High Power Laser Therapy

(HPLT)

Revolutionizing The Non-Surgical

Treatment ofNeuro-musculoskeletal Pain

and Wound Healing PHYSICIAN SEMINAR

HPLT – High Power Laser Therapy• HPLT was first introduced to the medical field in 2002 by then CEO

of Avicenna Laser Technology, Inc, Bruce R. Coren, DVM, MS. The company invented and developed the first High Power Therapeutic Laser to receive FDA clearance in 2003.

• TMA – Technological Medical Advancements is a spin off from Avicenna and was founded not only to advance the field of Laser Medicine but also to bring other innovative medical devices to the market place.

• TMA offers the most powerful laser platforms in the world and thus allowing physician's of all medical disciplines the capability to heal injuries previously refractive to traditional medical care.

The Design of the TMA Laser • The TMA laser was designed from the ground up to

be a therapeutic medical laser. • It was developed using research by our own

biomedical engineers and clinicians as well as collaboration with a major medical school and university optics department.

• We investigated important criteria such as wavelength, power and power density, optics and beam delivery in order to afford the greatest penetration and delivery of a therapeutic dose capable of stimulating tissue healing in deep seated pathologies.

LASER— an acronym for:

Light Amplification by Stimulated Emission of Radiation

Lasers in Medicine

Surgical Lasers:

• Are used to cut, coagulate, and evaporate tissues.

• This type of laser replaces the scalpel of the surgeon.

Lasers in Medicine

Therapeutic Lasers:

• Are used for the stimulation of cell function.

• The biological effect is photochemical not thermal, as is the case with surgical lasers.

Who is using TMA (HPLT)• Pain Management Specialists, Orthopedists, • Neurologists, Interventional Pain Management • Doctors, Physical Medicine and Rehab, • Physiatrists and Family Practice Physicians• Chiropractors and Physical Therapists• Podiatrists, Naturopaths and DOM’s• MLB, NBA, NFL and College Sports Teams • Medical Colleges• The United States Military and VA Hospitals• Veterinarians –Equine and Small Animal

Comparison of “Class IV” Surgical and Therapeutic Lasers

• Surgical lasers collimate high amounts of laser energy into a beam of high intensity resulting in tissue destruction

• High Power Therapeutic Lasers take a high amount of laser energy but instead of beam collimation you get beam divergence resulting in tissue stimulation

Properties of Infrared Laser Light

• Laser Energy is just another form of energy on the electromagnetic spectrum. Depth of penetration is determined by wavelength and energy density. Just like with x-rays when deeper penetration is required, more energy must be delivered to reach the target tissues. In general the higher the wavelength the greater the depth of penetration. The TMA high power laser delivers infrared light at an optimal wavelength of 980nm.

Biological Effects of Therapeutic Lasers

• Laser therapy aims to bio-stimulate injured and dysfunctional tissues.

• Clinical studies and trials of Class III & IV laser technology indicate the following beneficial effects of light therapy on tissues and cells.

Cellular Effects of Laser Energy

• Chromophores are components of molecules which absorb light.

• The stimulation of chromophores on mitochondrial membranes incites the production of ATP.

• Leading to a biological cascade of events.

Cellular Effects of Laser Therapy Continued:

• Increased Growth factor response within cells and tissue as a result of increased ATP and protein synthesis.

• Accelerated cell reproduction and growth leading to faster repair of damaged tissues.

• Increased metabolic activity- via increase in enzyme outputs, oxygen and nutrient availability.

Wound Healing Effects of Laser Therapy

• Faster Wound Healing- Laser significantly increases fibroblast and collagen production which are essential for tissue repair.

• Improved Vascular Activity- Increased capillary production leads to faster wound closure.

• Greater Tensile Strength – Surgical repaired wounds heal with greater tensile strength, including skin, tendon, ligament and fascia.

• Scar Tissue Reduction- Wounds heal with less scar tissue formation.

Wound Healing

PRE-LASER AND AFTER TWOMONTHS OF TRADITIONAL THERAPY

AFTER TWO 5 MINUTE LASER THERAPYTREATMENTS AT 7.5 WATTS

Anti-inflammatory Effects of Laser Therapy:

Anti-inflammatory via an anti-edemic effect as it causes

vasodilatation and activation of the lymphatic drainage system.

Analgesic Effects of Laser Therapy:

• Via increased endorphin release.

• Anti-inflammatory via less edema as a result of lymphatic system activation and less swelling.

• Via Suppression of nociceptors.

Immune System Effects of Laser Therapy

• Strengthening the immune system response via increasing levels of lymphocyte activity and through a newly researched mechanism termed photo-modulation of blood.

• Documented evidence of Tumor size reduction in animals. Mechanism of action unknown.

Miscellaneous Effects of Laser Therapy

• Improved Nerve Function via increased nerve cell reconnections

• Trigger Point Resolution

• Acupuncture Point Stimulation

• Dermatology, Respiratory, GI and OB-GYN cases also being treated by numerous Avicenna clinicians in the field.(Corporately we only make claims pertaining to treatment of neuromusculoskeletal pain and would healing.)

Summary of LT Biological Effects• Accelerated Tissue Repair and Cell Growth• Faster wound Healing• Reduced Fibrous (Scar) Tissue Formation• Anti-Inflammation• Anti-Pain (Analgesia)• Improved Vascular Activity• Increased Metabolic Activity• Improved Nerve Function• Immunoregulation• Trigger Point Resolution and Acupuncture Pt. Stimulation

Laser Safety

Safety protocols must ensure sufficient precautions are taken to protect the health and safety of employees and patients. Use of safety goggles to prevent retinal exposure is paramount.

All Lasers are Not Created Equally

• Although all therapeutic lasers bio-stimulate tissue, that is where the similarities end.

• Laser Therapy is all about Physics!

Therapeutic Laser Classifications

• Therapy lasers are classified based on their power output

• Class IIIa = lasers 1 to 5mw of power (laser pointers)

• Class IIIb = lasers 6 to 500mw in power (typical cold laser you read about)

• Class IV = lasers above 500mw of power

• TMA Laser Platforms = 1,000 – 60,000 mw maximum continuous wave output

Energy Medicine and Therapeutic Laser Physics

• The therapeutic dosage of laser energy is measured in Joules• Dosage is a function of the lasers power output• For every one watt of continuous laser power output, one joule of

laser energy is delivered per second of time• For a pulsed laser the energy delivery depends on the duty cycle. Duty cycle tells us what percentage of time the laser is on or actively firing. If the duty cycle is 50% then the laser at 1 watt only delivers 0.5 Joules / Second. For any given time period a continuous wave laser delivers twice as much energy than a pulsed laser with a 50% duty cycle

How Laser Light Penetrates Tissue

• As light energy hits the surface of the skin and subsequent deeper layers, some of it is scattered and some of it is absorbed and some is reflected

• At each tissue interface less energy is available to pass further through to the next layer because of the effects of absorption, reflectance and transmission

Laser Tissue Interactions

Absorption Curves

980 nm: Low melanin, low water, low hemoglobin absorption thus an optimal wavelength to choose when designing a therapy laser for stimulating tissue at greater depths of penetration.

Physiological Effects Light – Tissue Interactions

• 65% of laser energy is absorbed in the skin and subcutaneous tissue layers with the following having a high affinity for absorption:

• Hemoglobin in blood

• Melanin in skin, hair, moles, etc.

• Water (present in all biological tissue)

• In order to overcome those factors one most start with large quantities of energy on the skin

Therapeutic Laser Penetration• Prime Determinants of Laser Penetration and

Concomitant Tissue Stimulation are:

• Power – measured in Watts or milliwatts

• Wavelength – measured in nanometers

• Power Density – measured in mw / cm2

• Frequency – continuous wave versus pulsing

Importance of Power Density• Approximately 65% of the energy delivered is lost

in the epidermis

• If you don’t start with enough energy on the skin, there will not be enough to stimulate cell healing in deeper tissues

• If you do not have sustained power density over a long enough period of time treatments may be ineffective

Multiple Wavelength Lasers vs.

TMA Single Wavelength Continuous or Pulsed Wave Laser

• A laser with two or more wavelengths only has the ability to penetrate as deep as each individual wavelengths allows

• Most class iv lasers that pulse or have a high duty cycle coupled with multiple wavelengths of energy emission will not penetrate as deep as CW lasers of a single wavelength or lasers that can pulse but still maintain a high average power output

• Continuous wave lasers = 100% duty cycle, laser is always delivering energy which is needed to overcome absorption in the superficial layers

• Newer generation of TMA lasers can now pulse yet still maintain a high average power output allowing for greater tissue saturation with less thermal effects

In Laser Medicine 1 + 1 Does not Equal 2

• Dual wavelength lasers only penetrate as deep as each wavelengthindividually. The penetration is notadditive, even our competitors agree, and there is no real benefit to this scenario. There are no scientific studies to support the benefits of a dual wavelength laser.

• For purposes of penetration it is more advantageous to have one wavelength of greater power. that stimulates cell metabolism and tissue regeneration at all tissues in its pathway

• The TMA laser is also available in a 810nm wavelength

Sponge Theory• In order to get penetration you must create significant energy density to

overcome absorption in the superficial layers of the skin. With low power density and even with pulsed class iv lasers it is like pouring small amounts of water onto a large sponge (the dermis and subcutaneous tissues) and expecting the water to leak through. In order to do so you must saturate the superficial layers of the sponge- with enough water-energy to soak the sponge-superficial tissue structures, so as you pour more water-energy over the sponge it will start to penetrate or leak through. This it what is needed and why it is important to deliver a high amount of laser on the skin especially if you want to reach deep seated pathologies.

• Low power or pulsed class iv lasers just cannot provide the energy necessary to overcome the absorptive capabilities of the superficial skin layers and that is why they fail to deliver a positive outcome when trying to reach deep seated pathologies.

How Much is Enough• 49-73 mw/cm2 for cell stimulation1

EFFECTS OF INFRARED LASER EXPOSURE IN A CELLULAR MODEL OF WOUND HEALING

Mark D. Skopin and Scott C. Molitor, Department of Bioengineering, University of Toledo, Toledo OH

• This study shows an optimal wavelength (980 nm) and power density range for wound healing and tissue stimulation

Laser & Tissue PowersTissue Layer Max Power (mw/cm2)Epidermis 206 Dermis Layer 182Dermis Plexus Super. 1352nd Dermis Layer 115Dermis Plexus Prof. 93Muscle Tissue 9.7

Power Setting 5 Watts, 3.0cm spot size, 980nm(This is a snapshot in time. Calculated using computer models by U of Toledo).Translation – As laser light or energy penetrates through the body more and more energy is absorbed so by the time you start reaching deeper structures there is not enough therapeutic energy to cause adequate tissue stimulation and thus the reason why low power lasers as well as pulsing lasers Cannot effectively treat deep seated pathologies.

Translation of Previous Two Slides

• Translation – It is important to comprehend that as laser energy penetrates through the body, more and more energy is absorbed at each tissue interface, so by the time you start reaching deeper structures there may not be enough therapeutic energy to cause adequate tissue stimulation unless you start with a sufficient amount of energy on the skin. This is the reason why low power lasers as well as pulsing lasers with low power output fail to deliver when treating deep seated pathologies.

Other Factors Affecting Lasers Penetration• Duty Cycle – 100%

• Laser is firing continuously

• Duty Cycle – 50%

• Laser is firing 50% of the time. This will not only cut energy delivery but it will also affect ability to penetrate.

• Pulsing – Lasers that pulse also do not emit continuous energy

• TMA can operate at 100% continuous wave output or pulse the laser energy while still maintaining a high average power output. Maintaining a high power output is key to treating deep seated pathologies.

Class III vs. “Class IV” Laser Beams

With a high power output the laser beam can easily penetrate deeper joints especially when compared to a class iii laser which at best only offers Superficial penetration.

Laser Physics

With a high power output the laser beam can easily penetrate deeper joints

Why Therapeutic Lasers Fail• Under penetration - The typical low level or cold laser or weak

or pulsed class iv laser does not concentrate the laser energy sufficiently to allow for adequate penetration

• Under-dosage – The typical low level or cold laser or weak or pulsed class iv laser does not deliver enough energy to adequately stimulate deep seated inflammatory conditions

• TMA protocols are successful because they call for delivery of significantly larger amounts of therapeutic energy than industry standard protocols.

TMA Philosophy• TMA’s goal has always been to build the most efficacious laser

available to deliver the best outcomes.

• Our lasers are built from the ground up and are designed to get patients who have failed traditional therapy better

• Our competitors lasers are built based on economic factors

• There is a hugh difference between making a patient feel better vs. actually getting them better.

• There are no shortcuts to treating deep seated pathologies and one must deliver the correct dosage of laser energy in order to get the best outcomes.

“The Key to Better Outcomes”

• Higher the power output of laser energy

• The Greater The Penetration

• The Faster the Therapeutic Outcome

• The Quicker the Patient Returns to Normal

• This is the main reasons we keep advancing our technology and developing more powerful lasers.

Why More Power is Better• More power equates to deeper

penetration, faster delivery of the proper therapeutic dosage, and ultimately better outcomes

• A 30 watt laser will not only penetrate deeper, it will put more therapeutic energy to the target pathology

• It will do this 3X faster than a 10 watt laser and 5X faster than a 12 watt laser with a duty cycle of 50%

Evidence Based Medicine• The effects of HPLT can easily be documented

• Clinician’s can measure results using outcome assessment tools:

• Pressure Algometer

• Inclinometer , Goniometer

• Thermal Imaging and Doppler Studies

• VAS, PDQ – Pain Disability Questionnaire

• These tools are vital to document outcomes which ultimately lead to adequate reimbursement

Lasers vs. Standard Modalities Currently Used to Treat Neuromusculoskeletal Pathologies

—HPLT —A New Trend in Pain Management

• Profound anti-inflammatory and analgesic effects

• Pain relief typically immediate

• Non-invasive and no side effects

• Profound tissue regeneration of all tissue types

• Overall contraindications minimal

Clinical Translation of the Previous Slide as it Pertains to the Spine

• Decreased inflammation of disc, nerve roots and the cauda equine• Increase microcirculation of spinal structures• Accelerate healing of annular defects• Decreased formation of abnormal/non functional scar

tissue• Decreased scar tissue and non-osseous hypertrophic

changes• Reduce pain associated with prolotherapy injection• Decrease or even eliminate need for epidurals

Clinical Translation of the Previous Slide as it Pertains to the Lower Extremities

• Decreased inflammation of nerve tissue

• Accelerated Reinervation of nerve fibers

• Increase blood flow and microcirculation of tissue structures

• Accelerate healing of open wounds

• Decreased formation of abnormal/non-functional scar tissue

Clinical Translation as it Pertains to the Lower Extremities Continued…

• Increase synovial fluid and cartilage production

• Increase collagen and fibroblast production

• Increase osteoblastic activity and fracture healing

• Decreased bony edema – osteochondral bone bruise

• Decrease in pain associated with epidural, prolotherapy or other invasive injections

Applications of Laser Therapy• Disc Pathologies, Spinal Stenosis, Radicular Pain,

spondylolesthesis, and sacroiliac dysfunction

• Peripheral Neuropathy and other Nerve Entrapment Syndromes

• Failed surgical back syndrome

• Accelerated Post Surgical, Soft and hard Tissue healing

• Arthritis (Degenerative Joint Disease)

• Foot and Ankle Pain

• Muscle, Ligament and Tendon Injuries

• Ulcerations and Open Wounds

Introducing the 2012 TMA Suite of Laser Platforms

• A technological advancement in energy output and delivery

• The TMA suite of laser platforms offer the world’s most powerful and advanced therapeutic laser system ranging in power output from 10 – 60 watts or 10,000mw -60,000mw.

• As a physician based company we have treated or will know how to treat any condition you are confronted with, the ultimate result being a better outcome

• With the superior training and clinical support we provide physicians, the above goal will readily be achieved

Introducing the 2012 TMA Diowave Laser Platforms

10 -15 Watt Laser Platform 20 - 30 and 60 Watt Laser Platform

Changing the Way Physician’s Manage Pain

www.tmainternational.com1-(866)-862-6606