Previously, we have looked at a general treatment approach, as well as treatment frequency for acute conditions in particular. Here, we will look further into treating chronic conditions. As opposed to acute conditions where our goal is resolution, the goal in treating chronic conditions is essentially to prevent an active decline with an incurable condition.
A complete recent physical examination is crucial when addressing a chronic condition, as it is likely that there have been compensatory changes in secondary or even tertiary biomechanically associated sites. For example, lumbar spine degeneration and iliopsoas muscle strain are often seen with the primary issue being degenerative joint disease of the pelvic limb (like with CCL rupture). Thus, a recent physical exam is a must as the progression of chronic disease can be quite dynamic and multifaceted. Not addressing all of the patient’s areas of pain or discomfort may lead to unsatisfactory results and difficulties managing client expectations. The natural progression of arthritis can be better assessed and addressed by reading and understanding the subtle symptoms that the patient develops as their condition continues to deteriorate.
It is just as important for the laser operator to have a thorough knowledge base in anatomy. Using the iliopsoas as an example, the operator must be able to visualize the target structure, from its origin at the lumbar spine to its insertion point at the lesser trochanter of the femur. The same principle applies to skeletal structure and neural pathways.
The third important aspect of treating chronic conditions lies in setting realistic goals and expectations prior to initiating a treatment regimen. Age is not a disease, but it is a consideration. Each case will have individual factors, which will be taken into account when establishing these goals. The adept operator will keep in mind that geriatric patients have a slower rate of response to therapy, partly due to a slower metabolic rate, but also potentially due to concomitant disease.
Primarily, promoting quality of life via a sustained palliative response is always the primary goal. Secondly, it is our long-term expectation to be able to prevent an active decline by slowing the progression of the disease. Lastly, we may also be able to taper pharmaceuticals or even discontinue them. There are so many unique factors that each case must be handled as a separate entity.
Once these three factors have been addressed, we can proceed with a complete picture and a common goal for the case. Typically, a chronic condition will need an extended induction (or initial) phase of treatments. This induction phase is usually around 6 treatments, but with these cases, it may extend up to 9 or 12 treatments before an effective and sustained clinical response is seen.
Unless the patient is in established pain, an every other day frequency is typically applied when starting laser therapy for these cases. Once significant clinical improvement is seen, the operator should consider tapering the treatment frequency so as to promote a continued response. In this fashion, the patient is expected to undergo several treatment phases, from frequent “induction”, to less frequent “transition”, and then long term “maintenance” phase treatments.
Sometimes, a client will report the patient seemed a little stiff after the first few treatments. Although this may seem unsettling, this is actually an encouraging sign of active tissue remodeling taking place. Remember, part of the cascade of events that happens with photobiomodulation is vasodilation and angiogenesis. It can be easily explained to the client by making the analogy of blood flow returning to a foot after it went numb from kneeling for too long. This is similar to the “pins & needles” feeling we get with reperfusion of tissues after an ischemic event. When noted, it should be transient and low grade, and is usually seen early after initiating the modality. If it is not seen, that does not mean that the patient is not responding effectively, it just means each patient is an individual and not a statistic.
As the patient progresses through treatment phases, we are able to maintain a clinical response while periodically tapering on the frequency of treatments. It is important for the client to be aware that regardless of the current treatment schedule, they are to return as soon as possible if there are any setbacks or sudden decline. Photobiomodulation offers the operator a certain flexibility in order to enable not only a long-term response, but be able to address acute to chronic events as well.
Many patients will benefit from long-term photobiomodulation therapy. Our patient base will also continually grow as we enable longer life spans via the advancements in the medical field. The savvy laser operator will also be dedicated to keeping an eye out for patients predisposed to arthritic changes, such as working dogs/athletes, chronic NSAID/opioid users, breed predisposed for DJD, patients with surgical implants or a history of traumatic injuries, etc.