain control achieved When possible, use direct skin contact Acupuncture points: Li 4, ST 36, K 3 and P 6

Leg & Foot SLD Laser SLD and Laser

Knee MENT SCHEDULE OSTEOARTHRITIS CHONDROMALACIA PATELLA LIGAMENTOUS INJURIES OSGOODE SCHLATTER S DISEASE MENISCUS INJURIES POST-OP REHAB X per WEEK # of WEEKS 2-3 4-8 2-3 4-6 2-3 3-6 2-3 3-6 2-3 3-6 3-5 4-6 VER 13 RICH-MAR 2009 Treat with knee flexed to open up joint space Treat over joint line and include upper quadrant and popliteal space if indicated by pathology 10-18 10-18 JOULES dose 8-18 8-18 Pulsed @ high PULSING Pulsed @ high 0100-0180 0103-0183 joules mode CONSOLE SETTING 0080-0180 0083-0183 Medial and lateral joint lines and other sites of pathology

Achilles Tendonitis MENT SCHEDULE X per WEEK # of WEEKS 3 4-6 VER 13 RICH-MAR 2009 Over tendon insertion at calcaneus Medial and lateral aspects of Achilles tendon 12-18 12-18 JOULES dose 8-18 8-18 Pulsed @ me PULSING Pulsed @ me 0120-0180 0122-0182 joules mode CONSOLE SETTING 0080-0180 0082-0182 Tendon insertion at calcaneous and origin of soleus and gastrocnemius muscles

Ankle & Foot MENT SCHEDULE SOFT TISSUE INJURIES ANKLE SPRAIN OSTEOARTHRITIS BUNION FRACTURE REFLEX SYMPATHETIC DYSTROPHY X per WEEK # of WEEKS 2-3 3-4 3-5 3-6 2-3 4-8 2 2-4 3-5 2-4 2-3 4-6 VER 13 RICH-MAR 2009 Over affected area(s) With extensive swelling, first treat lymphatic drainage in groin, posterior knee and finally, injury site 10-18 10-18 Pulsed @ me 0100-0180 0102-0182 JOULES dose 6-18 6-18 PULSING Pulsed @ me joules mode CONSOLE SETTING 0060-0180 0062-0182 2-4 most painful points over affected area(s)

Plantar Fasciitis MENT SCHEDULE X per WEEK # of WEEKS 2-3 3-6 VER 13 RICH-MAR 2009 Over insertion of fascia at metatarsals and origin of plantar fascia at calcaneus 12-18 12-18 JOULES dose 10-18 10-18 Pulsed @ me PULSING Pulsed @ me 0120-0180 0122-0182 joules mode CONSOLE SETTING 0100-0180 0102-0182 3-5 most painful areas, including over insertion of fascia at metatarsals and origin of plantar fascia at calcaneus

Other SLD Laser SLD and Laser

MENT SCHEDULE Fibromyalgia 3 X per WEEK # of WEEKS 4-6 VER 13 RICH-MAR 2009 BILATERAL MENT 8-12 8-12 JOULES dose 6-10 6-10 Pulsed @ low PULSING Pulsed @ low 0080-0120 0081-0121 joules mode CONSOLE SETTING 0060-0100 0061-0101 Option 1: Treat tender points: suboccipital area, lower cervical spine (transverse process of C5-C7), upper trapezius, supraspinatus, 2nd rib (costochonial junction), lateral epicondyle (2 cm distal), gluteal, greater trochanter of femur, medial fat pad at the knee Option 2: Treat as indicated on diagram Monitor patient's level of fatigue and decrease time per site if needed Do not exceed a total of 60 joules laser energy

1 Wound Healing Introduction Research indicates that phototherapy can accelerate wound and tissue repair by as much as 30% - 40% Best results are acheived when phototherapy is an adjuct to an evidencebased Wound Care Program Phototherapy can be used in conjunction with all types of dressings and types of wound regardless of stage The Mechanism of Action diagram (Introduction pg 3) outlines the physiological activities that are stimulated by phototherapy The cumulative effect of the multiple inter-active processes and events is an accelerated inflammatory cycle with diminished symptoms and earlier normalization VER 13 RICH-MAR 2009 Since phototherapy does not exacerbate the inflammatory process but rather condenses the time frame from onset to resolution through acceleration of processes, it can be used immediately post injury Rapid initiation of therapy in acute inflammation assists in limiting the scope and duration of the inflammatory event and minimizes the pain and severity associated with it Most of the beneficial phototherapy effects seen in acute inflammatory events are also initiated in more chronic inflammatory conditions, such as chronic wounds The light energy accelerates and enhances healing activities carried out by the body Several of the unique characteristics of phototherapy that work to alleviate pain and inflammation also play an important role in accelerating the healing process Phototherapy positively impacts the wound healing progress through the stages of inflammation, proliferation, remodeling and maturation, in open surface wounds as well as closed connective or soft tissue injuries

Wound Healing Treatment Protocols 2 Remove and discard dressing Cleanse wound bed and surrounding tissue Debride dead tissue as required For open areas cover wound or phototherapy device (which ever is larger) with clear protective barrier Protective goggles are to be worn by patient if laser device is used (not required for SLD devices) Apply SLD / Laser with gentle contact for duration of treatment (If painful, hold device as close as possible without contact Once pain relief is achieved, use direct skin contact) Stage 1 & 2 Wounds (closed or partial thickness) Unless too painful, use SLD devices to treat the entire wound margin and wound bed directly (increasing blood flow, decreasing localized edema, reducing redness and swelling in the area) Stage 3 & 4 Wounds (full thickness) If less than 3 cm depth, treat entire wound margin and wound bed with SLD If greater than 3 cm depth, use Laser device around wound margin Note If wound aperture is significantly smaller than underlying wound bed, do not treat opening directly Treat the peripheral tissue directly over the internal wound edge with either the SLD or Laser, depending upon the depth required Phototherapy enhances contraction of the wound margins Over the wound bed, use either the SLD or Laser device, depending upon the size of the wound opening VER 13 RICH-MAR 2009 Monitor amount and quality of granulation tissue formation If over production (hypergranualtion) is noted, decrease the number of phototherapy treatments per week If hypergranulation continues, cease the intervention

3 Wound Healing Stage X Dark Eschar over Wound If the dark eschar is going to be debrided, treat with either SLD or Laser device for the prescribed treatment time Eventually, the wound will become soft (boggy) making debridment easier Healing will begin from the inside out Note Only use phototherapy if goal of treatment is intervention rather than 'wait and see' For frail and elderly individuals, the presence of a closed, non-draining, black eschar can be preferable to a wound that is open and draining Stage X wounds can be deep, requiring a protracted healing time Number of Treatments VER 13 RICH-MAR 2009 The most significant effects are often evident in the first 3 weeks of phototherapy followed by gradual healing After completing 25 treatments, phototherapy is often stopped for a 'light holiday' to determine whether the wound will continue to heal on its own If healing stops or regresses, reinitiate phototherapy for another set of 25 treatments or until healed Exudate Production For the first couple of weeks, the amount of exudate can increase, as the light energy accelerates the inflammatory process during this phase of healing In the next stage, the proliferative phase, the amount of exudate decreases Wound healing progresses from inside to out with the wound margins contracting gradually and decreasing in size Negative Pressure Dressings Phototherapy can enhance the effects of negative pressure dressings For optimal results, deliver photherapy after dressing has been removed and cleaned If treating over transparent dressing around the periphery, increase dose by 2-4 joules

Wound Healing Treatment Guidelines 4 Superluminous Diode (SLD) and Laser Treatment Schedule First Week and Subsequent Weeks (minimum of 3 x per first week and minimum of 2 x per week after) Stage 1 & 2 2-4 joules wound bed/margin Stage 3 & 4 4-6 joules wound bed Stage 3 & 4 6-8 joules wound margin Closed Eschar 4-8 joules over eschar and surrounding tissue If wound healing has not commenced within 1-2 weeks, evaluate other factors which may be negatively affecting healing (eg insufficient protein and/or fluid intake, inadequate pressure relief, bacterial burden) Consider increasing dosage (time) by 50% up to the maximum recommended dose for another 2 weeks All wounds should be evaluated weekly using the standard Wound Assessment Record (including wound measurements or tracings) Treatment Reaction Periodically a treatment reaction can occur during or shortly after therapy (warmth, tingling, sharp prickling, needling or an increase in pain or discomfort) VER 13 RICH-MAR 2009 This is most frequently experienced with chronic wounds, the result of an increase in local microcirculation Decrease the treatment dose by 50%, and then gradually increase to the original recommended dose

Acupuncture Points GV 15 GV 14 GB 20 BL 10 B 37 LI 16 GB 21 TW 14 SI 11 LI 12 GV 4 GV 3 BL 31 BL 32 BL 33 BL 34 BL 23 SI 8 GB 29 GB 30 BL 36 LI 11 LI 10 TW 5 LI 5 LI 4 Extra 28 GB 31 GB 32 Extra 28 Extra 28 GB 33 BL 40 VER 13 RICH-MAR 2009 BL 57 BL 60 GB 40

Acupuncture Points BL 2 Bitong Li 20 ST 2 Li 15 Li 14 GB 14 TW 23 GV 245 GB 8 Bitong ST 7 ST 6 Extra 5 P6 H 7 Si 3 VER 13 RICH-MAR 2009 ST 35 GB 34 ST 36 ST 41 Liv 3 SP 10 SP 9 SP 6 K 3