1 The use of EPAs In the management of Inflammation/edema/swelling Hand therapists Feb 2016 Alison M Hoens Physical Therapy Knowledge Broker, UBC, PABC, VCHRI, PHCRI Clinical Professor, UBC Research, Education & Practice Coordinator, PHC With content from Dr. J Anthony Clinical Associate Professor 1 What are we treating? Inflammation Edema Swelling Are these synonymous terms? Is the treatment the same? Is trauma induced inflammation the same as immune-mediated inflammation? 2 3
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1
The use of EPAs
In the management of Inflammation/edema/swelling
Hand therapists Feb 2016
Alison M HoensPhysical Therapy Knowledge Broker,
UBC, PABC, VCHRI, PHCRI
Clinical Professor, UBC
Research, Education & Practice Coordinator, PHC
With content from Dr. J AnthonyClinical Associate Professor 1
What are we treating?
� Inflammation
� Edema
� Swelling
� Are these synonymous terms? Is the treatment the same?
� Is trauma induced inflammation the same as immune-mediated inflammation?
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ELECTRICAL STIMULATION
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HVPC
Intensity
Duration
Interpulse interval
9900 microsec100 microsec
Pulse duration
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3
ESTIM FOR INFLAMMATION, EDEMA,
SWELLING - HVPC
� Waveform: Twin peak monophasic
� Frequency: ~ 1-200 Hz
� Pulse Width: ~ 5-65 microsec (fixed)
� Peak Current: High
� Interpulse Interval: Long
� Total Current: Very low (~ 1.5 mA)
� Polarity: Yes
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ESTIM FOR INFLAMMATION, EDEMA, SWELLING - PHYSIOLOGICAL RATIONALE
� Release of “wound-healing” factors –histamine from mast cells; serotonin from platelets (Fyfe & Chahl 1982, 1984; Williams 1974; Williams et. al. 1976), leading to vasodilation & activation of adhesion molecules
� Probably by altering membrane permeability to Ca++ and other ions (e.g. Mortimer & Dyson 1988, Dinno et. al. 1989)
� This effect may be mechanical in part (Schilcher, 2006)
� Appears to accelerate inflammatory stage to make it as efficient as possible
� Encourages edema to occur more rapidly, then subside more rapidly (Fyfe & Chahl 1985, Hustler 1978)
Slide
courtesyDr J Anthony
US for inflammation/ edema/swelling: Summary
� US works best in tissue that has high
protein (collagen) content
� In early phase of repair, low dose is
effective (eg. Larsen et al, 2005), higher dose can be
after Watson, T (2008) Ultrasonics 48; 321-329 and Robertson, Ward, Low & Reed (2006) “Electrotherapy
Explained”, 4th ed. p 288., Alexander LD et al (2010)
Ultrasound is valuable not because it changes the sequence of the healing events, but because it has the capacity to stimulate or enhance normal events
and increase the efficiency of repair phases. (Watson)
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Slide courtesy
Dr J Anthony
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US Technique Tips
� Size of area: not greater than 2x sound head� Duration of Rx: 5 – 10 minutes for twice the area of the
treatment head face (= 2.5 – 5 mins for every ERA)
� Calibration of equipment!� studies show that ultrasound equipment is
frequently delivering less energy than expected (see, e.g. Kollmann 2005, Artho 2002, Pye 1996, Rivest 1987)
� US devices should be calibrated at least once per year –more frequently if in constant use
� Calibration is not the same as electrical safety check
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Contraindications & Precautions
Physiotherapy Canada 62(5), 2010.
Special Issue on Electrophysical Agents.
Houghton PE, Nussbaum EL, Hoens, AM.
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LOW LEVEL LASER THERAPY
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LASER: Mechanisms
� Photo-biomodulation:� Photo-biostimulation
� Photo-bioinhibition
� Laser photons are absorbed by photosensitive organic molecules (chromophores)
� Chromophores are molecules which absorb light:
� respiratory chain enzymes (e.g. cytochrome-c oxidase; red -near IR)
� hemoglobin, myoglobin; visible red
� water; infra-red
� also non-mitochondrial photoacceptors (e.g. NADPH-oxidase, NO-synthase)
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Slide modified
fromDr J Anthony
LASER – Mechanism of Action
Photobiomodulation
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Chung H, et al. Annals of Biomedical Engineering, 2011Slide modified from
Dr J Anthony
LASER Reduces Inflammation
� Reduces prostaglandin E2 concentrations
� Inhibits cyclooxygenase-2 (COX-2) in vitro
� Reduces TNFα
� Enhances local hemodynamics
� Increases cellular oxygenation and mitochondrial ATP
Fulop A, et. al (2010))
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Slide courtesy
Dr J Anthony
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LASER: Mechanism cont’d
� Light in the green to red / near IR wavelengths catalyzes the ability of nitric oxide synthase to generate NO, leading to:
� Vasodilation (relaxes vascular smooth muscle)
� Modulation of inflammatory & immune response by inhibiting T- and B-cell diversification and leukocyte recruitment
� Production & regulation of several cytokines, chemokines and growth factors regulating the pro-and anti-inflammatory response (next slide)
� Modulation of angiogenesis (upregulates VEGF)
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Slide courtesy
Dr J Anthony
Why is NO modulation important?Because of the effect on cytokines & growth factors
Prindeze, 2012
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Slide modified from
Dr J Anthony
LASER For Inflammation, Edema, Swelling
Clinical Application
� CI/Ps; Goggles for patient and therapist
� Clean lens - check with manufacturer
� Contact is better than non-contact � Apply some pressure on contact
� 904 nm LASER 1-4 J min total dose
� 820 nm LASER 4-16 J min total dose
� Increase dosage for increased pigmentation of skin
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Slide courtesy
Dr J Anthony
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LASER Reduces Inflammation
“Red and near infrared LLLT administered
with mean laser output of 2.5–100 mW, irradiation times of 16–600 sec and doses of
0.6–9.6 J reduces inflammation significantly,
and is equally effective as NSAIDs in animal laboratory studies.”
Bjordal J, et al, (2010)
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Slide courtesy
Dr J Anthony
Contraindications & Precautions
Physiotherapy Canada 62(5), 2010.
Special Issue on Electrophysical Agents.
Houghton PE, Nussbaum EL, Hoens, AM.
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Therapeutic Application
� Colour
� Red vs. Infra-red
� Dose
� J / point*
� # of points
� Technique
* See handout for calculating Joules if your LASER does not do so automatically
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Further details available: www.walt.nu
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Further details available: www.walt.nu
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LASER Technique
� Contact
� Grid
� Point
� Non-contact
� Grid
� Scanning
http://www.lasermedix.com
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LASER Technique Tips
� Contact (with pressure) is preferable to
non-contact
� Clinical relevance of frequency of pulsed
output still unclear
� Current guidelines are < 1 kHz for acute, > 1 kHz for chronic
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BC LASER Safety GuidelinesHigher Power Laser Safeguards
Higher power health care and industrial lasers, classes 3b (i.e. 5 – 500 mW) and Class 4 (now seen clinically)
• Use in a controlled area.
• Laser eye protection is required.
• Only authorized personnel must occupy the area.
• The area must have an appropriate warning sign.
• Any windows, doorways, openings, etc. must be either covered or restricted
Take home message: strong evidence that it is effective for pain & mod evidence that it attenuates secondary cell death d/t reducing cell metabolism & neutrophil activity
COLD FOR INFLAMMATION, EDEMA, SWELLING - PHYSIOLOGICAL RATIONALE
� To decrease local metabolism (McAuley, 2001; Merrick, 2002)