Editor's Note: Part 1 of this article appeared in the March 2018 issue and covered documenting 1) laser penetration, 2) technique performed and 3) effective dosage.
4. Document Treatment Goals
Photon tissue interactions fall into primary, secondary and tertiary responses. Laser therapy ultimately will result in acceleration of pain relief, inflammation reduction and tissue repair.
According to Hode and Tuner in Laser Phototherapy, the photons, which are the packets of light energy produced by the laser, penetrate through the skin and into the cells. The cells are then able to absorb and convert this light energy to chemical energy that is able to promote healing and pain relief.
The light energy is absorbed in the cytochromes (receptors in the cell). As a result, the rate of ATP production from the cell is increased – bringing the rate of cell metabolism from a depressed rate, as is the case in damaged tissue, to a normal level.
As a result of this increased cell metabolism, many different biological effects may occur. Cell repair is stimulated among all different tissues; tendon, bone, skin, nerve and muscle can all be affected. Laser light has been shown to regenerate nerve cells and restore nerve function.
There has been shown to be an increase in prostaglandins, increased enzymes and growth factors, and cellular products after laser therapy. Angiogenesis can occur, along with reduction of fibrous tissue formation, which is beneficial to healing of chronic wounds. The end results of all of these biological effects are reduction of pain, resolution of inflammation and increased tissue repair.
Key Documentation Items:
- Pain relief only
- Inflammation reduction only
- Tissue repair only
- Combination of items 1-3
5. Document Health and Safety Precautions
Appropriate health / safety precautions should be routine in the office. For example, use clear plastic film on the laser treatment head/aperture when treating the mouth, ear and other moist surfaces or open wounds. Goggles should be worn by both clinician and patient.
Key Documentation Items:
- Adding clear plastic film to treatment regimen
- Goggles worn by patient and clinician
6. Document Treatment Results
Improvement can be judged by the patient's decreased pain or objectively by:
- Inspection: reduced swelling, redness, bruising
- Palpation: reduced tenderness and less pain
- Function: increased strength, mobility, ROM
- Imaging: IR image, thermography, MRI, photos
Key Documentation Items:
- Findings from inspection as necessary
- Findings from palpation as necessary
- Findings from function as necessary
- Findings from photos and imaging as necessary
Putting It All Together
Below are two examples of documentation with a laser that illustrate the principles of appropriate documentation discussed in this two-part series.
Scenario #1: treatment given and plan of care: Laser therapy (S8948) was applied to the patient's right medial, anterior, lateral and posterior knee to reduce swelling and pain related to the sprain, by Cindy Anderson, CCPA. Both the patient and clinician were wearing appropriate protective goggles.
With direct skin contact technique, an 810 nm, 7W continuous wave GaAlAs laser, modulated down to 4W of average power, was applied equally over each area of the four regions of the knee for a total of 15 minutes, delivering a total of 3,600 Joules. The expected dose at the target tissue 2-3 cm deep is 5-10 Joules/cm2 with 20 Joules/cm2 at the surface, estimating 180 cm2 treatment area (three playing cards).
There was a noticeable reduction of swelling of the anterior medial section of the knee after application from a 3+ to a 2+ edema grade. Tenderness went from a +3 to a +2 grade. Pain levels dropped from a 5/10 (very distressing, strong, deep and piercing) to a 2/10 (discomforting). The patient should be seen again in three days if the swelling or pain stays the same or worsens.
Scenario #2: treatment given and plan of care: The patient was treated today by Dr. Jones with a 910 nm, 250W peak power, 2W average power, superpulsed therapeutic laser (S8948) to the right shoulder and cervical spine. Both the patient and clinician were wearing appropriate protective goggles.
With direct skin contact, 662 Joules were applied to the C5 and C6 spinous processes, right facet joints, right paraspinal muscles, scalene, and trapezius regions and 662 Joules were applied to the right anterior shoulder tendons and the subacromial bursa regions for a total of 16 minutes to reduce the pain, tenderness and inflammation caused by the cervical sprain, facet capsulitis, C5 disc herniation with C6 radiculitis, and right shoulder sprain / strain. The expected dose at the target tissue up to 4 cm deep is 3-6 Joules/cm2 with 12 Joules/cm2 at the surface, estimating 120 cm2 treatment area (two playing cards).
The patient reported 75 percent subjective improvement with intensity of pain after treatment. It was recommended that the patient continue to use ice on the right cervical spine region for 15 minutes and off for one hour, and to the shoulder for 10 minutes and one hour off. Repeat three times throughout the day for the next two days, and then return in two days.
Key Points to Remember
Proper laser therapy documentation creates a paper or electronic trail of your patient's progress toward the treatment plan and goals you, as the chiropractor, have established. As discussed in this article and the previous one, always make sure you document the following:
- Laser penetration
- Method of treatment (i.e., technique and specific site of treatment)
- Effective dosage; including 15 minutes or other duration of time
- Physiology and treatment goals
- Health / safety precautions
- Results of treatment
