Manual Medicine Group

Dry Needling for Somatic Pain (Trigger Points): on the "Efficacy of specific needling techniques in the treatment of myofascial pain syndrome"

2011-12-16T23:05:00.000-08:00

SITE NOTES:

still reviewing meta data.
this study is in review.
posted temporarily for discussion purposes.

Efficacy of specific needling techniques in the treatment of myofascial pain syndrome
Candice Brunham
Kelly McNabney
Jody Wiebe
Jeff Norwood
Research Supervisors:
Dr. Darlene Reid
Dr. Babak Shadgan

Needling Intervention + Adjunct Therapy vs Adjunct Therapy vs Control
• Comparison of superficial DN + stretching vs stretching vs control (Edwards & Knowles, 2003):
– No significant difference between
groups immediately post
treatment
– Superficial DN + stretch favoured
at follow up for increase in PPT

Discussion – Needling vs Needling Intervention
• No trends seen due to heterogeneity
of studies
– Study by Irnich et al (2002)
found acupuncture
to be significantly more effective than DN
– Ceccherelli et al (2002)
found deep
acupuncture to be more effective than
superficial acupuncture
– Birch & Jamison (1998)
found relevant acupuncture to be more effective than irrelevant acupuncture
• Future studies comparing needling
techniques are needed to determine
the most effective technique

Discussion – Needling vs
Other Intervention
• Studies which favoured lidocaine injection
over DN techniques involved only one
treatment session
• Study by Ga et al (2007)
which favoured
IMS over lidocaine injection had 3
treatments over 3 weeks
• The form of dry needling may play a role in
treatment efficacy
• Study by Ilbuldu et al (2004)
favoured
laser over DN, but subjects received a
greater number of laser treatments

Implications for Practice
• Best practice involves a structured
interdisciplinary approach including
physical and cognitive behavioral strategies
• The national institute of health (USA)
consensus statement on acupuncture
(1997) concluded that it may be useful as
an adjunct treatment

• This review indicates a need for future
investigation of dry needling therapies as
part of a comprehensive program
Conclusions
• No clear evidence that Dry Needling techniques are more efficacious than placebo, sham, or alternative treatment techniques
• No clear recommendations can be made regarding
the most effective needling technique or optimal
length and frequency of treatment
• Results suggest that multiple treatment sessions are
more effective on pain outcomes than single
treatment sessions
• Level of evidence does not exceed moderate

Acknowledgements:
Dr. Darlene Reid, Dr. Babak Shadgan,
Charlotte Beck, Dr. Angela Busch, &
Meredith Wilso

RSD

2011-12-04T03:47:00.001-08:00

[Case:
Complex Regional Pain Syndrome
( Reflex Sympathetic Dystrophy )

This is a constellation of symptoms springing from increased sympathetic tone at one or more extremities. Pain, erythema, and edema are seen. Lymphedema and fascial strains may be noted along the extremities. This may occur after blunt force Trauma, a crush or fall injury, or surgery.

We see a sympathetic overload. Changes in tissue circulation occur. Tender points, tissue changes, or vertebral rotations are noted over T5-7, T10-L2. Motor and tissue changes may be seen along C4-T1 or L1-S3. Compensatory patterns over unaffected areas may be noted.

The complex is fairly responsive to Reflexive De-Afferentation Techniques, OMT, and manual drainage techniques.

www.manual.blogspot.com]

A Case to Study: Neuro-MyoFascial Trigger Points, Cervical Somatic Dysfunction

2011-08-19T04:47:00.000-07:00

chief complaint:
constant, moderately severe
neck and shoulder pain,
with primary limitation of cervical flexion,
x 2 weeks, with increased intensity x 1 day,
precluding ability to do common office tasks.
Persistent aching to pounding severe pain was what crippled ability to do even standard deskwork.
No sudden falls or known recent physical trauma traceable as possible trigger events.
Areas highlighted in red correspond to neuro-myofascial adhesions and active trigger point distribution. The NMTPs formed a reverb circuit.

What are the primary lesions?
Treatment modes recommended?
Does Trigger-Point Needling and Infiltration Work?

MMG Homepage? Click here.

Athletic Injuries Galore

2011-08-09T08:30:00.001-07:00

Just finished taking care of someone with
a hardly walkable, fairly unswollen knee.
In other words, it will look normal to most.

Primary inciting injury inversion fall, medial knee caught fall on concrete June 2011.
Main complaint: moderately severe, constain pain, marked by sharp spikes that accompany sudden limb weakness, limiting stair descent more than walking.
Pes anserinus and infrapatellar bursitis as primaries.
Medial collateral and coronary ligaments sprained.
Iliotibial band bursitis, too.
Conclusion:
cheerdancing IS a competitive sport,
cheerdancers are atheletes,
these are real injuries.

Brother @Rheysonn Cornilla, i'm sad i missed out on Zark's burgers today.

Mind body medicine workshops

2011-08-04T18:19:00.001-07:00

How do we maximize the mindbody connection in treatment?
Wondering who else would be interested in joining a pilot class for Mind-Body Mobilization?
Basic precepts for the intervention techniques:
How do we rapidly shift to parasympathetic healing mode, and what to do with once there.
Will include, at a minimum, synthesized R.D.T. work, OMT, N.L.P., & clinical Hypnosis.
Rheysonn, we gotta talk soon, bro.
Email me suggestions, please, everyone.

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A Primary Spine Care Pratitioner Network in the Philippines?

2011-07-22T00:40:00.001-07:00

The Establishment of a Primary Spine Care Practitioner and its Benefits to Health Care Reform in the United States Murphy DR, Justice BD, Paskowski IC, Perle SM, Schneider MJ Chiropractic & Manual Therapies 2011, 19:17 (21 July 2011)

http://www.chiromt.com/content/pdf/2045-709X-19-17.pdf

Thought the community might benefit from access to this article.

Email us feedback!

Rheysonn
Dionne
Harold
Strix

Would you believe that clinical research is important?

2011-07-09T11:39:00.000-07:00

An example of why clinical research is important to the practicing doctor

by Henry Davld Nava Dlmaano on Saturday, July 9, 2011 at 3:33pm

A longtime friend of mine, whom I'll refer to here as P.A., happens to be consulting me for chronic low back pain with radiating pain/numbness/pins-&-needles sensation to both left & right legs. The symptoms started over a year ago (nearly two years now), particularly for the left leg & back. Now, her right leg also has symptoms. She happens to be a year older than me, is athletic, does gym & other physical activities, has a healthy lifestyle with no vices.

She's never had any major trauma, but she was part of the Judo team back when she was a college student. No medical problems other than this one. taking her cue from my prior advice, she's had an MRI scan done for her lower back at National Kidney Transplant Institute (she spent about P9k for it, about as much as you'd spend if you had it done here in Cebu City). What it revealed was L4-L5 and L5-S1 bilateral foraminal stenosis stemming from degenerative disc disease & facet joint hypertrophy of the same levels. So I've advised her to consider surgery, especially since she's symptomatic for nerve impingement for over a year now (going past the 1-year mark is normally not a good idea, as recovery of nerve function following decompressive surgery is significantly poorer if you've allowed the nerve under impingement to remain so for more than a year). Her main setback is the cost of undergoing surgery; so right now, she's managing the BACK pain symptoms using acupuncture.

Here's a transcript of our most recent conversation via live chat:

P.A.

The doc here at the acupuncture clinic says that with the [acupuncture] treatment we should be able to address the injury [she means the degenerative spine disease], not just the pain -- and I may not need surgery. Is that possible?

H.D.

he's going to REVERSE the degenerative process with acupuncture? hmm. seems like i'm going to have to give you a crash course on clinical medical research methodology here. Hold on to your seat.

okay. well, you can always try going alternative while you're waiting for a shot at definitive surgery. i don't know the PROVEN clinical impact of acupuncture (OTHER THAN for pain relief) well enough to vote for or against that claim. but the good thing is, you can always ask your acupuncturist for HARD CLINICAL RESEARCH DATA that proves acupuncture can do what he says it can do -- remove the need for surgical decompression. and by "remove the need for surgery", i don't mean just the short-term effects; we measure the clinical benefit of surgery in terms of YEARS (with 2-year post-operative follow-ups being the MINIMUM requirement for efficacy surveillance). so i guess you'd want to see hard data from THOUSANDS of acupuncture patients with the SAME DISEASE AS YOU -- and you'd want to see how acupuncture can save their impinged nerves without them having to later undergo surgery anyway (as compared to patients who DON'T undergo acupuncture AND instead have surgical treatment for their radiculopathies).

without clinical research data like that to convince you about the SAFETY & EFFICACY PROFILE of the treatment in question, i'd say the claim that acupuncture can CURE YOU TOTALLY is about as good as saying MX3 or Circulan can cure you totally. (we always say that the first precept of medical practice is "first, do no harm". treatments don't always work; but even if they don't, the least you can do is make sure the patient doesn't end up with a complication in the process of treatment. hence, the need for research data that can prove SAFETY, and preferably, EFFICACY of the treatment. take your acupuncture for example: it's both safe & effective for controlling your back pain, or any other type of pain -- and THAT'S PROVEN BY RESEARCH. but the question here is: can it safely & effectively cure degenerative lumbar radiculopathy without the need for later surgery?)

now here's what you need to do: ask your acupuncturist for STUDIES (yes, more than one research) that are "clinical trials" or "prospective clinical cohorts" with "adequately powered samples" & "clinical outcome measures that are blinded". (nevermind what that means -- if the research has any of these features, it will likely declare itself as having such.)

in particular, you'd like the research data to have the ff features:

> LARGE clinical trial or LARGE prospective cohort (preferably a multi-center study);

> must be something that actually compares ACUPUNCTURE versus SURGICAL DECOMPRESSION as treatments;

> must include patients that actually have lumbosacral RADICULOPATHY -- patients that are strictly screened for, and fit the clinical description of, a patient suffering from lumbosacral nerve impingement due to narrowed canals (no more, no less);

> must have at least 2 years' worth of post-treatment ff-up data (each patient is regularly checked up for 2 years right after the treatment protocol is FINISHED -- not 2 years after the symptoms start, or, not 2 years after the patient enters the study pool);

> the sample of patients at the END of the study must relatively be equivalent to the sample at the BEGINNNING (i.e., not many patients were lost to ff-up during the entire duration of the study -- about 80% of the original patients should still be accounted for at the end, in order for the study to be credible);

> there must be NO TREATMENT CROSS-OVERs -- where patients undergoing acupuncture later cross over to the surgery side, or patients who had surgery cross over to the acupuncture side;

> treatment success must be measured by ANY OR ALL of the ff CLINICAL OUTCOME MEASUREMENT TOOLS -- the VAS score for pain (back pain AND leg pain), the Roland-Morris Disability Questionnaire for degenerative spine disease, the Oswestry Disability Index for back pain, and maybe even the SF-36 questionnaire (these are all world-accepted VALIDATED TOOLS for evaluating clinical functionality of patients with back problems; any other means of measuring or defining "treatment success" just won't cut it);

> outcome measurement (as mentioned above) must be "blinded" -- i.e., the research person doing the measurement(s) over the entire ff-up period MUST NOT KNOW if the patient he/she is evaluating is a patient belonging to the acupuncture group or the surgery group (in order to prevent BIAS TO TREATMENT EFFECTS from occurring on the part of the evaluator);

> the complication rates of both acupuncture & surgical decompression must be reported in detail -- and remember that "failure of primary treatment" is in itself a complication (e.g., you get the acupuncture, symptoms are relieved for a while, but then they come back, and you eventually need surgery for it). [note also that there are other complications to consider: risk of getting an infection from bacteria or viruses; risk of delay of definitive treatment; risk of developing chronic pain which is non-responsive to any treatment; risk of paralysis; even risk of dying from a procedure, although that's actually close to nil, even for spine surgery.]

if your acupuncturist can show you at least 3 studies [i wouldn't want to settle for just ONE study, i'd like to at least base my decisions on a consensus of 3 studies] which meet all these requirements, then you have my vote for going alternative instead of having the surgery. i know it seems too technical; but you see, saving patients' lives is a technical task to begin with -- which is why the research & evidence-gathering involved is also quite technical. think of it as proof that we doctors don't take our patients' problems lightly. ^_^

and besides, any medical practitioner who knows what he/she is doing should also intimately know the hard basis for whatever he/she does. if you don't know the hard science behind your practices, how would you be sure that your practices are SAFE & EFFECTIVE, right? (by "science", i am referring to the scientific method of research.) this is, to a large extent, what you pay good money for -- to make sure that your medical care provider actually knows his/her stuff. because why would any patient bother spending good money on a practitioner who doesn't really know if what he's doing is rational or not?

bottom line: is it possible for him to do what he says acupuncture can do? yes -- but he has to first show some hard evidence that it really can.

P.A.

what he said was that I MAY not need surgery, not that I definitely won't need it. in any case, it's good for the pain so that's what I keep going back for :)

when he told me that what I said was that I am definitely getting another MRI before surgery if only so we can see if there has been any improvement to my back.

H.D.

what he's implying is that you may not FEEL THE NEED to have surgery done if you are kept pain-free (which is most likely true for any patient -- no symptoms, no need for any further treatment). but the question that you have to ask him is, can he guarantee that you're nerves won't get damaged from progressive degenerative compression just the same, EVEN THOUGH THE ACUPUNCTURE KEEPS YOU PAIN-FREE? because i'm pretty sure that no amount of acupuncture (or any other treatment offering mere symptomatic, non-decompressive releif) can reverse the degenerative changes in your spine that are causing nerve compression.

i'll make him a bet. get the MRI after his treatment is done. if it shows any improvement in the size of your foraminal canals [compared to the first MRI scans from last month], i'll pay for the MRI. but if it doesn't show any change, he pays for it. deal

i'm serious with that bet. i say put your money where your mouth is.

P.A.

hahaha ... I'll have to tell him that first. :D

H.D.

for the sake of image uniformity, you have to get the MRI repeat scan also in NKTI, where you had the first one done.

although essentially, from the standpoint of orthopedics, you don't need a repeat MRI -- not unless your symptoms grow worse and/or you end up waiting maybe more than a year from the first MRI scan before you have any surgery done. if your symptoms don't worsen, we can assume that the involved levels of your lumbar spine are status quo. although it's highly likely that the canals will get narrower over time. how much time till things worsen PARTLY depends on how much load you place on your back.

P.A.

I will surely do that. the equipment is good and the price is even better :)

2011-07-02T01:32:00.001-07:00

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Paper Mastery

2011-06-16T20:44:00.001-07:00

The moment you know everything there is to learn
about that one thing you say you've mastered,
i'd like to congratulate you, because,
right then, you're already
20% there!

You can walk again!

2011-06-15T07:14:00.001-07:00

Okay, now that we've fixed your back, now that you can walk again,
here are a few guidelines we've found most useful to tell patients:

1. Hydrate! Fascia is a colloidal structure in terms of behaviour. The better your fluid status is, the more useful fascial sliding we'll get.
2. Walking is good. Swimming is great.
3. Whatever it is, take it easy.
4. Resist the tempation to run, jog, leap, and go up and down large flights of stairs, at least for two weeks after our last treatment.
5. Sugar sucks up water and feeds inflammation. Avoid it for at least three days.
6. Never sit down for more than 45 minutes straight. Get up. Stretch. Unwind.
7. Turmeric, fish body oils, flax seed oil: these are your anti-inflammatory friends. An alkaline vitamin C will help. Red hot chilli peppers, if you can tolerate them, will do wonders for you.
8. Get your greens. Go by color. Deeper, darker greens are best.
9. Shift all your salt to unadulterated natural sea salt. Iodized salt in the Philippines is pure sodium plus pure chloride plus iodine. More sodium isn't a good idea. Real sea salt has trace magnesium and calcium that will really help.
10. When in doubt, don't invent. Ask me about whatever it is i can help you with.
11. Weight loss for the portly is a necessity. Gradual continued fat loss is best. Rapid weight loss is traumatic to your system, And is likely not a sustainable change.
12. Release unproductive emotions. Seek and stock up on grattitude, love, and laughter.
13. Don't take my word on any of this. Take it for testing, and prove us right.

www.manualmed.blogspot.com

What is "Tensegrity?"

2011-06-15T03:36:00.001-07:00

@TranceDoctor:
How is it that we can heal with our hands?
dionne-thehealingparadigms.blogspot.com/2011/06/tensegrity-power.html?spref=fb

2011-06-01T03:19:00.001-07:00

"the kitchen is all foreplay!"
(Chef Ed Quimson)

"the thrust is automatic
when you've set is up right"
(S. Toledo, D.BT, D.OI)

"great idea!"
(@iamstrix)

Help Wanted

2011-05-16T21:56:00.001-07:00

@iamstrix:
the Manual Medicine Group
needs the best Occupational Therapist
still in the philippines
to join us for clinics.
www.manualmed.blogspot.com

Elbow Pain?

2011-05-04T10:34:00.001-07:00

Free assessments for tennis elbow
or pain on the outer elbows.
Conducted by university professor, clinician.
Mail us. strix02@yahoo.com

posted from Bloggeroid

Fix Scoliosis!

2011-05-03T05:31:00.001-07:00

How to correct lumbar primary scoliosis lesions without thrust techniques, and with more permanent results.
An evolving dialogue and practice forum for my colleagues and students is also at:
www.manualmed.blogspot.com
http://yfrog.com/h2vojqp

posted from Bloggeroid

2011-04-23T12:40:00.001-07:00

@iamstrix:
Because of cultural sitting differences,
the japanese knee replacement needs to be able to bend to 135°.
The caucasian knee needs only 90° to be funtional for normal activities of daily living.

The Emmett Technique is in the Philippines?

2011-03-10T06:58:00.000-08:00

Weekend Workshop! Ask us about it!

Ask us about great group discounts!

The Emmett Technique Body Pressure Therapy

Doers and Do-nots

2011-03-06T11:04:00.001-08:00

Heard of the latest fashion scandal?

Basically, a fashion designer substituted his tags
for off-the-rack tags on department store clothes he passed off for his own, at a price upgrade of tens of thousands a piece. He got caught because he forgot to unstitch one of the rtw labels.

Today, passing by
a wall at eastwood where fashion critics and columnists have their faces plastered, i am strangely taken back to the notion that

some people talk,
and some people do.

In an ideal world, we all walk our talk.
Ideally, we are so good at what we do, so overflowing with passion for it, that we lead our fields by example, by results.
It would then be great if those exceptional at what they do could also teach well.
It would be great if every clinician could be a good academician.
It would be great if every academician knew how to do well what they teach.

Too often, however, those who can't do
just adore criticizing what they don't really grasp.
Often, those who can do things aren't able to share their knowledge.
Often, those who can't do things are particularly good at talking.

I wonder if we could all stop cursing and criticizing the darkness.
I wonder if we could start looking for the light, head for it, and describe the journey so others might take up a similar path.

May we more often walk our talk, say what we mean, and mean what we say.

www.manualmed.blogspot.com

Pain has many names

2011-01-31T03:46:00.000-08:00

I hope we always remember to check for emotional content. So much of pain is colored by personal perception. We would be remiss as caretakers of the body if we did not notice the mental and emotional burdens our patients carry.

upcoming Manual Medicine Workshops, Seminars, Lectures.

2010-11-13T23:12:00.001-08:00

Mind-Body Conference Philippines

2010-10-22T03:56:00.000-07:00

The Manual Medicine Group
is extending an invitation
to join us at
“HORIZONS,”
the 4th Philippine
Mind-Body Conference.
November 27 - 28, 2010
Legend Villas, Mandaluyong City.

Neuro-Linguistic Programming 2:15pm; Nov 27, Sat
Manual Medicine for Pain Mgmt 3:45pm; Nov 27, Sat
Cranial-Sacral Therapy 10:45am; Nov 28, Sun

To book with us, or If you have any questions, clarifications, or suggestions;
please DO get in touch with us either through landline: +6324287602,
mobile: +639228593562, or email: fitwerks2003@yahoo.com.

An open invitation for a workshop on manual medicine

2010-10-11T05:41:00.000-07:00

This is an open invitation to a talk and a Workshop with the Manual Medicine Group in November 2010.

We will have an esteemed colleague, on break from his Doctoral studies, join us for a kindly volunteered talk on "Listening Skills:"

Valentin C. Dones III, MSPT, PTRP, DMS, CMT

Assistant Professor

College of Rehabilitation Sciences

University of Santo Tomas

Graduate School
University of Santo Tomas

Core Group Researcher
Center for Research and Movement Science

University of Santo Tomas

Please RSVP with Rheysonn Cornilla on Facebook to confirm your interest in joining us.

Treatment for Hip Joint Pain

2010-10-05T06:54:00.000-07:00

Acetabulo-femoral (Hip Joint) Capsulitis, Acute

History:

· Night pain at hip joint, unresponsive to traditional physiotherapy.

· Pain along buttocks.

· On and off groin and / or anterior thigh pain.

Findings:

· Limitation in ranges of motion is in capsular pattern:

o limitation in medial rotation > flexion and abduction > extension.

· Passive testing shows hard end-feel.

Intervention Done:

· Local infiltration with 40mg triamcinolone plus 1% lidocaine, to complete 5 ml total volume, using a 23 guage 3.5 inch spinal needle.

Aftercare Instructions:

· Limit weight-bearing x 2 weeks.

· Surgery should be avoided for up to six weeks from date of intervention.

· Repeat infiltrations may be attempted in three months.

· Annual X-rays should be done, monitoring for degenerative changes.

Manual Medicine Interventions:

· No hard “adjustments” or chiropractic intervention at this joint for at least two weeks, please.

· Osteopathic and PT intervention:

o Range-of motion pain-free activities may be started immediately, but should be graded, and may be gradually increased in frequency and end-range attempted.

o Stretching may be done, gradually encouraging further motion end-ranges.

Excerpted, with copyright maintained by author, from:

Orthopedic Medicine Interventions Dissected

Sandro Strix S. Toledo, M.D., Dip. OMI

What is Craniosacral Therapy?

2010-09-16T23:54:00.000-07:00

What is

Craniosacral Therapy?

Cranial-Sacral Therapy (CST)

The cranial-sacral (craniosacral) system addresses bones and membranes that surround the central nervous system. Restrictions here can pull on and strain neural tissues, and affect correspondingly innervated somatic areas, organs, or tissues. Craniosacral Therapy or CST uses very light hands-on techniques. These techniques deal with pressures and movements of and between brain structures. Hands-on application of CST resistance to certain tissue pressures or movements are often meant to induce responses that decrease, unwind, or remove neural tissue strain. CST Induction techniques are meant to propagate proper movements between brain structures.

CST, while particularly effective for treatment-resistant headaches, also has positive bearing on varied cases of unresolved chronic muscle and joint pain. Case studies have shown usefulness in helping resolve some digestive and neuro-endocrine disorders. Learning curves, attention spans, and memory retention are often reported improved.

An urgent call exists for strong Randomized-controlled-blinded studies on both the mechanism of action and effectiveness of CST. While ardent practitioners and patients attest to its wondrous effects, strong scientific validation is still lacking.

In the very least, a profound relaxation response is almost always possible with CST. For those for whom "nothing else has worked," CST may be of some help. My biggest concern with CST is the large inter-practitioner discrepancy in in both the rhythm and amplitude of the movements they say they notice in patients. Two different practitioners may read the number of "cycles of flexion-extension" very differently -- even when "readings" are taken a few seconds apart.

My personal advice: find a CST practitioner you are truly comfortable with. Hopefully that practitioner has also had at least a year of successful interventions. As with surgical interventions, the more experience, the better.

Personal caveat: If you find a practitioner who says they always have a 100% success rate with CST, i would suggest you run away, very quickly, in the opposite direction. That doctor is either extremely gifted or downright scary. (On the off chance that they've developed a system that absolutely always works, for any indication, please send me their contact numbers. I need to learn what they are doing. My magic isn't that good yet. So i'm sticking to my science, and letting God do the rest.)

Looking for a CST Practitioner?

POSITION STATEMENT ON LASER ACUPUNCTURE by the Australian Medical Acupuncture College

2010-09-13T03:13:00.000-07:00

POSITION STATEMENT ON LASER ACUPUNCTURE

LASER, an acronym for Light Amplification by Stimulated Emission of Radiation, was developed in the early 60s. It is a form of electromagnetic radiation, in the visible or infrared region of the light spectrum, generated by stimulating a medium, which may be solid or gaseous, under special conditions. The beam of light thus generated has uses in almost every area of technology which exist today.

Laser was first used in the medical field as a focussed, high power beam with photo thermal effects in which tissue was vapourised by the intense heat. During the early phase of its use as a surgical tool, it was noted that there appeared to be less pain and inflammation following laser surgery than conventional surgery.
It was postulated that this effect was related to the use of surgical lasers with a Gaussian beam mode (see fig) In this mode the power of laser is highest at the centre of the beam with the power then falling off in a bell-shaped curve with the weakest power at the periphery of the beam diffusing out into the undamaged tissues (2). This phenomenon was called the "alpha-phenomenon" (35). Thus the "low power" segment of the beam was postulated to be responsible for the decreased pain and inflammation in the wound. Workers in the field recognised this effect. Laser devices were manufactured in which power densities and energy densities of laser were lowered to a point where no photo thermal effects occurred but the photo-osmotic, photo-ionic and photo-enzymatic effects were still operative. Thus the use of "cold" laser or "soft" laser, as it was first known, came into medical use.

The earliest experimental application of low power laser in medicine was first reported in 1968 by Endre Mester in Hungary. He described the use of Ruby and Argon lasers in the promotion of healing of chronic ulcers. In 1974, Heinrich Plogg of Fort Coulombe, Canada, presented his work on the use of "needleless acupuncture" and pain attenuation. The first clinical applications of the GaAIAs diode laser appeared in the literature in 1981.

Since then a multitude of devices, from many different countries, generating a variety of laser beams of varying power, wavelengths, frequencies and claims of clinical effects have been brought onto the market.

Its use is now widespread in almost every medical speciality, especially dermatology, ophthalmology and medical acupuncture.

Japan and several Scandinavian countries are at the forefront of clinical research work with laser. Low Level Laser Therapy (LLLT) is also used in Australia, Canada, France, Korea, People's Republic of China, U.K. and many other countries. A tissue repair research unit, examining the effects of laser, now exists at Guy's Hospital, London. Many centres of research are now developing around the world.

It is to be noted that lasers machines are used widely by physiotherapists, veterinary surgeons (3) as well as practitioners of alternate therapies. It is unregulated by any authority at the present time, apart from the need for the equipment to conform to Australian standard safety regulations.

The aim of this position paper is to present the current views, on the use of laser, of the Australian Medical Acupuncture College.

The photo-chemical effects of light in medicine are well known e.g. blue light is absorbed by bilirubin and thus undergoes photo-chemical change. THis is the basis of the treatment of neonatal jaundice. Another use is that of ultraviolet light to treat psoriasis in PUVA treatment. The use of a laser as a mechanism to induce photo-chemical changes in tissues is an extension of this effect.

Laser has three characteristics which make it different from ordinary light. It is monochromatic, parallel and coherent. It is the last characteristic which is the most significant factor in skin penetration, thus allowing a photo-chemical effect to occur in deeper tissues. Absorption spectra (1) can be plotted for any chemical or biological system. In any clinical setting the absorption of laser and hence its biological effect depend upon skin pigmentation, amount of fat, water and vascular congestion of tissues.

Penetration of laser into tissues falls off at an exponential fashion. Thus increase of laser power applied to tissues does not result in a linear increase in biological effect.

Once absorbed a photochemical effect can be induced by the following mechanisms

1. Neural: Laser causes in vitro changes in nerve action potentials, conduction velocities and distal latencies. Experimental evidence includes Bishko's work in Vienna where he demonstrated significant pain relief following low power HeNe and infra-red laser stimulation of acupuncture points. Walker demonstrated increased levels of serotonin in chronic pain patients after treatment with low power HeNe laser (46).

2. Photoactivation of enzymes: one photon can activate one enzyme molecule which in turn can process thousands of substrate molecules (1). This mechanism provides a theoretical framework in which a very small amount of energy can cause a very significant biological effects.

Primary photoacceptors, which are activated by laser, are thought to be flavins, cytochromes
(pigments in the respiratory chain of cells) and porphyrins (14,15). They are located in mitochondria. They can convert laser energy to electro-chemical energy.

It is postulated that the following reaction is activated by laser (1):

Low doses of laser stimulation ATP in mitochondria activation of the Ca++ pump Ca++ in the cytoplasm (via ion channels) cell mitosis cell proliferation. Higher doses of laser stimulation hyperactivity of the Ca++/ATPase pump and exhaust the ATP reserves of the cell failure to maintain osmotic pressure cell explodes.

3. Vibrational and rotational changes in cell membrane molecules: Infra-red radiation results in rotation and vibration of molecules in the cell membrane leading to activation of the Ca++ pump as in the cascade above.

Different wavelengths may stimulate different tissue responses which may be synergistic and thus produce better clinical effects.

It is essential that basic parameters of laser physics are understood by the practitioner in order to achieve the best results in any given clinical setting.

Wavelength The wavelength of a laser is determined by the medium from which it is generated. Wavelengths of low power lasers in common clinical use in Australia today are 632.8nm ( Helium Neon, gas) in the visible light range, 810nm (Gallium / Aluminium / Arsenide, diode) and 904 nm (Gallium / Arsenide, diode) in the infra red region of the light spectrum. Other wavelengths are used more commonly in surgical settings. The wavelength is the prime determinant of tissue penetration. Lasers which penetrate less deeply are suitable for acupuncture point stimulation and biostimulation. Infra red lasers penetrate more deeply and are used in deeper tissue stimulation such as trigger points.
Energy
Energy is a measure of the dose of laser given in any treatment
Laser energy, in joules, is calculated from the formula:
Joules = Watts x Seconds
It can be seen from this formula that energy, expressed as joules, is related to the power of the laser and the duration of irradiation so that a higher power laser takes less time to generate the required number of joules than a lower power laser. The range of powers of laser devices used in Australia varies from 1.5 to 100 mW. Principles of laser dosing should be understood by users as some clinical effects, especially with higher power lasers, appear to be dose related. Acupuncture points are stimulated with energy ranging from 0.01-0.05 joules/point while trigger points may be stimulated with 1-2 joules/point or higher, depending on the tissue depth.
Energy Density
This parameter is used in the calculation of doses for biostimulation of wounds and is calculated as:
Energy density (J/cm2) = Watts x Seconds/Area of laser spot size (cm2)
4J/cm2 is regarded as the optimal dose for biostimulation, based on empirical findings.

Power Density
This is a measure of the potential thermal effect of laser and is fixed by the characteristics of the machine for any given power output and spot size. It is calculated from the formula:
Power density (Watts/cm2) = Waifs/area of the probe tip (cm2) 1 0,OOOmW/cm2 will produce a sensation of heat
A wide range of conditions are amenable to management by Iaser, (3,4,5, 42). Many of these include conditions not amenable to or unresponsive to current drug or physical therapies such as osteoarthritis (16,18), back pain (17), post-herpetic neuralgial (9,20) , chronic pelvic inflammation (44) and rheumatoid arthritis (22,31).

Laser may be used in three different ways

1. To stimulate acupuncture points

Laser is used to stimulate acupuncture points using the same rules of point selection as needle acupuncture. Laser acupuncture may be used solely or in combination with needles for any given condition over a course of treatment.

2. To treat trigger points

In some musculo-skeletal conditions higher doses of laser may be used for the deactivation of trigger points. Trigger points may be found in muscles, ligaments, tendons and periosteum. Direct irradiation over tendons, joint margins, bursae etc may be effective in the treatment of conditions in which trigger points may play a part. Children and the elderly may require smaller doses. Areas of thick skin or muscle may require higher doses for penetration than finer skin areas e.g. ear.

3. To promote healing

The biostimulatory effects of laser have been widely investigated both in vivo and in vitro.

In vitro experimental evidence has demonstrated acceleration of collagen synthesis in fibroblast cultures due to acceleration of mRNA transcription rate of the collagen gene. Superoxide dismutase activity is increased (this decreases prostaglandins). This is postulated as one mechanism of pain and oedema reduction. Other effects are: inhibition of procollagen production in human skin keloid fibroblast cultures and stimulation of phagocytosis by macrophages, increased fibroblast proliferation, as well a wide variety of cellular responses.
In vivo effects demonstrated in animals include increased formation of granulation tissue and increased rates of epithelialisation in laser irradiated wounds, stimulation of suppressor T-cells, increased collateral nerve sprouting and regeneration of damaged nerves in rats and tendon and ligament repair in race horses.
Bio-stimulatory effects of laser are governed by the Arndt-Schultz Law of Biology i.e. weak stimuli excite physiological activity, strong stimuli retard it. The implication of this for wound healing is that, as treatment of a wound is continuing and there appears to be a slowing down of healing, a reduction of the laser dosage may be needed. By virtue of the Arndt-Schultz Law and the changed responsiveness of the tissues, what was originally a stimulating laser dose may have become an inhibitory dose of laser. The optimal energy density for biostimulation, based on current clinical experience, is 4J/cm2. Dose must be adjusted according to individual response.
Biostimulatory effects of laser may be used in the following conditions:

1. the promotion of healing of wounds e.g. venous and arterial ulcers, burns, pressure sores.
2. treatment of skin infections such as herpes zoster, labialis and genitalis.
3. treatment of apthous ulcers.

Laser may have an enhancing effect on healing wherever inflammation is present.
Bio-inhibitory effects of laser may occur at higher doses e.g. 8J/cm2. Treatment of keloid scars has been successful at these doses. Class 4 Lasers are used.
Reprinted with permission of Standards Australia from Australian Standard: Laser Safety AS 2211-1991

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