L5_Laser therapy

What is laser?
- Light Amplification by Stimulated Emissions of Radiation
- A beam of electromagnetic radiation
- A discrete wavelength at different regions of the spectrum (e.g. microwave, UV, etc.)

Applications in medicine
- Dermatology
- Removal of malanomas or angiomas
- Ophthalmology
- Treating diabetic retinopathy
- LASIK for eyesight correction
- Urology
- Removal of kidney stones
- Neurosurgery / spinal surgery
- Removal of tumor in various tissues
Energy Levels of an Atom
- Laser discectomy

Energy levels of an atom

 Excitation
L5_Laser therapy of Electrons
Excitation of electrons

Random
process

Different Wavelengths
Different wavelengths
L5_Laser therapy
Electromagnetic spectrum
- LASER for physiotherapy: 600 – 1000 nm (visible light: 390 – 700 nm)

Typical LASER Generator

Typical LASER generator

What is happening at the atomic levels?

What is happening at the atomic levels?

L5_Laser therapy
Properties of a LASER beam
- Monochromaticity
- A discrete frequency and definite wavelength
- Coherence
- EM waves are in phase
- Collimation (parallel)
- Photons move in a parallel fashion
- Create a concentrated beam of light with minimal divergence

What is the active ingredient?

- Monochromaticity (single wavelength): is responsible for treatment effects
- Coherence: is lost in tissues
- Collimation (parallel): is not related to treatment effects

Classification of LASER
Class Power Effect Applications
1 or IM Low No effect on eye or skin Laser pointer
CD players
Barcode readers
2 Low (< 1 mW) Safe on skin Laser pointers
Safe for momentary viewing, 3D scanners
eye protected by aversion responses
3A Low to medium (< 5 mW) Little hazard to skin Laser pointers
Not inherently safe, eye protected 3D scanners
by aversion responses
3B Medium (≤ 500 mW) Little hazard to skin Therapeutic use for
Direct viewing hazardous wound healing and
pain relief
4 and 5 High (> 500 mW) Hazardous to unprotected skin and Surgical use
eyes
L5_Laser therapy
Overarching physiological effects
- Low level laser therapy (LLLT) triggers photochemical reactions within cells
- Biological changes without significant temperature increases
- Causing a cascade of cellular responses (like photosynthesis)

Potential physiological effects

Increase cell metabolism (ATP)
- Normalize mitochondria function
- Increase the size and number of mitochondria
- Response depends on the redox state of cells

Increase vascularization
- Stimulate hemoglobin to release nitric oxide that stimulates angiogenesis
- Promote endothelial cell activity and proliferation
- Increase growth factors for neovascularization

Anti-inflammatory effects
- Increase proliferation of neutrophils and macrophages
- Stimulate immunoglobulins and lymphocytes
- Improve tissue oxygenation (via improved circulation)
- Modulate levels of cytokines, growth factors and inflammatory mediators
- Reduce prostaglandin level

Facilitate collagen synthesis

- Enhance fibroblasts / keratinocytes proliferation
- Increase basic fibroblast growth factors (bFGF)
- Increase proliferation of epithelial cells (at low dose)
- Inhibit fibroblast proliferation & increase cell death at higher dose (> 1050 J/cm2)
- Increase collagen synthesis from fibroblasts
- Promote better alignment (migration) of collagen tissues at remodeling phase
- Transform fibroblasts to myofibroblasts
- Facilitate wound contraction

Analgesic effects
- Increase pain threshold (esp. A and C fibers)
- Alter axonal flow or inhibit neural enzyme
- Increase the latency of nerve conduction
- Increase serotonin and endorphin production
 L5_Laser therapy
Biphasic Dose Response
Biphasic dose response

Therapeutic effects
Wound healing
- Increase tensile strength
- Promote wound contraction and collagen synthesis
- The effect on tensile strength is higher in the first 10-14 days after injury
- Reduce the risk of hypertrophic scar

- Immunological effects
- Bactericidal effects
- Increase phagocytosis by leukocytes

- Hasten recovery of acute inflammatory process

- Decrease prostaglandin generation and improve circulation

- Scar tissue
- Less scar tissue and better cosmetic effect due to better collagen alignment
- Greater epithelialization and less exudate, which promote wound closure

- Dose dependent

** Indications
- Simple lacerations and abrasions
- Chronic varicose ulcers, diabetic ulcers and pressure sores
- Hypertrophic scar tissues
- Burns and post-operative wounds
 Stages of Pressure Ulcer
L5_Laser therapy
Stages of pressure ulcer

Stages of Pressure Ulcer

www.invacare.co.uk

www.invacare.co.uk
L5_Laser therapy
Pain relief
- Acute pain:
- Through faster healing
- Anti-inflammatory responses
- Endorphin production

- Chronic pain:
- Endorphin production
- Increase pain threshold

Bone healing
- A systematic review
- 13 in vitro and 12 animal studies
- 11/13 in vitro studies
- Accelerated osteoblasts proliferation and differentiation
- More growth factors (e.g. bFGF, TGF-b1) production
- Promote new bone matrix formation
- Depending on wavelength, energy and power
- Accelerate bone healing in all animal studies
- Increase bone strength via increased metabolism
- Increase bone mineralization and collagen alignment

Cartilage healing
- A rat study, LLLT
- Stimulate chondrocytes to produce mucopolysaccharides (for holding collagen together to
ensure cartilage integrity)
- Improve experimentally induced cartilage lesions
- An artificially induced osteoarthropathy study in rabbits. After 4 weeks, LLLT significantly:
- increases articular cartilage regeneration
- increases chondrocyte regeneration

Clinical evidence
- A RCT regarding LLLT in chronic diabetic foot ulcers
- A review on 4 RCTs on laser therapy in venous leg ulcers
- Chronic pain (> 12 weeks)
- LLLT vs pharmacotherapy for myofascial pain (at masticatory muscles)
- LLLT: 6-7/10 -> 0/10
- NSAID: 6-7/10 -> 5-6/10
* LLLT dose: 0.5 W for 60 s, continuous = 6-30 J/spot
- A systematic review on joints with chronic inflammation
- A Cochrane review on RA
L5_Laser therapy
Clinical applications
- Wound healing
- Pain reduction (acute and chronic)
- Arthritis (OA, RA)
- Soft tissue injury
- Traumatic, inflammatory or overuse injuries
- Muscle tear and tendinopathy
- Laser acupuncture

Treatment parameters
- Single or cluster probes
- Wavelength
- Beam/spot size (optional)
- Peak power output / Average power output (in pulsed LLLT)
- Average power density
- Energy (dosage)
- Time of treatment per spot
- Frequency (in pulsed LLLT)
- Treatment area
- Energy density for the whole treatment area
- Total energy delivered
- Treatment intervals

Types of applicators
- Single probes
- Small area
- Cluster probes
- A collection of multiple laser/LED diodes with different wavelengths and power outputs
- Larger area

Wavelength
- Short wavelength (red, 600-700 nm)
- Treating superficial diseases
- Wavelength (700-770 nm)
- NO physiological effect
- Long wavelength (near infrared, 780-950 nm)
- Treating deeper-seated disorders
- Due to longer optical penetration through tissue
L5_Laser therapy
Pulse frequency
- Acute: low frequency
- Chronic: high frequency / continuous
Condition Frequency Rationale
Acute MSK injury 2.5-20 Hz Tissue repair, growth factor response
Chronic MSK disorders 150-5000 Hz Stimulate metabolism and inflammatory
response
Chronic pain 73-700 Hz Pain relief
Acute wound 2.5-20 Hz Tissue repair, clean debris
Chronic wound 700-5000 Hz Stimulate inflammatory response, stir up the
condition
Unresolved infected wound 5000 Hz Bactericidal effect, induce inflammatory
response
Resolving wound (no infection) 20 Hz Stimulate growth

Output of a LLLT device

- Power = Watt (W = J/s)
- Average power (W) for pulsed LLLT
= average power of probe (W) x frequency (Hz) x pulse duration (s)

Probe Power output (W)

- Power density (W/cm2 ) =
Area of irradiation (cm2 )

* Area of irradiation = probe area (spot) in contact with the skin

** Power density indicates the strength of the probe
L5_Laser therapy
Dosage
- Total dosage of LLLT is expressed in either Energy (J) or Energy Density (J/cm2)
- Energy = Power (W) x Time (s)
Power (W) × time (s)
- Energy density (J/cm2 ) =
Probe area (cm2 )
- Since the power of the device and the spot size of the probe are fixed, we only need to consider:
- Energy density (total dose)
- Time of irradiation
- Acute/superficial condition: low dose
- Chronic/deep-seated condition: high dose
- Optimal energy density: 3-12 J/cm2
- Increase the dose if there is no physiological response within 2-3 Rx

Condition Target dose

Initial treatment 1-4 J/cm2
Acute lesion 1-4 J/cm2
Chronic lesion 4-50 J/cm2
Superficial diseases 1-10 J/cm2
Deeper-seated disorders 10-50 J/cm2

Calculation of dosage
Power (W) × time (s)
- Energy density (J/cm2 ) = = Power density × time
Probe area (cm2 )

Chronic tennis elbow (Short wavelength = 675 nm, continuous)

- Target dose (energy density) = 4 J/cm2
- Spot size in contact with the skin = 0.125 cm2
- Power density = (0.1/0.125) W/cm2 = 0.8 W/cm2
- Energy density = Power density x time
4 J/cm2 = 0.8 W/cm2 x time
- Time = (4/0.8) = 5 s

Acute sprain ankle (Pulse frequency = 10 Hz, pulse duration = 50 ms; short wavelength = 675 nm)
- Target dose (energy density) = 2 J/cm2
- Peak power of probe = 30 mW = 0.03 W
- Average power of probe = 0.03 x 10 x 0.05 (W/cm2) = 0.015 W/cm2
- Spot size in contact with the skin = 0.125 cm2
- Power density = (0.015/0.125) W/cm2 = 0.12 W/cm2
- Energy density = Power density x time
2 J/cm2 = 0.12 W/cm2 x time
- Time = (2/0.12) = 16.7 s (~17 s)

** Caution: some machines may give the same peak power output regardless of frequency!!
L5_Laser therapy
Infected pressure sore wound bed at sacrum for 10 cm2 (continuous, cluster probe)

Wavelength 660 nm x 10 diodes 950 nm x 9 diodes

Average power 10 mW = 0.01 W 15 mW = 0.015 W
Total power (0.01 x 10 + 0.015 x 9) = 0.235 W

- Target dose (energy density) = 1.5 J/cm2

- Total target dose = 10 x 1.5 J = 15 J
- Total energy = Power x time
15 J = 0.235 W x time
- Time = (15/0.235) = 63.8 s (~64 s)

Treatment interval
- Acute: more frequent with lower dose
- Chronic: less frequent with higher dose

Condition Interval
Acute MSK problem Daily (stimulate the response)
Sub-acute MSK problem 2-3x per week (allow body to continue the repair)
Chronic MSK problem 1-3x per week (more frequent for low grade inflammation)
Acute wound Daily
Chronic wound 1-2x per week
Infected ulcers 2x per week until infection clears

Summary
Condition Dose Wavelength Pulse frequency Treatment frequency
Acute cases Low Depend on the Low Daily for the first 3-4
depth of tissues Rx then decrease
Chronic cases High to trigger Depend on the High to 1-3x per week
inflammatory depth of tissues continuous
response, use low
dose afterward
Superficial Low Short Depend on Depend of chronicity
tissues chronicity
Deeply seated High Long Depend on Depend on chronicity
tissues chronicity
Wound/ulcer Low (depending Depend on the Low 2x per day initially
/pressure on wound margin/ depth of tissues (timing and frequency
sore/ burns wound bed) tends to be less
important), then 1-3x
per week
Infected High Depend on the High 2x per week
wound depth of tissues
L5_Laser therapy
Dose considerations
- Transmission: Adipose or highly vascularized tissues will absorb the light and reduce penetration
- Depth: Deeper seated lesion may need more treatment
- Sensitivity: People who are sensitive to light may need less treatment

Penetration depth of laser

- Intensity of laser decreases as it passes through tissue
- 200 mW Gallium-aluminum arsenide (GaAIAs) laser
- Reduce to 16 mW at 1.5 cm
- Reduce to 1.4 mW at 3.5 cm
- Shorter wavelength (shorter visible)
- Absorbed by pigments, amino acids and nucleic acid at epidermis
- He-Ne laser (632.8 nm)
- Penetration depth: 2-10 mm
- Longer wavelength (near infrared)
- Absorbed by water
- GaAIAs laser (904 nm)
- Penetration depth: 10-50 mm

- Factors affecting penetration

- Composition and thickness of epithelium
- Melanin content
- Vascularization
- Depth of the target tissues from the skin
- Wavelength of LLLT

- Distance from skin

- Knee, finger, toe, and temporomandibular joints = 1.5-5 mm
- Cervical joint = 8-20 mm
- Lumbar joint = 25-35 mm

Dosages for chronic joint disorders (recommended doses)

Location Dose per spot (J/cm2)
IR 820, 830, 1060 nm IR 904 nm HeNe 632 nm
Finger/toe/TMJ
0.5-15 0.2-1.4 6-30
(Depth: 2 mm)
Knee
3.7-120 0.3-19 1.7-30
(Depth: 4 mm)
Cx spine
2-60 0.4-28 3-90
(Depth: 12 mm)
Lx spine
16-160 10-35 Not applicable
(Depth: 30 mm)
L5_Laser therapy
Treatment techniques
Contact methods
- Spotting
- Small treatment area
- At the tender spot, trigger point or acupuncture point
- Gridding
- Larger treatment area
- Treatment area is divided into a grid system
- Laser is irradiated to each grid

Non-contact method
- Scanning
- Large treatment area or skin contact is impossible
- Move the probe continuously over the wound surface
- The distance between the probe and the target tissues should be < 10 mm

Laser hazard
- Unlikely to harm skin because it has no thermal effect
- May damage retina
- The lens of the eyes can focus laser beam onto the retina and cause thermal damage

Precautions
- Eye protection
- Laser-protective spectacle or goggle
- An isolated room/area
- Warning sign outside to warn passersby
- Turn on the laser device only when the probe is contacting the skin / or in the right position
- Turn off the device before removing the probe
- Infected tissues/open wounds
- Aseptic technique
- Clean the probe with alcohol wipe before and after treatment
- Photosensitive skin
- People receiving immunosuppressive drugs
- Eczema and psoriasis receiving treatments
- Systemic lupus erythematosus (SLE)

Contraindications
- Eye treatment
- Suspected neoplasm: may release growth factor
- Suspected or confirmed pregnancy: may affect fetus growth
- Hemorrhagic region: vasodilate and increase blood loss
- Post-steroid injection area: no treatment within 48 hours after injection