Identify and Treat Equine Sacroiliac Problems

By Elaine Pascoe With Kevin K. Haussler, DVM, DC, PhD – See more at: http://practicalhorsemanmag.com/article/identify-and-treat-equine-sacroiliac-problems-11803#sthash.Omnty5wB.dpuf

 

Your horse gallops, jumps, collects, turns and extends his stride with power from his hindquarters. And his sacroiliac (SI) joint?the ?meeting place of his pelvis and spine?is critical at every stride. It transfers the action of his hind legs to his back, translating the push into forward motion.

Given the forces that this joint handles day in and day out, it’s not unusual for horses to develop SI pain. The trick is recognizing the problem: SI injuries are notoriously hard to pin down, with subtle and confusing signs, easily mistaken for other physical or even behavioral problems. Even a “hunter’s bump,” a raised area at the top of the croup that’s often thought to reveal SI trouble, isn’t a reliable sign.

How can you tell if your horse develops SI pain? And, more to the point, what can you do to help him if he does? For this article, we asked Kevin Haussler, DVM, DC, PhD, of the College of Veterinary Medicine and Biomedical Sciences at Colorado State University, for help in answering those questions. Who’s at Risk? Any horse can injure his SI joint in a fall or some other accident. The injury may leave the joint less stable than it was originally, so it can become a source of chronic pain. Performance horses may develop SI problems through simple wear and tear?and the more mechanical stress the joint comes under, the greater the risk, Dr. Haussler says. SI problems are fairly common. In one recent survey, these problems accounted for more than half of 124 horses presented for back problems at the University of Minnesota equine clinic. Show jumping and dressage seem to be especially hard on the joint, according to a study carried out by Sue Dyson, FRCVS, and others at the Center for Equine Studies, Animal Health Trust, Newmarket, United Kingdom. That study analyzed records of 74 horses seen for SI pain at the center. Dressage horses and show jumpers accounted for almost 60 percent of the group. Slightly more than half were warmbloods, suggesting that breed may play a role. And horses with SI pain tended to be taller and heavier than average, another sign that mechanical stress is an important factor. Under stress, Dr. Haussler says, the joint can be injured in several ways. The SI ligaments can tear, just as ligaments and tendons in a limb can give way under stress. And the joint itself, like the hock or any other joint, can become inflamed. Over time, osteoarthritis develops?cartilage wears away and bone remodels. Thoroughbred racehorses sometimes get pelvic stress fractures directly over the SI joint, and those need to be differentiated from SI joint arthritis.

What You’ll See SI problems are hard to spot. The joint has almost no range of motion and is buried under layers of muscle and fat, so you can’t really see or feel it. And signs of SI pain are often frustratingly vague. Your first hint of trouble may be a change in your horse’s performance or attitude?he’s not working at his usual level or seems unwilling to work. He lacks impulsion behind, and his quality of movement isn’t what it was. Your farrier may tell you that your horse is difficult to shoe behind. You may see other signs as well. Some may show up when your horse works on a longe line or in-hand. But ?often signs are worse when your horse is ridden or is asked to canter, because these demands call for more hind-limb ?impulsion and put more stress on the SI. Sometimes the signs are apparent only when your horse is ridden, and sometimes they are felt only from the saddle. Horses with SI problems may not look lame, even to a skilled observer, but they often feel worse to a rider.

Besides lack of impulsion and reduced quality of movement, you may notice that your horse

 

    • is reluctant to move forward.

 

    • holds his back rigid.

 

    • tends to throw his rider upward and forward.

 

    • is reluctant to work on the bit.

 

    • has trouble with lateral work, such as shoulder-in and half-pass.

 

    • is stiff and crooked at the canter.

 

    • changes his leading hind leg (swaps off behind) at the canter.

 

    • has trouble with flying lead changes.

 

    • bucks and kicks out.

 

  • refuses jumps.

Working your horse in-hand (on a firm surface), you may also see that he travels with a wide-based gait behind and has trouble with foot placement on circles. A “hunter’s bump” just indicates a prominent bony crest?the tuber sacrale underneath the muscles at the top of the croup. Prominence on one or both sides may be normal for a particular horse, Dr. Haussler says, but if your horse has pain, muscle spasms and joint stiffness in the SI or pelvic region, then the bump is likely to be significant. It may signal subluxation a partial displacement of the tuber sacrale.

Asymmetrical muscling in the hindquarters is another red flag?or, perhaps, a red herring. Unfortunately, most signs of SI pain can be produced by other conditions. In fact, SI pain often appears along with other musculoskeletal problems. In Dr. Dyson’s study, 25 percent of the horses also had lameness in a front or hind limb, and another 25 percent had arthritis or other problems somewhere in their spines. The problems are often related, but it can be hard to know what came first. Did a lower-leg lameness cause your horse to change his way of going in a way that stressed his SI? Or did SI pain cause him to alter his gaits in a way that overloaded a limb and caused the lameness? Solving the puzzle is a challenge for your veterinarian. Determining the Problem Your horse’s performance history and a clinical examination are the starting points for the diagnosis, Dr. Haussler says. Your veterinarian will watch your horse in motion and perform a hands-on exam, checking for asymmetries and for pain in response to manual pressure. Only the top parts of the dorsal (upper) SI ligaments can be felt directly, and signs of pain and swelling here suggest ligament damage. The joint itself and the ventral ligaments are too deep to check this way, but rectal palpation of the SI region may also produce a pain response. The SI joint can also be blocked with an injection of local anesthesia (in the same way that nerve or joint blocks are done in the limbs). This test can confirm that the SI region is the source of your horse’s discomfort, but it doesn’t tell ?exactly what’s going on. The joint’s deep location makes it difficult to image, but several techniques can help zero in on the nature of the problem:

    • A bone scan (nuclear scintigraphy) can reveal osteoarthritis. Your horse is ?injected with a radioactive substance that accumulates in areas of active bone remodeling, and a gamma camera tracks the substance as it moves through his body.

 

    • Ultrasound scans can detect damage to ligaments. Transrectal ultrasound (the technique used for equine pregnancy checks) may reveal irregular SI joint margins?a sign of arthritis?as well as damage to the ventral (lower) SI ligament.

 

    • Ultrasound or radiographs can help identify a displaced tuber sacrale.

 
Even with these tools, it’s sometimes hard to figure out the exact nature of an SI problem. But knowing the cause of your horse’s pain will increase the odds of ?successful treatment and make a relapse less likely.

Customize His Treatment
Treatment should be customized to the individual case, Dr. Haussler says. Medication, reduced exercise, physical therapy and alternative therapies may all play a role in the program. Here are three key components:

 

    • Reduce inflammation. This is the first step in treating SI pain. Your veterinarian may prescribe a course of oral phenylbutazone (bute) or another nonsteroidal anti-?inflammatory drug. If arthritis or ligament damage is diagnosed, local injections of corticosteroids can help reduce pain and inflammation. The injections are similar to those used in other inflamed joints, such as the hock.

 

    • Reduce exercise. Limited exercise helps by strengthening the muscles that surround the joint?but too much work will aggravate the injury. Your veterinarian can help determine how much and what type of exercise is best for your horse. The program might call for light work in-hand, on the longe line or in a round pen for several weeks. If your horse is comfortable with that, you might start light riding at the walk and then at the trot. Increase work slowly, ?watching carefully for signs that your horse is uncomfortable or ?unwilling.

 

  • Allow turnout. Stall rest isn’t recommended for most SI injuries. In most cases, turnout in a small paddock with good footing is helpful. Avoid deep mud, large rocks, poor footing and steep hills, which may aggravate SI problems.

Arthritis in the SI joint can lead to chronic, low-grade pain. In this case, careful management will help keep your horse comfortable.

 

    • Use a progressive (gradually increasing) exercise program to strengthen and supple his hindquarters. Tailor the length, frequency and intensity of the work to suit your horse, Dr. Haussler says, backing off if your horse seems unwilling or if other trouble signs return.

 

    • Use cross-training techniques?for example, alternate flatwork, hacks in the field and cavalletti work to avoid constant or repetitive stress on the joint.

 

    • Avoid activities that are especially hard on the SI region: jumping, galloping, abrupt transitions, tight turns and circles.

 

  • Turn out your horse as much as possible. Moving around at liberty will help him maintain flexibility, reducing joint stiffness.

Several alternative therapies may help keep your horse on the road to recovery:

 

    • Acupuncture may be useful for pain control in the SI region.

 

    • Therapeutic exercises can help restore impulsion and coordination in the hind limbs. Hind-limb stretching exercises that draw the leg forward (protraction) and backward (retraction) may help relax spastic muscles or contracted connective tissue and restore joint mobility.

 

    • Chiropractic or osteopathic techniques may be helpful in chronic cases to restore normal, pain-free joint mobility.

 

    • Massage may help relax muscle tightness in the croup or upper hind limbs.

 
The outlook for horses with SI injuries depends on the severity and duration of the problem, Dr. Haussler says. A horse with a mild injury should recover and has a good chance of returning to full work. Horses with more severe cases of osteoarthritis or ligament damage may return to a low level of exercise, but their outlook for returning to high performance isn’t so good. As a rule, a horse who responds well to treatment has a better chance of full recovery than one who does not.

The Benefits of Massage

Massages feels amazing, especially after a grueling workout—and their benefits aren’t just skin deep. Soft tissue massage is exceptionally good for bone-weary athletes and people with inflammation-related chronic conditions like arthritis and muscular dystrophy, according to research from McMaster University. Vigorous exercise causes small tears in your muscle fibers, and your body’s natural repair process naturally leads to inflammation and soreness.

To see if massage truly aids recovery, the researchers biopsied volunteers’ legs over the course of three sessions—once while at rest, a second time after they’d vigorously exercised on a stationary bike and received a 10-minute massage on one thigh, and a third biopsy two and a half hours after the second to track the repair processes between the massaged and un-massaged legs.

Unsurprisingly, massage reduced the production of cytokines, which play a critical role in inflammation, and stimulated mitochondria—the tiny powerhouses inside your cells that convert glucose into energy for cell function and repair. So make sure to schedule regular massages; your muscles will adapt better to the demands of increased exercise.

Why Ice and Anti-inflammatory Medication is NOT the Answer

This is a reprint from Stone Athletic Medicine:

 

In July I posted a blog discussing The Overuse of Cryotherapy. The controversy surrounding the topic made it one of the most popular blogs I’ve written. What is surprising to me is that a controversy exists at all. Why, where, and when did this notion of anti-inflammation start? Ice, compression, elevation and NSAIDs are so commonplace that suggesting otherwise is laughable to most. Enter an Athletic Training Room or Physical Therapy Clinic nearly all clients are receiving some type of anti-inflammatory treatment (ice, compression, massage, NSAIDs, biophysical modalities, etc). I evaluated a client the other day and asked what are you doing currently – “Well, I am taking anti-inflammatories and icing.” Why do you want to get rid of inflammation and swelling? I ask this question for both chronic and acute injury!

The Stigma of Inflammation:

Editor in Chief of The Physician and Sports Medicine Journal (Dr. Nick DiNubile) once posed this question: “Seriously, do you honestly believe that your body’s natural inflammatory response is a mistake?” Much like a fever increases body temperature to kill off foreign invaders; inflammation is the first physiological process to the repair and remodeling of tissue. Inflammation, repair, and remodel. You cannot have tissue repair or remodeling without inflammation.  In a healthy healing process, a proliferative phase consisting of a mixture of inflammatory cells and fibroblasts naturally follows the inflammatory phase (1). Researchers headed by Lan Zhou, MD, PhD, at the Cleveland Clinic, found that in response to acute muscle injury, inflammatory cells within the damaged muscle conduct phagocytosis, contribute to accumulation of intramuscular macrophages, and produce a high-level of Insulin-like growth factor 1, (IGF-1) which is required for muscle regeneration (3). IGF-1 is a primary mediator of the effects of growth hormone and a stimulator of cell growth and proliferation, and a potent inhibitor of programmed cell death. Similarly, in 2010, Cottrell and O’Conner stated “overwhelmingly, NSAIDs inhibit or delay fracture healing” (2). And you want to stop this critical process of healing by applying ice, because inflammation is “bad”?

The Anecdotal Rationale for Ice:

Somewhere along the line the concept that ice facilitates healing became conventional wisdom. Sorry, that wisdom is wrong. I had someone tell me the other day, “We need to ice, because we need to get the swelling out.” Really? Does ice facilitate movement of fluid out of the injured area? No, it does not. The lymphatic system removes swelling. The Textbook of Medical Physiology says it best: “The lymphatic system is a ‘scavenger’ system that removes excess fluid, protein molecules, debris, and other matter from the tissue spaces. When fluid enters the terminal lymphatic capillaries, any motion in the tissues that intermittently compresses the lymphatic capillaries propels the lymph forward through the lymphatic system, eventually emptying the lymph back into the circulation.”  Lymphatic drainage is facilitated by contraction of surrounding muscle and changes in compressive forces that push the fluid back to the cardiovascular system. This is why ankle pumps work so well at removing swelling.

Inflammation is a necessary component in the first phase of phase of the healing process. Swelling is controlled by the body’s internal systems to attain homeostasis. If swelling is accumulated it is not because there is excessive swelling, rather it is because lymphatic drainage is slowed. The thought that ice application increases lymphatic flow to remove debris makes no sense. Gary Reinl, author of “Iced! The Illusionary Treatment option gave me a good analogy. Take two tubes of toothpaste, one is under ice for 20 minutes, the other is warmed to 99 degrees. In which tube will the toothpaste flow fastest?  It does not take an advanced physics degree to know that answer.

What might surprise you is that ice actually reverses lymphatic drainage and pushes fluid back to interstitial space. A study published in 1986 (yes, 1986, is old, but this is a foundational study) found when ice is applied to a body part for a prolonged period of time; lymphatic vessels begin to dramatically increase permeability. As lymphatic permeability increases fluid will pour from the lymphatics into the injured area, increasing the amount of local swelling (5). Ice can increase swelling and retard debris removal!

The Acronym RICE is Bogus:

The acronym RICE is bogus in my opinion. First, Rest is not the answer. Rest does not stimulate tissue repair. In fact rest causes tissue to waste and can cause abnormal gene transcription of collagen tissue. Evidence has shown that tissue loading through exercise or other mechanical means stimulates gene transcription, proteogenesis, and formation of type I collagen fibers (See studies by Karim Khan, Durieux, Mick Joseph, and Craig Denegar). Our body has all types of cells. When a cell is born it has no clue what type of cell it will eventually become. This infancy cell – for lack of a better term – is called a progenitor cell. Progenitor cells can be changed to a specific cell type. Load in tendon tells our body to turn a progenitor cell in to a tenocyte. Load in bone tells a progenitor cell to become an osteocyte. Ever wonder why myositis ossificans (calcification or bone growth in muscle) develops? The direct, repeated trauma turns progenitor cell currently living within muscle to an osteocyte. Subsequently, we develop bone growth within muscle.

The other reason RICE is bogus is obvious; Ice. Ice does nothing to facilitate collagen formation. Ice will not influence progenitor cell development. Ice does not regenerate tissue. Ice does not facilitate healing – it inhibits natural healing process from occurring. Ice does not remove swelling; it increases swelling and lymphatic backflow.

Closing thoughts:

Bottom line, ice and NSAIDs are over utilized. I am not saying never, but I am saying ice is not a magical cure all that fixes everything and is required for healing. It is not the gold standard that it has come to be. My goal with this blog is to get individuals to stop and think before immediately turning to ice and NSAIDs. Is it really the best option? Is it necessary for this injury at this stage? I understand it is not the only form of treatment clinicians use, but ice certainly is the most heavily used. Go ahead, I will wait while you look at your treatment logs.

My goal is to get this trend reversed one clinician and one patient at a time. Have you seen the video discussion between Kelly Starrett, DPT and Gary Reinl? If not I recommend you watch it. It’s fascinating. I am glad to have expert minds like Kelly and Gary in this fight with me.

I ask health care professionals to do one thing, just try it. Pick one client with chronic musculoskeletal pain, skip the ice, skip the NSAIDs and try to use light exercise as a repair stimulus. Then, try skipping the ice on a client with an acute mild injury. The outcomes might surprise you.

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Cold Laser for All Animals and People

Cold laser therapy offers a wide range of options for tissue therapy, wound healing, pain management, and improved circulation. Cold laser therapy is a game changer for many pets suffering from painful injuries. This technology allows us to successfully treat many injuries including tissue damage, inflammation, wounds, and even scars with minimal invasion.

The technology has been used in Europe since 1970 to promote healing, but has only been approved by the FDA for use in the U.S. since 2002. It is only recently, though, that U.S. veterinarians have begun using it to treat many different conditions that affect pets today, such as fractures, ligament and tendon injuries, post-surgical incisions, arthritis, nerve injuries, sprains, muscle strains, abrasions, lesions, and more.

Cold laser therapy is non-invasive and makes use of light in order to stimulate activity or regeneration in cells in addition to increasing blood circulation. Unlike hot laser treatments that target tissue deep beneath the skin’s surface, cold laser therapy treats injuries or damage on or near the surface – without the risk of cutting or burning from the lasers. Most conditions require between three and eight treatments, though I have seen great improvement after the first laser session. Most animals enjoy their seession: many fall asleep or thoroughly relax. th

 

Could Your Horse Do Better at Shows?

If your horse has squeaky clean X-rays and MRI’s, does that mean the horse is pain free? You can ask the same question about your own body. The answer is, of course, no. If you play tennis or ski or ride or dance or even garden, you know you can hurt without being injured. The same goes for your horse.  What surrounds the skeleton is of more importance than the skeleton itself. Until fairly recently, the fascia has been largely ignored by most health care professionals, and cannot be seen in standard tests such as X-rays and MRIs.

The body work that I do on horses is meant to alleviate the pain and stress of horse sport. If the body is balanced and symmetrical, then the body can move gracefully, without distortion.  This restoration of the body can be done gently and thoroughly with a combination of myofascial release, stress point, and trigger point therapy,

Strains, due to injuries and accidents, get lodged in the body when a horse compensates movement during the healing process. Unless these compensations are fully released and realigned,  they eventually become chronic strains that limit coordinated movement and cause pain. Horses need massage just as much, if not more, than any human athlete, since they have to carry someone on their back! The benefits of massage are the same for horse or human, with increased suppleness, better range of motion, and quicker recovery from injury.  This therapy is so much more than a relaxation massage. It improves performance and longevity in whatever sport or casual use they are involved in.

My biggest thrill is to help an animal become pain free. They behave and perform differently. Their whole personality and energy can change. And the results of the massage can be long lasting.

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Whole Body Treatment

The usual approach to treating sore muscles is to use liniment for a relaxing rubdown, or use a high tech blanket, or maybe do some leg stretches.  And if none of those techniques work, what is next?  Trigger points, or muscle knots, are small patches of contracted muscle fibers that cause aching and stiffness. When activated through strain or injury, they cause pain either at the site itself, or refer it somewhere else in the body.

Thousands of muscle fibers contract to create movement. Sometimes muscle fibers can tear, leading to tension, swelling, and heat. What may begin as a small numbers of fibers, barely noticeable, can become a progressive problem as the micro trauma spreads to adjacent muscle fibers.

Conscientious riders will be aware of the smallest change in movement or behavior and take action before the problem becomes a major injury.

When muscle fibers are injured, the surrounding area becomes shortened and tight. This uneven stress can be transferred through the fascia and cause additional pain and restrictions in other parts of the body as trigger points or stress points.  My job is to apply gentle pressure until the restriction is released, and free movement and balance are restored. Muscle tension, pain, postural imbalances, and improved circulation are all benefits of stress and trigger point therapy. As Jack Meagher always said, “That is called putting your finger on the problem!”

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New Uses for Cold Laser

Cold laser therapy works by altering or stimulating cellular function. The light energy penetrates,  depending on the wavelength,  and affects cells and blood vessels.  The laser can block a nerve’s ability to send a pain signal to the brain, increasing blood flow or decreasing swelling. It may also significantly speed wound healing.

It’s noninvasive. When used correctly, it doesn’t have any side effects. It can be used weekly or monthly for pets with chronic pain, giving them better quality of life. In cases of severe pain caused by surgery or trauma, laser treatment can be used twice a day for a few days and then daily to diminish pain and speed healing.

Some exciting new areas of study for laser healing are range of motion, baldness, jaw clicking, Parkinson’s, Alzheimer’s, and  stress. treating stress, anxiety and depression with cold laser therapy. The protocol for stress combines ancient Chinese medicine and laser technology that’s used on acupressure points to boost  endorphins and dopamine. These chemicals naturally help your body reduce the physical effects of stress.

Lasers have been shown to speed healing time by about 50%. th

 

The Body Remembers

The nervous system remembers the pain and trauma of an injury. With your horse, you might see this as stiffness at the beginning of a workout, or extreme caution. When a rider tells me their horse just “doesn’t want to jump anymore”, I suspect muscle pain and get to work looking for it.

Trauma accumulates in the body, starting at birth. Have you considered how much trauma there is for a foal during the birth process? The results can set up tight muscle patterns that last a lifetime, unless manually removed.

Myofascial release aims to relax contracted muscles, improve blood and lymphatic circulation, and stimulate the stretch reflex in muscles. Often I stand back after just one bodywork session and see that the body is already reorganizing itself. The body looks less chopped up into sections and more of one flowing form.  During a session the body of the horse is educated in the process to move the way it is supposed to: in balance and without restrictions. If the connective tissue that covers every muscle, bone, nerve, blood vessel,  and organ in the body is free of restriction, the horse will move and behave in a completely different way.

Myofascial therapy relieves soft tissue restrictions that cause pain. Some causes of chronic muscle pain are easier to diagnose than others: trauma from birth or a fall, cumulative posture misalignment , a compressed nerve from poor saddle fit, etc.

When pain is caused by Myofascial tightness the diagnosis can be difficult, as fascia restrictions do not show up on MRI scans or X-rays. Yet, those restrictions can play a significant role in creating pain and malfunction in the structure of the back and legs. Every horse (and dog and human!!) should experience pain free movement that can result from having restrictions removed.

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Preventing Injury in Your Riding Horse

What would your horse be like if all his muscles were in a state of relaxation, free from tension? Deep tissue massage, stress and trigger point therapy, and myofascial release
will help the connective tissue become more elastic, thereby allowing the muscle to  return to its natural shape.

It is very important for horses to maintain a comfortable and free range of motion.  If certain muscles are tight, other muscles in the body will compensate and take up the extra workload. They may be ridden like this for weeks, months or years, until the body can no longer call on extra resources because it does not have them. This ultimately leads to ruptures of soft tissues and thickening of the tendon and ligaments, which eventually can cause permanent dysfunction of the affected area.

Muscles attach to  bones in pairs of opposites, and cross one joint or more. Muscles free from tension will carry out the function of keeping joints in alignment.  This allows joint fluid to flow evenly within the joint, and this reduces unnatural wear and tear of joints.

Each muscle is attached to bone by tendons. Muscles are designed to take 90% of workload and tendons the other 10% The muscle is where the elasticity is. If the muscle is not functioning properly then the tendons will take more load and can eventually tear.

Equine massage therapy is a very powerful tool in injury prevention for horses.

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Immediate Pain Relief

Cold laser treatments provide pets with relief from painful symptoms of a variety of medical conditions and diseases. These treatments are non-invasive and painless. Recovery time is greatly reduced.

Both laser therapy and acupuncture are based on traditional Chinese medicine’s concept of chi, or energy. Ancient theories about how chi moves through the body mirror modern medicine’s understanding of how the nervous system functions in the body. Both acupuncture and laser therapy pinpoint specific spots along the body’s chi (or nervous system) where there are blockages, which obstruct the flow of energy or information throughout the body. Blockages hinder the body’s ability to function at an optimal level and heal at an accelerated rate.

Both acupuncture and laser therapy have been shown to increase circulation throughout the body, reducing inflammation, relieving pain, and accelerating healing. These therapies offer pain management and treatment for conditions like immune-related disorders, skin conditions, arthritis, and reproductive disorders.

Low level laser therapy is being successfully used treat pain or stiffness associated with arthritis and other degenerative joint conditions, acute injuries, and post-operative recovery for surgical patients. It has been found to be an excellent, well-tolerated alternative to drugs. This type of laser treatment is different from surgical lasers that cut. This wavelength of light penetrates the skin without cutting or burning it. It stimulates the cells and blood vessels that lie just beneath the skin. It does this without causing any harm to the tissues.

The laser’s contact with injured or diseased tissue promotes the production of ATP, a substance essential to cellular reproduction and repair. This enhances the body’s natural healing abilities. Laser therapy strengthens injured tissues, which makes them less vulnerable to re-injury during the recovery process. It also reduces internal scarring, another potential source of pain and stiffness. Painkilling drugs can only mask the symptoms — they don’t treat the underlying issues.

 

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