Laser Therapy

Abdulaziz Awali, PT, MPT, DPT, PhD

Physiotherapy Department
Umm Al-Qura University
 Content of the Lecture
• Physics and properties of laser.
• Methods of application and dose calculations.
• Physiological effects and indications.
• Contraindications and precautions.
 Introduction
• ‘Laser’ is an acronym for Light Amplification by Stimulated Emission
of Radiation.
• Lasers have wide application in medicine and surgery.
• In physiotherapy, laser is used for the treatment of open wounds, soft-
tissue injuries, arthritic conditions, and various types of pain.
 Physics of Lasers
• A laser is a form of electromagnetic energy that has wavelengths
and frequencies that fall within the infrared and visible light
portions of the electromagnetic spectrum.
• Electromagnetic light energy is transmitted through space as
waves that contain photons.
• Each photon contains a definite amount of energy, depending on
its wavelength (color).
• A laser consists of a gain medium, which is a
material (gas, liquid, solid) with specific optical
properties contained inside an optical chamber.
• When an external power source is applied to the
gain medium, photons are released, which are
identical in phase, direction, and frequency.
• To contain them, and to generate more photons,
mirrors are placed at both ends of the chamber.
• One mirror is totally reflective, whereas the other
is semitransparent.
• The photons bounce back and forth
reflecting between the mirrors, each time
passing through the gain medium, thus
amplifying the light and stimulating the
emission of other photons.
• Eventually, so many photons are
stimulated that the chamber cannot
contain the energy. When a specific level
of energy is attained, photons of a
particular wavelength are ejected through
the semitransparent mirror appearing as a
beam of light.
• Thus, amplified light through stimulated
emissions (LASER) is produced.
 Properties of Laser
• The laser light is emitted in an organized manner rather than in a
random pattern as from incandescent and fluorescent light sources.
• Three properties distinguish the laser:
1. Coherence.
2. Monochromaticity.
3. collimation.
v Coherence:
• Coherence means all photons of light emitted from individual gas
molecules are of the same wavelength and that the individual light
waves are in phase with one another.
• Normal light, on the other hand, is composed of many wavelengths
that superimpose their phases on one another.
vMonochromaticity:
• Monochromaticity refers to the specificity of light in a single, defined
wavelength; if the specificity is in the visible light spectrum, it is of
only one color.
• The laser is one of the few light sources that produces a specific
wavelength.
vCollimation:
• The laser beam is well collimated, that is, there is minimal divergence
of the photons.
• That means the photons move in a parallel fashion, thus concentrating
a beam of light.
Directional
Light

Divergent
Light
 Types of Lasers
• Lasers are identified according to the nature of the gain medium.
• The gain mediums used to create lasers include the following
categories: crystal and glass (solid-state), gas, semiconductor, liquid
dye, and chemical.
• Lasers can be categorized as either high- or low-power, depending on
the intensity of energy they deliver.
• The use of low-power (low-level lasers) are used for the healing of
wound and soft tissue injuries, control acute or chronic inflammation
or edema, and for pain control.
 Low-Level Laser Therapy
• Low-level laser therapy (LLLT) is the dominant term in use today. But
Therapeutic laser, low-power laser, or low-energy laser are also used
for laser therapy.
• Most commonly used lasers:
1. Gallium aluminum arsenide (GaAlAs)
2. Helium neon (HeNe)
3. Gallium arsenide (GaAs) Low-level lasers
• The GaAlAs laser is the newest and currently the most commonly
used laser.
• These lasers can vary in wavelengths with the wavelength depending
on the aluminum content.
• Tissue penetration for this laser is approximately 2–3 cm.
• This laser naturally produces a continuous wave, but can be delivered
in a selected pulse mode, similar to ultrasound.
 Dose Calculations
• It is recommended that the dose delivered to a patient during a treatment
session should be based on the ENERGY DENSITY rather than the power
or other measure of dose.
• Energy Density is measured in units of Joules per square centimeter
(J/cm2).
• One of the most significant inhibitors to the more widespread adoption of
laser therapy in the clinical environment relates to the difficulty in getting
these ‘effective’ laser doses to work on a particular machine.
• Few devices enable the practitioner to set the dose in J/cm2. Some will
provide Joules, some Watts, some watts/cm-2, …… etc.
vPower and Power Density
• Power is measured in watts or milliwatts, or power density
(irradiance), measured in mW/cm2.
• Power is the rate of energy flow, and power density is the amount of
power per unit area.
• Laser applicators generally have a fixed power, although in some cases
this can be reduced by pulsing the output.
• Because high-intensity lasers have the potential to cause harm, all
lasers are assigned four classes, according to their power range.
• The power of most laser diodes used for therapy is between 5 mW and
500 mW. This is in the 3B class power range.
Class Power (mW) Effects
1 <0.5 • No hazard
2 <1 • Safe for momentary viewing; will provoke a blink
reflex
3A <5 • Commonly used for laser pointers
• Poses an eye hazard with prolonged exposure
3B <500 • Used for therapy
• Can cause permanent eye injury with brief exposure
• Direct viewing of beam should be avoided
• Viewing of diffuse beam reflected from skin is safe
Can cause minor skin burns with prolonged exposure
4 >500 Surgical • Can cause permanent eye injury before you can react,
and industrial • Can cause serious skin burns,
cutting lasers • Can burn clothing,
• Use with extreme caution
vWavelength.
• Most therapeutic laser applicators
include near-infrared (≈700 to 1100
nm) or red (≈600 to 700 nm) light.
• Applicator with longer wavelength,
penetrates more deeply than red light
à therefore is most suitable for
treating deeper tissues up to 3 to 4 cm
deep.
 Method of Application
• Although the method of application may vary depending on the
presenting condition, wherever possible the treatment head or probe
should be applied with a firm pressure to the area of tissue to be
treated (contact technique).
• Using a firm pressure or contact technique is important for :
1. Maximize the power density on the tissue surface,
2. Treat deeper-seated lesions more effectively.
3. Treating trigger points and thus effectively combines laser with
acupressure-type treatments.
 Treatment of Open Wounds and Ulcers
• For comprehensive treatment of open wounds, irradiation is applied in
two stages: the first using standard contact technique around the edges
of the wound; the second, during which the wound bed is treated,
using non-contact technique.
vTreatment of Wound Margins
• For this, a single-diode probe is the
ideal unit to apply treatment around the
circumference of wound at
approximately 1–2 cm from its edges.
Points of application should be no
more than 2–3 cm apart, and the
treatment unit should be applied with a
firm pressure to the intact skin, within
the patient’s tolerances.
v Treatment of the Wound Bed
• Using non-contact technique, the dosages applied during
treatment will be much lower than during application over intact
skin (1–10 J/cm2) with 4 J/cm2 being most commonly
recommended
• The wound may be ‘mapped’ with a hypothetical grid of equal-
sized squares (typically 1–2 cm2 ), each of which may be regarded
as an individual area of target tissue and treated accordingly at the
recommended dosage.
• Some therapists have also employed some variant of scanning
technique (the probe is moved slowly over the area of the lesion
using a non-contact technique ).
 Physiological Effects of Lasers
v Light can stimulate ATP and RNA production within cells.
• The clinical effects of light are related to the direct effects of light
energy—photons—on intracellular chromophores in many different
types of cells.
• A chromophore is the part of a molecule that gives tissue its color
by absorbing some wavelengths of light and reflecting others.
• Absorbed light energy can stimulate chromophores to undergo
chemical reactions.
• For example, stimulating cytochrome-c oxidase, a chromophore
present in mitochondria will impact ATP production à affects
RNA production production and alters the synthesis of cytokines
involved in inflammation.
• Promote Adenosine Triphosphate Production
• Laser has been shown to improve mitochondrial function and
increase their production of ATP by up to 70%.
• Increased ATP production promoted by laser and other forms of
light is thought to be the primary contributor to many of the clinical
benefits of LLLT.
v Promote Collagen Production
• LLLT is also thought to enhance tissue healing by promoting
collagen production.
v Modulate Inflammation
• Laser causes changes in inflammatory mediators which will
likely increase blood flow; enhance keratinocyte migration and
proliferation; and enhance activity of T and B lymphocytes,
and macrophages.
• Laser can also stimulate proliferation of various cells involved
in tissue healing including fibroblasts and endothelial cells.
v Inhibit Growth of Microorganisms
• Laser light can also inhibit the growth of microorganisms including
bacteria and fungi including Staphylococcus aureus and
Escherichia coli.
• These effects may be due to direct cytotoxic impact of the
irradiation on the bacteria or stimulation of the antibacterial
immune response.
v Promote Vasodilation
• Laser light can induce vasodilation, particularly of the
microcirculation à accelerate tissue healing.
v Alter Nerve Conduction Velocity and Regeneration
• Laser light stimulation of nervous tissue increases peripheral nerve
conduction velocities à These positive effects occur in response to
laser irradiation over the site of nerve compression.
 Indications
• Soft tissue healing
• Bone healing
• Nerve entrapment conditions like carpal tunnel syndrome
• Pain Management
• The effects of laser light on pain may be mediated by its effects on
inflammation, tissue healing, nerve conduction, or endorphin release or
metabolism.
 Contraindications
• Impaired sensation.
• Impaired mentation.
• Malignancy.
• Low back or abdomen during pregnancy.
• Epiphyseal plates in children.
• Directly over the eyes
• Lasers can damage the eye, particularly the retina, because the light
is directional and thus is very concentrated in one area.
• Over Hemorrhaging Regions
• Laser therapy is contraindicated in hemorrhaging regions because it
may cause vasodilation and thus may increase bleeding.
• Over the Thyroid or Other Endocrine Glands
• LLLT to the area of the thyroid gland can alter thyroid hormone
levels in animals.
• Within 4 to 6 Months After Radiotherapy
 Precautions
• Direct Irradiation of the Eyes
• Because lasers can damage the eyes, the patient + the therapist
should wear goggles opaque to the wavelength of the light emitted
from the laser.
• Goggles should be marked with the wavelength range they
attenuate and their optical density within that band (frequency
band).
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