hello and welcome to laser lessons from Dr Phil this is Dr Phil Harrington my topic is care for acute and sports injuries less rice and more laser I welcome your comments on this video or shoot me an email at Laser lons from dril gmail.com this webinar will present information on acute and sports injuries review studies on the use of laser therapy for acute injuries and give clinical recommendations for the treatment of acute injuries an acute injury is typically the result of a single traumatic event and that twisting tearing or blunt force trauma leads to the microscopic damage of small blood vessels and connective tissues that microscopic damage also results in blood plasma and cellular fluid leaking into nearby tissues the leaking of fluid along with the collection of chemical mediators and dilation of blood vessels causes acute injury swelling as the blood migrates towards the skin surface the skin may appear dark red or have that characteristic black and blue appearance of bruising the sensation of pain is a result of the fluid collection certain chemicals released in the body as a result of cell injury along with lowered oxygen levels in the soft tissues also known as hypoxia in our clinics the acute injuries that we see are ligament sprains muscle and tendon strains knee injuries slips and Falls sports injuries and motor vehicle accidents now in the past why did we use ice on those injuries and I can remember being taught in my physical therapy modalities classes at Palmer College of Chiropractic they taught us that ice was used to decrease pain swelling and inflammation resolve spasms reduce soreness and it was best used after exercise or after a pain producing activity so anytime an athlete uh would perform in workouts or practice or a sporting event they were told to put ice on it immediately afterwards and the ways that we used ice included these when we apply eyes to the tissues of course that numbs the skin it may decrease inflammation but it also decreases circulation and decreases metabolic activity and the question would be does that help with healing a little historical view until two centuries ago ice was just an unfortunate side effect of winter but in the early 1800s one man saw dollar signs in Frozen ponds Frederick tutor not only introduced the world to cold glasses of water on hot summer days he created a thirst people never realized they had and then a Doctor by the name of John gory was granted the first US Patent for mechanical Refrigeration in 1851 and it was for his invention of the first ice machine back in 1845 Dr gory is considered the father of air conditioning and mechanical Refrigeration although he was ridiculed during his lifetime going back even further we have various medical uses of cold and Ice the use of cold as a therapeutic agent has a long and colorful history the Edwin Smith Papyrus which is the most ancient medical text known it's dated about 3500 BC made numerous references to the use of cold as therapy during any kind of trauma cold was used to treat inflammation in 400 BC hypocrates used cold to treat swelling and pain in 1050 ad anglosaxon monks used cold as a local anesthetic Baron delar a French army surgeon during Napoleon's Russian campaign packed the limbs in ice prior to amputations to render the procedures painless and at the right we see Dr Temple Fay the head of the neurosurgery department at Philadelphia's Temple University and that was in the 1930s Dr Fay is credited by many as having introduced hypothermia both whole body and localized to modern-day Medical Practice his interest in hypothermia as a therapeutic measure began in 1919 when as a sophomore in medical school he was asked by a professor why cancerous metastases were seldom found below the knees and the elbows interesting question in the 1940s the Germans obtained a copy of FaZe manuscript detailing his experience with hypothermia for the proposed purpose of searching for new ways to help German Airmen survive when shot down and stranded in the cold open North Sea Nazi scientists used concentration camp prisoners in a series of Infamous hypothermia experiments that were conducted conducted often times with an intentional end point of death in the early 20th century as a neurosurgeon Temple Fay pioneered human Refrigeration as a treatment for malignancies and head injuries now here I like to discuss a little bit of the passage of time and um uh the what we're going to talk about is the rice protocol we're going to spend a few slides talking about that Rice protocol which is the acronym coined in 1978 by Dr Gabe Merkin in his Sports Medicine book of course rice as we all know stands for rest ice compression and elevation to represent the four activities for treating acute athletic injuries the rice protocol has been ingrained in academic curricula as well as in public perception for over four decades and as a slightly humorous way to look at the passage of four decades there you see the Rolling Stones on the left in 1978 when Dr Amin coined the term and then in 2021 the um the stones now if you are a Stones fan of course you know that in 20 August of 21 drummer Charlie watt did pass away but hopefully you get my point here with the passage of time and the length of time that the rice protocol has been ingrained in uh therapeutic curricula in 1978 Dr mgan released the sports medicine book he coined the acronym r i standing for rest ice compression and elevation to represent the four activities for treating acute athletic injuries today if you look at various online resources one would be to look at the Harvard Medical School website and do a search for treating sports injuries now the Harvard Medical School uh they add protection as the first activity after an acut injury to make the acronym price instead of rice and then at the bottom they list the use of ice as a way to manage many injuries if you go to the preeminent doctor in the world and for those of you practicing clinicians now I empathize with you and the fact that your patients may be searching and and and believing Dr Google before they would believe you so I understand sometimes the uphill Road you have to climb but if you do go to Google what does Google say for acute injury treatment there you see it listed rest ice compression and elevation now to continue with my Classic Rock theme Here starting out with the Rolling Stones I will continue with Foreigner and to borrow some of their lyrics from one of my favorite Foreigner songs you're as cold as ice you're willing to sacrifice our love you'll never take advice someday you'll pay the price I know but my point that I'm trying to establish during this webinar is that if you are using ice on acute injuries you are possibly sacrificing the patient's healing again in 1978 Dr mkin coined the term rice as it says from his website dr.com he now has an article that he wrote in September of of 2015 why ice delays recovery and he says Dr murkin says when I wrote my bestselling book I coined the termer rice for the treatment of athletic injuries ice has been a standard treatment for injuries and sore muscles because it helps to relieve pain caused by injured tissue coaches have used my rice guideline for decades but now it appears that both ice and complete rest May delay healing instead of helping in a recent study athletes were told to exercise so intensely that they developed severe muscle damage that caused extensive muscle soreness although cooling delayed swelling it did not hasten recovery from this muscle damage a summary of 22 scientific articles found almost no evidence that ice and compression hastened healing over the use of compression alone although ice plus exercise may marginally help to heal ankle sprains that is uh direct quotes from Dr murkin's article why ice delays recovery that you can find on his website at dr.com we have to understand that healing requires inflammation when you damage tissue through trauma or develop muscle soreness by exercising very intensely you heal by using your immunity the same biological mechanisms that you use to kill germs that's called inflammation when germs get into your body your immunity sends cells and proteins into the affected area to kill the germs when muscles and other tissues are damaged your immunity sends the same inflammatory cells to the damaged tissue to promote healing the response to both infection and tissue damage is is the same inflammatory cells rush to Injured tissue to start the healing process the inflammatory cells called macrophases release a hormone called insulinlike growth factor or igf1 into the damaged tissues which helps muscles and other injured parts to heal however applying ice to reduce swelling actually delays healing by preventing the body from releasing igf1 and Dr bkin in his article will go on to say that anything that reduces inflammation also delays healing and that's going to include not only ice but cortisone type drugs any pain relieving medications such as non-steroidal anti-inflammatory drugs like ibuprofen immune suppressants again cold packs or ice and anything else that blocks the immune response to injury the immune response to injury is so important there are also studies that indicate that ice also reduces strength reduces speed reduces erance endurance and reduces coordination what does Dr mkin recommend he says if you are injured stop exercising immediately if the pain is severe if you are unable to move or if you are confused or lose even momentary consciousness you should be checked to see if you require emergency medical attention open wounds should be cleaned and checked if possible Elevate the injured part to use gravity to help minimize swelling a person experienced in treating sports injuries should determine that no bones are broken and that movement will not increase damage if the injury is limited to muscles or other soft tissue a doctor trainer or coach May apply a compression bandage since applying ice to an injury has been shown to reduce pain it is acceptable to cool an injured part for short periods soon after the injury occurs you could apply the ice for up to 10 minutes and remove it for 20 minutes but there's no reason to apply ice more than 6 hours after you have injured yourself so again from the time of injury there is no reason to be applying ice more than 6 hours after the injury so now we will look at several studies and when I cover studies in my presentations I realize it's difficult to to read all of it uh I'm just sharing these with you and we will run through these fairly quickly you can always scroll back in the video If you um find a a study that is of particular interest to you and and you can do your own research and find it but here we go in this study from the Journal of athletic training does cryotherapy improve outcomes with soft tissue injury and I always use red arrows to draw your attention in comparison with other Rehabilitation techniques the efficacy of cryotherapy has been questioned the exact effect of cryotherapy and more frequently treated acute injuries has not been fully elucidated Additionally the low methodologic quality of the available evidence is of concern so again drawing some question into whether cryotherapy does even improve outcomes with soft tissue injury this study indicates these data suggest that topical cooling a commonly used clinical intervention seems to not improve but rather delay recovery from Ecentric exercise induced muscle damage from the sport journal the rice protocol is a myth a review and recommendations uh I believe this is a Open Access paper that you can find on the internet from the author Dominic skia eventually the general public was quickly accepting the notion that any injury should be treated with the application of ice regardless of its severity or how it occurred so uh this in this in this article they go through the interesting history of the use of ice and in this case it was a young man who suffered a severed arm after jumping from a freight train and they packed the arm the severed arm in ice to preserve it continuing from this article the inadequate functioning of the lymphatic system is the primary contributor to the accumulation of waste products excess swelling and the inability to allow for the optimal recovery of damaged tissues and one of the foremost experts on not using eyes out acute injuries Mr Gary rhinol says there's not too much inflammation the problem is there's too little evacuation so we always think of the sprained ankle and how that swelling occurs in the area of the ankle joint and the problem is not that there's too much fluid going into into the area but rather that there's too little fluid getting out conclusions of this article in addition the application of ice has been found to not only delay recovery but to also damage tissue in the process the evidence suggests that the application ofce is only necessary if pain reduction is is the desired outcome and again Dr murkin indicates that from the time of acute injury after 6 hours there is no need to be applying ice 6 hours after injury another article on the topic is ice right does cryotherapy improve outcome for acute soft tissue injury and this article coming to us from the University Hospital gway in gway Ireland they conclude there is insufficient evidence to suggest that cryotherapy improves clinical outcome in the management of soft tissue injuries now what is the alternative many are suggesting that this should be used as an alternative rather than rice we should use the acronym meat for movement exercise analgesics and treatment but this is a presentation on laser therapy so let's examine how laser therapy can potentially help acute injuries laser therapy or photobiomodulation is the mechanism by which non-ionizing Optical radiation of red or near infrared is absorbed by endogenous chromophores to elicit photophysical and photochemical events at various biological scales without eliciting thermal damage so the beauty is we are shining red and infrared laser light on the tissues which is able to penetrate into the tissues and be absorbed by various chrom pores in the tissues to help enhance the healing process unfortunately in the history of laser therapy there have been dozens of terms used to describe this therapeutic procedure and Skeptics of laser therapy would indicate that if we cannot even agree on what we're going to call it why should they give us any Credence or any credibility so thankfully we now have the term photobiomodulation to describe this therapeutic procedure but then of course in everyday terminology you could think of it as a nickname we call it laser therapy an important point to remember is that this gentleman Dr Glenn Calder had introduced the term low-level laser therapy into the medical scientific literature in 1988 and at that time Dr calderhead was working with with surgical lasers and when he would perform a surgical procedure on tissue off to the sides of that surgical cut he noted that the tissues actually actually looked healthier so where the laser was performing the surgery he called that highlevel laser therapy and then off to the side he called that low-level laser so the important point that I want to make is that when he coined the term low-level laser therapy it referred to the reaction at the tissue and not the output power of the laser device I say that because many if not most of the therapeutic lasers being used in healthcare today are class 4 therapeutic lasers what's happening when we apply laser therapy in general we are improving microcirculation in the tissues we are increasing the delivery of oxygen into the tissues increasing tissue oxygenation and by stimulating various enzymes in the cells and in the mitochondria we are helping the cells to produce more energy the net physiological effects of laser therapy treatments are pain reduction inflammation resolution and accelerated tissue healing so when we talk about the use of laser therapy with acute injuries uh this is a paper I just really like to reference when they ask the question photobiomodulation are we inhibiting or resolving the inflammatory process so we all know that the non-steroidal anti-inflammatory drugs block certain Cox enzymes to interfere with the inflammatory process in the tissues and of course that interferes with healing as Dr mkin indicated earlier if the inflammatory process is an essential reaction for survival why do we often use anti-inflammatory drugs and therapies this paper asks well we would use it to relieve short-term suffering and especially pain but however the inhibiting of that inflammatory process is not the same as resolving the inflammation so inhibiting means that we are stopping in the process or stopping that activity at at a certain level in the steps of the inflammatory process whereas resolving means that we are assisting and helping this normal and natural process of inflammation proceed to its logical and healthy end now here they indicate that both nides and Ice inhibit the inflammation at process whereas laser therapy or photobiomodulation resolves the inflammatory process photobiomodulation can act as a therapy resolving inflammation and is not inhibiting the process which is a huge difference photobiomodulation significantly preserved mechanical behavior of inflamed tendons whereas nades did not and photo biom modulation significantly accelerated tendon healing whereas uh various steroids did not so a few more scientific papers looking at the use of laser therapy in animal studies here we're looking at the use of laser and cry cryotherapy for Achilles tendonopathy and rats are results demonstrate that cryotherapy in combination with laser can produce anti-inflammatory add-on effect the order of therapy Administration seems essential as Superior hystology and biochemical results were found in the ice first laser second group so if someone is going to use ice on an injury again it should be used within that six-hour window and if you're going to use ice and Laser together you would use ice first and and then laser second in this study they give you the parameters used for the laser and cryotherapy and here we see the outcome in the upper left is the control group which the animals did not undergo any type of procedure and then in the lower right is the group that underwent tendon trauma followed by 20 minutes of cryotherapy or ice and Then followed by laser therapy treatment 1 hour after injury and so let me emphasize again if you are going to use ice on acute injury use it within that 6-hour window in this study they're doing it within one hour and you can notice that group one and group six virtually identical our results demonstrate that cryotherapy in combination with laser can produce an anti-in anti-inflammatory add-on effect the order seems essential ice first laser second let's think about this for a moment the benefits that we are getting with our laser therapy treatments is to improve microcirculation in the tissues so putting ice in there will reduce the circulation and then by applying laser we are improving the circulation notice that bottom Arrow if they did laser first and then ice that displayed the poorest outcome so when you apply the laser you are improving circulation if you come along and use ice after the laser you will get bad outcomes so just to emphasize if you're going to put ice on an acute injury ice first and then laser we are seeing more and more trainers of professional and college sport sports teams using laser instead of ice and it's encouraging I had a major league baseball head trainer comment to me recently that we're using ice a lot less now only the older guys that came up using ice two players on the whole team the rest of them when they get acute injuries they come in and they want laser therapy so a few more studies to indicate here the effectiveness of photobiomodulation versus ice for a skeletal muscle recovery and in this one they show that there is great be evidence to support the use of photobiomodulation over cryotherapy for more effective post exercise recovery of skeletal muscle performance in other words it is superior after activity Superior to apply laser instead of ice a small animal study looking at the use of laser applied prior to muscle injury and here they found that laser applied immediately prior to injury had positive effects during the muscle regeneration process so there are indications that laser therapy treatments can actually help to precondition the tissues therapeutically before practice or an athletic event this study indicating or looking at the different therapy regimes on the process of tissue repair in paral lesion calcal tendon the conclusion laser therapy was effective in Improvement of collagen fibers organization of the calcal tendon after undergoing a partial lesion laser therapy on tissue repair another one indicating that laser stimulated collagen one proliferation improving the injured Achilles tendon healing process so the indication is showing more and more and more that with any acute injury apply laser immediately after that acute injury this study examined the esia reperfusion injury that happens in um certain types of injuries when you know when the blood flow is cut off that is esea when the blood flow is allowed to return that's reperfusion es keemia reperfusion injury is a by its nature a pro-inflammatory event but this indicates the modulatory ability that's why it's you know the term photobiomodulation is so good because in this case laser therapy attenuates the acute lung inflammation it favors production of interlan which is an anti-inflammatory cyto while at the same time decreasing the amount of tumor necrosis Factor reducing tumor necrosis factor which is a group of cyto kindes that cause programed cell death so again applying laser therapy immediately after this type of injury another one looking at Crush injury in Rat sciatic nerve simply stating that laser therapy should be started as soon as possible after peripheral nerve injury looking at human patients laser therapy for sports injuries laser is an effective treatment for sports injuries particularly jumper knee tennis elbow and achilles tendonitis so I've shared with you numerous studies to indicate that both uh you know laser therapy should be used on acute injuries as soon as possible afterwards because it is going to help with pain resolution and healing of those damaged tissues now some sometimes people will ask about class 4 therapeutic laser on acute injuries and they asked the question well what about tissue heating everyone knows that you do not put heat on an acute injury and if you have any experience with a client for therapy laser you know that it's possible that with some of the treatments there may be a mild elevation of tissue temperature the important point to note is that for acute injuries using the proper settings uh which would be proper power and dosage and treatment delivery technique there is no tissue heating so we're using lower power we are using pulsing uh pulsing frequencies to allow for cooling of the tissues and so when we use laser therapy on acute injuries even the class 4 therapeutic lasers there is no tissue heating so why do we use class 4 laser therapy for our photobiomodulation treatments the treatments are safe and non-invasive with no side effects they are effective for superficial wounds at Deep neurological conditions patients love the treatments it's an inclin service and yes we should use it as soon as possible on acute injuries so there you have it I've shared some information about acute and sports injuries studies on the use of laser therapies for acute injuries and I've given you some clinical recommendations for the treatment of acute injuries my name is Dr Phil Harrington this has been laser for acute and sports injuries l rice and more laser thanks so much for being with me I welcome your comments on the video or send me an email at Laser lessons from Dr Phil gmail.com