Cold Laser and Light Therapy

Cold Laser

and Light Therapy

By:

Dr. Wendy L.C. Varish, DC, FACO, CCSP, CCOHC

Laser and Light Therapy

© Wendy Varish, DC 2016 1

Clinical Applications of

Light Therapy and Cold Laser

in Chiropractic

Wendy Varish, DC, FACO, CCSP,

CCOHC

“Live as if you were to die tomorrow. Learn as if you were to live forever.”

-Mahatma Gandhi

Wendy Varish, DC, FACO, CCSP, CCOHC

Howards Grove Chiropractic

516 S. Wisconsin Drive

Howards Grove, WI 53083

(920) 565-3922 fax (920) 565-2142

[email protected]



WISCONSIN CT

CHIROPRACTIC TECHNICIAN

STATE REQUIREMENTS

www.dsps.wi.gov

Delegation by Chiropractors

• Chir 10.05 Physiological therapeutics.

• A chiropractor may delegate the performance of patient services through physiological therapeutics that include but are not limited to heat, cold, light, air, water, sound, electricity, massage, and physical exercise with and without assistive devices to an unlicensed person only if the delegation is consistent with s. Chir 10.02 and the unlicensed person has adequate training, education and experience to perform the delegated function to minimally acceptable chiropractic standards.

Delegation Rules• 446.02(7)(d)2.

2. Beginning on July 1, 2010, a chiropractor may

delegate adjunctive services only to a chiropractic

technologist.



Wisconsin State Statutes:• 446.01 Definitions. In this chapter:

• (1d) “Adjunctive services” means services that are

preparatory or complementary to the practice of

chiropractic. “Adjunctive services” includes all of the

following:

• (a) The taking and preparation of preliminary patient

histories, as defined by the examining board by rule.

• (b) Providing physiotherapy treatment, as defined by the

examining board by rule.

446.026 Regulation of chiropractic technicians:

• (1) (a) No person may provide adjunctive services unless the person is a chiropractic technician and is under the direct, on−premises supervision of a chiropractor licensed under this chapter.

• Chir 10.02

(2) The chiropractor exercises direct supervision of the unlicensed person performing the delegated service.

Chir 10.01 Definitions

(3) “Unlicensed person” means a person who does not possess a valid license to practice chiropractic in this state pursuant to ch.446

• (b) Except as provided in s. 446.025 (1) (b), no person may designate himself or herself as a “chiropractic technician” or “chiropractor technician,” use or assume the title “chiropractic technician” or “chiropractor technician” or any title that includes “chiropractic technician” or “chiropractor technician,” append to the person’s name the letters “C.T.,” or use any other title or designation that represents or implies that he or she is a chiropractic technician unless the person is certified by the examining board under this section.



Prohibited Practices

• Chir 12.06 Prohibited practices. (1) A

chiropractor shall not delegate to any

chiropractic assistant or other person any

recommendations, analysis, advice,

consultation or dispensing with respect to

vitamins, herbs, or nutritional supplements.

Nothing in this subsection may be construed

to prevent chiropractic assistants or

administrative employees from processing

sales of vitamins, herbs, or nutritional

supplements.

Chiropractic Technician - Licensing

• Beginning July 1, 2010 an applicant must hold a certification as a chiropractic technician to continue to provide adjunctive services delegated by a Wisconsin Licensed Chiropractor.

• (The process of granting a credential to persons currently practicing in the field, based on their past training and experience, is referred to as Grandfathering-no longer applicable.) Persons performing services that will fall within the new scope of practice for chiropractic technicians may apply for a credential by meeting the requirements of the State.

http://dsps.wi.gov

How to Apply for CT

Certificate1). Complete and submit appropriate application form #2884 and fee, including all documentation.

Application for Chiropractic Technician form #2884

2). Certificate of Completion from an approved course provider in relation to the adjunctive services provided by a Chiropractic Technician. (Provide either a copy of Certificate of Completion or Course Provider form #2865)

3). Determination to grant credential is made.Common Denial Reason:

Does not meet criteria above. Convictions of crimes or pending charges may be grounds for denial of license if the circumstances of the conviction or charge are substantially related to professional practice.

http://165.189.60.145/prof_docs_list.asp?profid=8&locid=0



CT Certification Renewal

• Biennial Renewal Due:

• Per Wisconsin State Statutes 440.08 (2), the required renewal date for the Chiropractic Technician credential is 12/14/even years.

• At this time, 6 hours of approved continuing education (CE) required for renewal

• Should you receive your initial credential in the months leading up to this date, you are still required to renew your license by the statutorily defined date. (but will not need the 6 CE credits until the next renewal).

What is Light??

• Light is actually Radiation:

– The process by which energy in various forms travels through space.

What is Light?

• Light (radiation) is a form of energy which behaves as both a particle and also a wave.

• Light particles are known as photons.• Photons are the basic units light. (Just as atoms

are the basic units of matter)

• Photons travel at 186,000 miles per second (300,000km)– faster than any other known particle.

• Energy is emitted and transmitted in the form of particles and waves

• Light energy is absorbed by matter.

http://docs.legis.wisconsin.gov/statutes/statutes/440/I/08

http://images.google.com/imgres?imgurl=http://farm4.static.flickr.com/3208/3055661754_36a8279043.jpg&imgrefurl=http://www.flickr.com/photos/20348545@N05/3055661754/&usg=__mi55i04GTLPqPPp-T_ajlumnzdc=&h=375&w=500&sz=87&hl=en&start=6&um=1&tbnid=EYC0wOhJHyFTKM:&tbnh=98&tbnw=130&prev=/images?q%3Dstar%2Btrek%2Benterprise%26hl%3Den%26safe%3Dactive%26rlz%3D1T4ADSA_enUS335US335%26sa%3DG%26um%3D1

http://images.google.com/imgres?imgurl=http://farm4.static.flickr.com/3208/3055661754_36a8279043.jpg&imgrefurl=http://www.flickr.com/photos/20348545@N05/3055661754/&usg=__mi55i04GTLPqPPp-T_ajlumnzdc=&h=375&w=500&sz=87&hl=en&start=6&um=1&tbnid=EYC0wOhJHyFTKM:&tbnh=98&tbnw=130&prev=/images?q%3Dstar%2Btrek%2Benterprise%26hl%3Den%26safe%3Dactive%26rlz%3D1T4ADSA_enUS335US335%26sa%3DG%26um%3D1



Electric and Magnetic

Properties of Light Waves

Because of the ability to exist as both a particle and wave, light

waves are considered electromagnetic in nature; they have

both electrical and magnetic properties.

What is Light??

• Terms used to Describe Light and Energy:

– Wavelength (width)

– Amplitude (Intensity - how high)

– Velocity (speed of light)

– Frequency (Rate = speed of light / wavelength)

Major Concepts of Light Therapy

• The sun emits energy in a broad spectrum

called the electromagnetic spectrum.



Sunlight is composed of every color.

When sunlight passes through a prism, the

visible light is separated into a rainbow of

different colors.

However, this prism is also separating forms of

radiant energy that is not visible to our eyes .



• The Sun emits almost every wavelength of

light, even light our eyes can't see.

• Sunlight your eyes CANNOT see(invisible)

• radio

• microwaves

• infrared

• ultraviolet

• X-Rays

• Gamma Rays

Electromagnetic Spectrum



Light and Energy

• Velocity (speed of light = 300 million meters per second)

• Wavelength (width)

– Defined as the distance between the peak of one wave

and the peak of the next

• Frequency

– Defined as the number of oscillations or vibrations

occurring in 1 second

– Expressed in hertz (Hz)

– (Frequency = speed of light / wavelength)

• Amplitude (intensity – how high)

Velocity

• Electromagnetic radiation always travels at

the speed of light. (~186,282 miles/sec or

~300,000 km/sec)

• For practical purposes we can say that

radio waves always travel at the speed of

light.



Wavelength, Frequency, Amplitude

t

Period

Frequency = number of waves per second

Wavelength

The shorter the wavelength, the higher the

frequency of the radiation.

The higher the frequency, the greater the

energy of the wave



• Ultraviolet light -- 100-380nm

– Considered ionizing radiation

– This penetrates and breaks covalent bonds

• Visible light approximately 380-740 nm

• Infrared light – approximately 740-1000 nm

– Far infrared to approximately 10,000 nm


• Radiation (including visible light in the 380-740nm

wavelengths), is made up of individual packets of

energy called photons.

• The energy of a photon relates to its wavelength:

– Short wavelength photons are very energetic

– Long wavelength photons have lower energy



Effects of Photon Energy

• The photons in the UV range (200-400nm)

creates chemical excitation within the cells,

which leads to alteration of DNA and RNA

synthesis.

• The photons in the red range (~630-660nm) are

strong enough to alter the shape of certain

receptor proteins in the mitochondrial cell

membrane …. But weak enough not to damage

the cell (including its DNA, enzymes, proteins,

and lipids).

Mitochondria

• Power house of the cell

• Involved with cellular respiration; cell division &

growth; cell differentiation; cell signaling; cell death



Cytochrome c

• Cytochrome c is highly

soluble protein found in the

intermembrane space of

the mitochondria

• Plays a vital role in cellular

oxidation in both plants and

animals.



Cytochrome c

• It is an essential

component of the

electron transport chain,

where it carries one

electron.

• It is capable of

undergoing oxidation and

reduction, but it does not

bind oxygen.

The main function of Cytochrome c in cellular

respiration is to transport electrons from

cytochrome c reductase (Complex III) to

cytochrome oxidase (Complex IV).



• Cytochrome c is suspected to be the functional

complex in Low Level Light Therapy.

• In LLLT, red light and some near infra-red

wavelengths penetrate tissue and appear

capable of increasing activity of cytochrome c

• Increasing the activity of cytochrome c

increases the metabolic activity of the cell and

frees up more energy for the cells to repair the

tissue.

• Silveira PC, Streck EL, Pinho RA. (2005). "Cellular effects of low power laser therapy

can be mediated by nitric oxide.". Lasers Surg Med. 36 (4): 307–14.



Cytochrome c Oxidase

Cytochrome C Oxidase

It is proposed that Cytochrome C Oxidase (Cox) is

the primary photoacceptor for the red to near IR

range in mammalian cells (Karu and Kolyakov 2005).

Nitric Oxide and Cox

• In stressed or hypoxic cells, the mitochondria produce

excess Nitric Oxide. (Brown 2001).

• The excess Nitric Oxide bond to Cox (Cytochrome oxidase).

This will competitively displace oxygen and will inhibit

respiration.

• After LLLT, increased nitric oxide (NO) concentrations can

be measured in cell cultures and in animals.

• It has been proposed that LLLT works by photodissociating

NO from Cox, thereby reversing the mitochondrial inhibition

of respiration due to excessive NO binding (Lane 2006).



When LLLT (red light) is applied, Nitric Oxide is released from its

binding to heme iron and copper centers in cytochrome c oxidase.

Oxygen is allowed to rebind to these sites.

Respiration is restored and leads to increased ATP synthesis

Phototherapy

• Phototherapy is the “Application of light to stimulate” -

-visible red and NIR light absorbed by Cytochrome c

oxidase

• Karu (2010) speculates that photoirradiation may

intensify the transfer of electrons within cytochrome c

oxidase by making more electrons available

• Karu TI et al., (2008) Photomedicine and Laser Surgery 26(6):593-599.

• Karu TI. (2010) IUBMB Life 62(8) 607-610.

• Silveira PCL, et al., (2009) Journal of Photochemistry and Photobiology B: Biology 95:89-92.

Therapeutic Application of Red

light at 636 nm…..

• Stimulates stressed cells

• Increases the mitochondrial membrane potential

• Increases activity of mitochondrial complex IV

(cytochrome c oxidase)

• Increases ATP and cAMP

• Directs cells into a cell survival pathway

• Restores homeostasis to cells



Therapeutic Window of Light


• The 635nm photon wavelength has just

the right amount of energy to stimulate

mitochondrial membrane proteins.

• This results in an increase of cellular

energy ATP.




• Small amounts of increased cellular energy

(ATP) have significant influences on how the cell

functions.

• Since the nervous system uses the greatest

amount of ATP energy, the greatest

improvement with laser/light therapy is seen in

neurological function.

To Summarize…

• In a clinical setting, we use radiation in the

red (~635-740nm) and infrared (~740-

1000nm) wavelengths

• Red and infrared are on the opposite side

of the visible spectrum as ultraviolet

• Ultraviolet (and smaller wavelengths) are

considered ionizing radiation and can be

damaging

• Red and Infrared (when applied correctly)

are therapeutically beneficial on a cellular

level!



Clinical Benefits

of

Light Therapy

3 Basic Effects of Light Therapy

• Tissue Repair

• Acceleration of Inflammation

• Pain Control

Effects of Light Therapy

• Speeds up inflammation (i.e. the HEALING

process

• Speeds up wound healing / soft tissue repair

• Increases microcirculation

• Decreases pain

• Muscle relaxation

• Increases range of motion

• Increases lymph drainage – improves immune

system function



Beneficial tissue effects of LLLT can include

almost all the tissues and organs of the body.

APPROVED CLAIMS FOR INFRARED THERAPY

“Infrared therapy emits energy for temporary increase in local

blood circulation, temporary relief of minor muscle and joint aches,

pain and stiffness and relaxation of muscles; for muscle spasms,

and minor pain and stiffness associated with arthritis.”

Laser therapy effective for acute and

chronic neck pain…

(Reuters Health, 11-12-2009) –Meta-analysis by Dr. Roberta T. Chow and

colleagues from the University of Sydney, Australia

• 16 randomized controlled trials (with 820

patients) that compared LLLT with placebo or

with active control as a treatment for acute or

chronic neck pain.

• Reports that low-level laser therapy (LLLT)

provides rapid relief of acute neck pain as well

as sustained improvements in chronic neck pain



Chow, cont.: 11/13/2009 Online issue of The Lancet…

• Data from two of the trials showed that LLLT was

69% more likely than placebo to improve acute neck

pain.

• In five trials looking at chronic neck, LLLT was

roughly four times more likely than placebo to

improve pain.

• In 11 trials that evaluated changes in visual

analogue scale, LLLT was associated with a mean

drop in pain intensity of 19.86 mm.

• Data from seven trials, with up to 22 weeks of

follow-up, showed persistent pain relief for up to 6

months, with a mean reduction in pain intensity of

22.07 mm.

Infrared therapy for chronic low back

pain: A randomized, controlled trialGeorge D Gale, MBBS FRCA FRCPC DAAPM, Peter J Rothbart, MD FRCPC, and Ye Li Pain

Research & Management. 2006 Autumn; 11(3): 193–196

OBJECTIVE: The objective of the study was to assess the degree of pain

relief obtained by applying infrared (IR) energy to the low back in patients

with chronic, intractable low back pain.

METHODS: 39 patients with chronic LBP of > 6 yrs duration were

recruited from patients attending the Rothbart Pain Management Clinic,

North York, Ontario. They were randomly assigned to IR therapy or

placebo treatment. 21 patients received IR therapy (800-1200nm) and 18

received placebo therapy for 7 wks (1x/wk). The principle measure of

outcome was pain rated on the numerical rating scale (NRS). The pain

was assessed overall, then rotating and bending in different directions.

RESULTS: The mean NRS scores in the tx group fell from 6.9 of 10 to 3

of 10. The mean NRS in the placebo group fell from 7.4 of 10 to 6 of 10.

CONCLUSION: The IR therapy unit used was demonstrated to be

effective in reducing chronic low back pain, and no adverse effects were

observed.

MECHANISMS

OF

LIGHT THERAPY

How does it work?



Clinical Phototherapy

Defined as....

• The delivery of the optimum amount of

photon energy to the diseased tissue or

tissues with the intention of modulating the

process of inflammation-repair and

through influencing the neuroimmune

endocrine system

Terms

• Photochemistry

– How light energy is absorbed by the tissue.

• Photobiology

– How light energy is used by tissue.

1st Law of Photochemistry/Photophysiology:

Light must be absorbed for Photochemistry or

Photophysics to occur



Photochemistry of Light Therapy

• “So far, what we see in patients and what we see in laboratory cell cultures, all point to one conclusion. The near-infrared light emitted by these LEDs seems to be perfect for increasing energy inside cells.

• LEDs have a similar physiological effect on human cells as they do on plant cells. LEDs stimulate cytochromes in the body that increase the energy metabolism of cells. Cytochromes are part of the “electron transport chain” that converts sugar into instant energy required by the body to perform all of its actions, such as raising a finger or healing a wound.”

Light Emitting Diodes Aid in Wound Healing—

Harry T. Whelan, MD, Professor of Neurology,

Medical College of Wisconsin



• Cytochrome c oxidase is

the terminal enzyme in the

electron transfer chain.

• It reduces oxygen to water

and utilizes the excess

energy to translocate

protons across the

mitochondrial membrane.

• Cytochrome c oxidase is

the enzyme responsible for

over 90% of the oxygen

consumption by living

organisms in the biosphere.



• The proton gradient across the

mitochondrial membrane is increased

by red light stimulation.

• Cytochrome c oxidase:

– photoreceptive site

– red light excites electron states that

drive increased ATP production

Tissue RepairLaboratory and clinical studies have proven Light Therapy to be effective for tissue repair related to:

Skin wounds

Ulcers

Ligament tears

Tendon Ruptures

Scars

Burns

Bone and Dental Tissue

How do various colors

(wavelengths) of light help

with Tissue Repair?



Therapeutic Effects of Different

Wavelengths of Light

• Red visible light (approximately 633nm)

will affect the mitochondria

• Near Infrared Radiation does not affect the

mitochondria, but does affect the cellular

membrane and stimulates cell proliferation

• Stimulation of the mitochondria within the cell

with RED light will effectively increase ATP

(energy) production from 2 ATP up to 18 ATP.

This is a 9-fold increase in cell energy !!

Imagine what YOU could do with 9x more energy!

Cell Injury

• When a cell is injured, the cell wants to “shut

down”.

• Think of this as a city that has been

devastated with a hurricane…

– The city shuts down

– Curfews are set

– People/workers are not allowed in or out….

– Supply lines for food, water, cleaning supplies are

limited



• In order to start the repair process

following a hurricane (or other natural

disaster, etc.)…

• The city must be re-opened so that

supplies and rescue workers can come in

and start the clean-up and repair

Following Cell Injury…

• In order to speed up healing, it makes

sense to increase the cell permeability.

• Near INFRARED light will increase cell

permeability.

• This, in effect, will speed up the

inflammation process.

• In addition…Red and Infrared Light therapy

increases microcirculation (not vasodilation).

This also helps with wound healing.

• This is comparable to making new roads or

detours so that supplies and workers can

access damaged areas.



Photo-

chemistry

of Light

Therapy

Absorption in the Mitochondria

and Cell Membrane by Chromophores

Elevation of ATP synthesis (Ca2+ and the respiratory chain involved);

Increases the energy in the cell.

DNA & RNA synthesis; protein synthesis;

mitosis and cell proliferation

Light (Photons) Applied to Tissue

Tissue Repair

Photobiology of Light Therapy

Light Therapy Promotes:• Inflammation (speeds up the process)

• Fibroplasia (increase in size and number of fibroblasts)

• Neoangiogenesis (formation of new blood vessels)

• Collagen Synthesis

Photobiology of Light Therapy

“Laser radiation at 633 nm has been shown

to stimulate collagen synthesis in cutaneous

wounds by enhancing the synthesis of Type I

and Type II procollagen mRNA levels.”

The Photobiological Basis of Low Level Laser Radiation Therapy—

Kendric C. Smith, Department of Radiation Oncology,

Stanford University School of Medicine



Photobiology

“Photoactivation of Enzymes—The light activation of enzymes is one of

the fastest growing fields of photobiology, and several reviews on this

subject have appeared. The importance of the light activation of enzymes

is that enzymes are catalysts. In principle, one photon can activate one

enzyme molecule, which in turn can process many thousands of

substrate molecules. This provides a huge amplification factor for

initiating a biological response with light. This remarkable amplification

factor may be the explanation for why low level laser radiation therapy is

effective. If the effect of one photon can be amplified biologically, then one

does not need a lot of photons to produce an effect. One just needs to

find the proper wavelength of light to stimulate the proper enzyme,

which in turn will stimulate the beneficial therapeutic effect.”

The Photobiological Basis of Low Level Laser Radiation Therapy—



The Inflammatory CycleInjury to tissue

Hematoma

Platelets

Fibroblasts

LeukocytesSerotonin released

Action potential decreases –nerves fire easier and the area is more sensitive

Bradykinin is released

Prostaglandins are released

Formation of new

blood vessels

Partial pressure of oxygen

increases in tissue

Fibroplasia

Collagen Synthesis

Tissue remodeling and

contraction

Starts around Day 3

Can take up to 100 days for tissue to mature completely

Phases of Wound Healing

Response

Time in Days

1 3 10 30

100

InflammationProliferation Maturation

Collagen Accumulation

Wound Contraction



Phases of Wound Healing

Response

Time in Days

1 3 10 30100

Inflammation-

speeds up and is not as severe

Proliferation –cell

healing occurs sooner and is faster

Maturation

Collagen Accumulation

Wound Contraction-occurs sooner

Remodeling

Photobiology of

Light Therapy

Neoangiogenesis(formation of

new blood vessels)

Injury

Collagen Synthesis

PlateletsMast cellsMonocytes

MacrophagesLymphocytes(Released factors:

HistaminePDGF, FGF,

Leucotrienes, &Other growth factors

Fibroplasia(Proliferation of fibroblasts)

Fibroblasts

New Collagen Tissue

Neurons

Nerve Tissue

Hematoma (Blood Clot)

Fibroblasts

LIGHT THERAPY FOR

PAIN RELIEF



Pain Control

Evidence suggests beneficial effects for many pain conditions

including, but not limited to, the following:

Carpal Tunnel Syndrome

Neck and Back Pain

Acute Phase Herpes Zoster [Shingles]

Post-Herpetic Neuralgia

How does Light Therapy Affect Pain?

• Most common theories involve changing the

cell permeability and increasing the action

potential.

• This results in

– increased endorphin release

– decreased bradykinin

– decreased C fiber activity

– blocking of Prostaglandin E1 and Bradykinin B in

plasma fibrin levels

• By increasing the Action Potential, the pain fiber

nerves are less sensitive and not as easily

stimulated

• We then are less likely to “feel” as much pain



Compared to “real

life”…. Think of the

Action Potential as the

Media & News reports.

If we are unaware of the tragedy (or pain),

then we really don’t think about it and are

unaffected by it in our daily lives.

There are three main neurotransmitters

involved in generating the action potential:

Glutamate – associated with acute pain. Appears to be

the dominant neurotransmitter when the threshold of

pain is first crossed.

Substance P –peptide that contains 11 amino acids and

is released by C fibers. It is generally associated with

intense, persistent, chronic pain, and used to relay pain

messages leading to the spinal cord and brain.

Glycine – this is involved in suppressing the

transmission of pain signals in the dorsal root ganglion.

Pain control due to increasing the Action Potential via:

-increased endorphin release

-decreased bradykinin

-decreased C fiber activity & production of Substance P

-blocking of Prostaglandin E1 and Bradykinin B in plasma fibrin levels



Light is scattered into tissue

Areas of high and low light differences

produce temperature and pressure

differences across the cell membrane

Cell permeability is affected which affects

the mitochondrial membrane

Increased receptor activity on the cell

membrane

Bradykinin is reduced

Endorphins are produced

Pain C-fiber activity is decreased

Sensitivity is decreased because

the Action Potential is increased

The Inflammatory CycleInjury to tissue

Hematoma

Platelets

Fibroblasts

LeukocytesSerotonin released

Action potential decreases –nerves fire easier and the area is more sensitive

Bradykinin is released

Prostaglandins are released

Formation of new

blood vessels

Partial pressure of oxygen

increases in tissue

Fibroplasia

Collagen Synthesis

Tissue remodeling and

contraction

Starts around Day 3

Can take up to 100 days for tissue to mature completely

Terms

• Photochemistry

– How light energy is absorbed by the tissue.

• Photobiology

– How light energy is used by tissue.



Effects of Light Therapy

Reviewed…

• Increases cell permeability

• Increases cell energy

• Increases cell division and repair

• Increases microcirculation

• Basically… it helps the healing of cells

quicker with less swelling and less

scarring. The cells heal faster and

stronger!

• "This technology may be the answer for problem wounds

that are slow to heal....diabetic skin ulcers and other

wounds in mice healed much faster when exposed to the

special LEDs in the lab. Laboratory research has shown

that the LEDs also grow human muscle and skin cells up

to five times faster than normal...."

• "Light close to and in the near-infrared range has

documented benefits for promoting wound healing in

human and animals. "http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pub

med&dopt=Abstract&list_uids=11568632

• "Near-infrared irradiation potentially enhances the wound

healing process, presumably by its biostimulatory effects." http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pub

med&list_uids=11722751

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=11568632

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&list_uids=11722751



Treatment

Parameters

Basic Terminology

• PowerMeasured in Watts or milliwatts.

MILLIWATT (mW) = one thousandth of a watt.

Power determines length of treatment

• WavelengthNANOMETER (nm) = one billionth of a meter.

Wavelength determines two things - depth of penetration & light absorption

• EnergyEnergy is a function of Power and Time

JOULE (J) = Power (W) x Time (s)Joule / cm² = 1w x 1 sec / 1 cm²

Energy is the preferred unit for reporting doses of treatment

3 Parameters

for Light Therapy

1. Power

2. Wavelength for Light Absorption

3. Wavelength for Depth of Penetration

» Wavelength is measured in nanometers (nm) which is one billionth of a meter.



Therapeutic Effect

Depth of Penetration

Light Absorption

Power

#1- PowerDetermines

Treatment Time

Power

• Power is measured in Watts or milliwatts (mW).

• One milliwatt (mW) = one thousandth of a Watt

• Power determines Treatment Time

Power



TR

EA

TM

EN

T T

IME

(seco

nd

s)

POWER (mW)

300 sec

600 mW0

30

60

90

120

150

180

210

240

270

60 120 180 240 300 360 420 480 540

There is an inverse relationship between power

and treatment time. To achieve a specified dose,

Treatment Time decreases as Power increases.

Comparison of

Treatment Times

EDCBADynatronics

Seco

nd

s

Light Absorption

#2- WavelengthDetermines

Light Absorption



Effects of Different Types

of Light Therapy

• Visible light (approximately 633nm) will

affect the mitochondria

• Near Infrared Radiation does not affect the

mitochondria, but does affect the cellular

membrane and stimulates cell proliferation

Photochemistry of Light Therapy

“The first law of photochemistry states that light must be

absorbed before photochemistry can occur. An absorption

spectrum is a plot of the probability that light of a given

wavelength will be absorbed by the system under

investigation.”

The Photobiological Basis of Low Level Laser Radiation Therapy



Electromagnetic Spectrum




Cluster Probe using Multiple Wavelengths -

660nm & 880nm

"Growth factor production and collagen synthesis may be

improved at wavelengths of 660-680 nm and stimulation of

new small blood vessel growth was produced at 880 nm

wavelength. Such studies have been limited by the constraints

of laser technology, but LED’s offer improved power and area of

distribution at longer wavelengths."

- Dr. Norman Salansky

880 nm

(590 - 740)

660 nm

(770 - 990)


#3- WavelengthDetermines

Depth of

Penetration



Wavelength & Depth of Penetration

• The longer the wavelength of the light

source, the deeper the penetration into the

tissue.

• The shorter the wavelength of the light

source, the lesser the penetration.

WAVELENGTH = Depth of Penetration

The Photobiological Basis of Low Level Laser Radiation Therapy—Kendric C. Smith, Department of Radiation Oncology,

Stanford University School of Medicine.

“Studies on the absorption spectrum of the palm of a human hand show

that radiation at 633 nm does not penetrate through tissues nearly as

well as does radiation at 830 nm".

WAVELENGTH

Near Infrared

880nm

Red

660nm

DEPTH OF PENETRATION

Red

660nm

Near Infrared

880nm




Tissue Penetration of Various Wavelengths

Wavelength

(nm)

Color Range Depth of

Penetration

(mm)

150-380 Ultraviolet <0.1

390-470 Violet to Deep

Blue

~0.3

475-545 Blue to Green ~0.3-0.5

545-600 Yellow to

Orange

~0.5-1.0

600-650 Red ~1.0-2.0

650-1000 Deep Red to

Infrared

2.0-3.0

1000-1350 Near to Mid-

Infrared

3.0-5.0

1350-12000 Infrared <0.1


• Systemic effects– Direct and Indirect Effects

• Clothing will decrease penetration

• Must press the unit down if contact is necessary– Law of Cosines

• Treatment depth increases over time

• Treatment depth dependent upon wavelength– 830nm penetrates deeper than 630 nm

– Some reflection occurs in unit not in contact with skin

“Direct” vs. “Indirect” Effect of

Penetration

• “Direct” Effect:

– the biological response that occurs from absorption

of energy by the tissues

• “Indirect” Effect:

– A lessened response that occurs deeper in the

tissues.

– The normal metabolic processes in the deeper

tissues are catalyzed from the energy absorption in

the superficial structures to produce the indirect

effect.



Wavelength and Power determine

Penetration/Absorption

Multiple Wavelengths

660nm & 880nm

Some modalities use multiple wavelengths –

allowing for multiple cellular effects.

880 nm

32 x 30 mW

660 nm

4 x 4 mW

Is it all about going deep?

• The skin is the largest and heaviest organ

in the body.

• 50% - 90% light is absorbed by the skin.

• Important systemic effects can be gained

by using lower power



Now…

How Do We Apply

the Light??

Three Options

for

Generating Therapeutic

Light

Laser • SLD • LED

What is Laser?

• Light

• Amplification by

• Stimulated

• Emission of

• Radiation



REVIEW…

Basic Properties of Visible Light

(400nm -700nm)

• Chromatic

– multiple colors

• Incoherent

– travels in all directions

• Uncollimated

– we can try to collimate with use of filters, etc.

Properties of Lasers

• Monochromatic –one

color

• Coherent –all the same

wavelength

• Collimated –in a beam due

to the lens

• Nothing else like it in

nature – purification of light

Ordinary Light vs.

Laser Light



Four Components of Lasers

1. Active Medium

-may be solid crystals (ruby), liquid dyes, gases (CO2 or Helium/Neon), or semiconductors (GaAs). Active mediums contain atoms whose electrons may be excited an energy source.

2. Excitation Mechanism

-pumps energy into the active medium by one or more of three basic methods; optical, electrical or chemical.

3. High Reflectance Mirror (Feedback Mechanism)

-A mirror which reflects essentially 100% of the laser light.

4. Partially Transmissive Mirror (Output Coupler)

-A mirror which reflects less than 100% of the laser light and transmits the remainder.

Classifications of Lasers

• Revised System --part of the revised IEC 60825

standard. From 2007, the revised system is also

incorporated into the US-oriented ANSI Laser Safety

Standard (ANSI Z136.1).

• Accepted by US Food and Drug Administration (FDA)

on laser products imported into the US.

• The classification of a laser: based on accessible

emission limits (AEL) that are defined for each laser

class.

– AEL is usually a maximum power (in W) or energy (in J) that

can be emitted in a specified wavelength range and exposure

time that passes through a specified aperture stop at a

specified distance.



Types of Lasers(Old classification – phased out after 2002)

• Class I Laser: < .5 mW power output– Not used as a therapeutic device

• Class II Laser : <1 mW power output– Minimally therapeutic

• Class IIIA Laser : < 5 mW power output– Lower end of power output, but demonstrate certain therapeutic

properties –primarily photochemical effects

• Class IIIB Laser : < 500 mW power output– Majority of therapeutic devices. Photobiomodulation. No photothermal

effects. Balance power and safety –no harm to skin or clothing,

potential damage to eyes.

• Class IV Laser : > 500 mW power output– Photothermal effects - Thermally destructive – some surgical in nature.

Revised Classes of Lasers

• Class 1

• Class 1M

• Class 2

• Class 2M

• Class 3R

• Class 3B

• Class 4

*classification system as specified by the IEC 60825-1 standard

• Class 1

– A Class 1 laser is safe under all conditions of

normal use.

• Class 1M

– A Class 1M laser is safe for all conditions of

use except when passed through magnifying

optics such as microscopes and telescopes.

Class 1M lasers produce large-diameter

beams, or beams that are divergent

https://en.wikipedia.org/wiki/International_electrotechnical_commission



• Class 2– A Class 2 laser is considered to be safe because the blink reflex

will limit the exposure to no more than 0.25 seconds.

– Only applies to visible-light lasers (400–700 nm). Class-2 lasers

are limited to 1 mW continuous wave, or more if the emission

time is less than 0.25 seconds or if the light is not spatially

coherent. Intentional suppression of the blink reflex could lead to

eye injury. Some laser pointers and measuring instruments are

class 2.

• Class 2M– A Class 2M laser is safe because of the blink reflex if not viewed

through optical instruments. As with class 1M, this applies to

laser beams with a large diameter or large divergence, for which

the amount of light passing through the pupil cannot exceed the

limits for class 2.

• Class 3R– A Class 3R laser is considered safe if handled carefully, with

restricted beam viewing. Visible continuous lasers in Class 3R

are limited to 5 mW. For other wavelengths and for pulsed

lasers, other limits apply.

• Class 3B– A Class 3B laser is hazardous if the eye is exposed directly. The

AEL for continuous lasers in the wavelength range from 315 nm

to far infrared is 0.5 W. For pulsed lasers between 400 and

700 nm, the limit is 30 mJ. Other limits apply to other

wavelengths and to ultrashort pulsed lasers. Protective eyewear

is typically required where direct viewing of a class 3B laser

beam may occur. Class-3B lasers must be equipped with a key

switch and a safety interlock.

• Class 4– Class 4 is the highest and most dangerous class of

laser, including all lasers that exceed the Class 3B

AEL.

– By definition, a class 4 laser can burn the skin, or

cause permanent eye damage as a result of direct,

diffuse or indirect beam viewing.

– These lasers may ignite combustible materials, and

thus may represent a fire risk, even from possible

reflections of the beam (operator must take great care

to control the beam path).

– Class 4 lasers must be equipped with a key switch

and a safety interlock. Most industrial, scientific,

military, and medical lasers are in this category.



Clinical Use of Lasers

• Low Level Laser Therapy

LLLT

“Soft” Laser

“Cold” Laser



Types of Lasers• InGaAlP 630-685 nm

– Indium Gallium Aluminum Phosphate

• GaAs 904 nm– Gallium Arsenine

• GaAlAs 780-870 nm– Gallium Aluminum Arsenine

• Ruby 694 nm

• Nd:YAG 1064 nm

• Ho:YAG 2130 nm

• Er:YAG 2940 nm

• Alexanddrite 720-800 nm

• Dye variable nm

• Rhodamine 560-650 nm

• HeNe 633 nm -used for cauterizing in hospitals

• Argon 350-514 nm

• CO2 10600 nm

• Excimer 193-248, 308 nm

Most commonly used in practice



Pulsing Laser Light

• May effect the body like pulsing electrical

current

• Fewer studies on the effects

• Changes the output

Pulsing Laser Light

• May be “super-pulsed” or “chopped”

• Often found in the Class IV lasers in order

to reduce thermal effects

– Twice the power not twice the depth (5-10%)

• Few studies to determine optimum

frequency of pulses

Q: Which frequency of pulses

should be used for various

conditions?

A: First -- must differentiate between “chopping” and

“super-pulsing”.

If a continuous laser is pulsed, the average output power

will be lower. With “chopped” lasers, approximately 50%

of power is lost (50% duty cycle).

• There is evidence from cell studies that the pulsing can

make a difference, but evidence from clinical studies is

almost absent.

• Must choose a frequency based upon the anecdotal

evidence for what is best for the condition(s) being

treated.



Super-pulsed Lasers

• Greater depth of penetration may be

achieved in some cases

• Depth of penetration is dependent upon

– Wavelength

– Whether the laser is super-pulsed

– Power output

– Absorption by the tissues

Options for Application of Light

Therapy:

• Laser

– Single or multiple diodes

• SLD

• LED

LED and SLD

• LED – Light Emitting Diodes

– Usually more superficial conditions

– Initial studies show that lasers may be more

effective, but both are effective

• SLD – Super Luminous Diode

– Ability to produce several specific

wavelengths for greater spectrum of effects.



LED and SLD

• LED (light-emitting diode) – special p-n junction

semi-conductor diode that emits visible light

when an electric current passes through it.

• A diode has a section of N-type material bonded to a

section of P-type material, with electrodes on each end.

• Electricity is conducted in only one direction.

• When no voltage is applied to the diode, electrons from the

N-type material fill holes from the P-type material along the

junction between the layers, forming a depletion zone.

When the negative end of the circuit is hooked up

to the N-type layer and the positive end is hooked

up to P-type layer, electrons and holes start

moving and the depletion zone disappears.



The peaks of the LEDs and optimum

wavelengths are not exact, but spread out

about +/- ~10 nm so there is an overlap of

available LEDs and the biologically optimum

wavelengths.

A broader treatment area and multiple

wavelengths are possible using LED’s vs. Laser

WAVELENGTH SPECTRUM




The BIG Controversy…

Laser

vs.

LED and SLD

LED’s vs. Lasers

• LEDs do not deliver enough power to damage

the tissue, but they do deliver enough energy to

stimulate a response from the body to heal itself.

• With a low peak power output but high duty

cycle, the LEDs provide a much gentler delivery

of the same healing wavelengths of light as does

the laser but at a substantially greater energy

output.

• For this reason, LEDs do not have the same risk

of accidental eye damage that lasers do.



LED’s vs. Lasers

• LEDs are neither coherent nor collimated and

they generate a broader band of wavelengths

than do the single-wavelength laser.

• This allows a broader surface area of treatment.

• The multiplicity of wavelengths in the LED,

contrary to the single-wavelength laser, may

enable it to affect a broader range of tissue

types and produce a wider range of

photochemical reactions in the tissue.

“LIGHT IS LIGHT”

“If wavelength and dosage are identical,

results will be the same”

Chukuka Enwemeka, PhD, PT

“LIGHT is LIGHT”

"In these cases, the coherent and noncoherent light (i.e., both lasers

and LED’s) with the same wavelength, intensity and dose provides

the same biological response.”

"In this view, laser therapy is really a form of light therapy, and lasers are

important in that they are convenient sources of intense light at

wavelengths that stimulate specific physiological functions.”

—T.I. Karu; Cellular Mechanisms of Low-Power Laser Therapy

—Jeffrey R. Basford, M.D., Department of Physical Medicine

and Rehabilitation, Mayo Clinic, Rochester, Minnesota.

Low-Energy Laser Therapy: Controversies and New Research Findings



"Lasers are just convenient machines that produce

radiation; It is the radiation that produces the

photobiological and/or photophysical effects and

therapeutic gains, not the machine."

—Kendric C. Smith; The Photobiological Basis of Low Level Laser Radiation Therapy.

Department of Radiation Oncology, Stanford University School of Medicine

"...according to all available data, does not depend

on the coherence of radiation."

"Photobiological Principles of Therapeutic Applications

of Laser Radiation“ published by Yu. A. Vladimirov, et al

in Biochemistry (Moscow)Volume 69, Number 1 / January, 2004

“ Wavelength determines depth-of-penetration –

the longer the wavelength the deeper the

penetration.

Qualities unique to lasers such as collimation and

coherence do not affect depth-of penetration since

both are lost once light has penetrated the first

millimeter of tissue.”

–D.C. Laycock, Ph.D., MIPEM, MBES, CGLI.,

“Lasers vs. Super Luminescent Light Emitting Diodes”

"An analysis of published clinical results from the point of view of

various types of radiation sources does not lead to the

conclusion that lasers have a higher therapeutic potential than

LEDs.

...The coherent properties of light are not manifested when the

beam interacts with a biotissue on the molecular level

....The conclusion was that under physiological conditions the

absorption of low-intensity light by biological systems is of purely

noncoherent (i.e., photobiological) nature....specially designed

experiments at the cellular level have provided evidence that

coherent and noncoherent light with the same wavelength,

intensity, and irradiation time provide the same biological

effect.

Successful use of LEDs in many areas of clinical practice also

confirms this conclusion."

Professor Tiina Karu (Biomedical Photonics Handbook, 2003).



“By light interaction with a biotissue, coherent properties of laser

light are not manifested at the molecular level. The absorption of

low-intensity laser light by biological systems is a purely

noncoherent (i.e., photobiological) nature. On the cellular level,

the biological responses are determined by absorption of light with

photoacceptor molecules. Coherent properties of laser light are

not important when cellular monolayers, thin layers of cell

suspension as well as the layers of tissue surface are irradiated.

In these cases, the coherent and noncoherent light (i.e., both

lasers and LED’s) with the same wavelength, intensity and dose

provide the same biological response.”

Cellular Mechanisms of Low-Power Laser Therapy (Photobiomodulation)—T.I. Karu

What about the light scattering

effect of

Laser Light vs. LED Light?

Tissue scattering degrades coherent effects of lasers:

“At first glance, the polarization and coherency aspects of laser irradiation are attractive

as sources of biological effects, since (poorly defined) resonant effects might be

hypothesized to occur in the interaction of laser radiation and cellular components.

However, this view may not be tenable since 1) stimulative effects are reported following

irradiation with nonlaser light sources and 2) tissue scattering, as well as the fiber optic

delivery systems used in many experiments, rapidly degrade coherency.

Thus, any effects produced by low-energy lasers may be due to the effects of light in

general and not to the unique qualities of lasers. This view is not difficult to accept when

it is remembered that wavelength-dependent photobiochemical reactions occur

throughout nature and are involved in such things as vision, photosynthesis, tanning, and

vitamin D metabolism. In this view, laser therapy is really a form of light therapy, and

lasers are important in that they are convenient sources of intense light at wavelengths

that stimulate specific physiological functions.”

Low-Energy Laser Therapy: Controversies and New Research Findings—

Jeffrey R. Basford, M.D., Department of Physical Medicine and Rehabilitation,

Mayo Clinic, Rochester, Minnesota



Laser Light Scatters in Tissue

LIGHT IS LIGHTSLD vs. Laser

“Lasers, however, have some inherent characteristics which make their use in a

clinical setting problematic, including limitations in wavelength capabilities and

beam width… Light-emitting diodes (LEDs) offer an effective alternative to

lasers.

Due to the nature of light physics and engineering constraints of laser design, the

range of wavelengths attainable is limited. Due to the coherent beam of light

unique to lasers, their ability to easily treat large areas is also limited.

Development of light emitting diodes (LED) offers an alternative source for light

therapy that can be designed to produce many wavelengths and in an array to

emit light at wavelengths proven, in prior studies of laser light, to speed wound

healing.”

Medical Applications of Space Light-Emitting Diode Technology—Space Station and Beyond—

Harry T. Whelan, M.D., John M. Houle, B.S., Deborah L. Donohoe, A.S., L.A.T.G., Dawn M. Bajic,

B.S., Meic H. Schmidt, M.D., Kenneth W. Reichert, M.D., George T. Weyenberg, R.N.,

David L. Larson, M.D., Glenn A. Meyer, M.D., James A. Caviness, M.D.

By the time laser-generated light has passed through

the first millimeter of tissue, the unique qualities of

collimation and coherence are primarily lost.



APPLICATIONS

CONTRAINDICATIONS / WARNINGS for

Light TherapyDo not use Light Therapy:

• Over and around the uterus during pregnancy.

• Where there is active ongoing hemorrhaging / bleeding tendencies.

• When there is any indication or diagnosis of blood clots.

• Over and around the thyroid gland.

• Cancer (tumors or cancerous areas).

• Over open wounds unless covered with a clear sterile protective

barrier. (An open wound may be treated in the non-contact mode without

protective barrier since the probe is never placed on the wound in the non-

contact mode).

• Over the cardiac region and Vagus nerve.

• Where analgesia/ pain relief may mask progressive pathology.

• Over an area that has been treated with a photosensitizing agent.

• In a patient taking medication that may cause sun-sensitivity (some

antibiotics and St. John’s Wort)

• In a patient with Epilepsy (pulsed light therapy)

• Over the growth plates in children

• Direct irradiation of eyes.



Indications for Light Therapy• Tension Headache

• Migraine Headache

• TMJ

• Neck-Shoulder Pain

• Frozen Shoulder

• Tennis Elbow or Golfer’s Elbow (Lateral and Medial Epicondylitis)

• Osteoarthritis over the thumb (1st MCP joint)

• Low Back Strain

• Sciatica

• Hip or Knee Arthritis or Injury

• Tendinitis – Achilles

• Ankle Sprain

• Plantar Fascitis

• Wound Repair

• Burns

• Carpal Tunnel Syndrome

• Sinusitis

• Sports Injuries

• Trigger Points

• Shingles

* Be sure to stay within your scope of

practice!

WI Chiropractic

Scope of Practice

• The practice of chiropractic is the application of

chiropractic science in the adjustment of the

spinal column, skeletal articulations and

adjacent tissue which includes diagnosis and

analysis to determine the existence of spinal

subluxations and associated nerve energy

expression and the use of procedures and

instruments preparatory and complementary to

treatment of the spinal column, skeletal

articulations and adjacent tissue.

Clinical Studies of LLLT:

• >130 double-blind positive studies confirming

the clinical effect of LLLT.

• More than 3000 research reports are published

with more than 90% of these studies verifying

the clinical value of laser therapy.

• About 250 papers are annually published in

peer reviewed scientific papers.



Various resources to find

research…

• www.pubmed.com

• www.medscape.com

• www.laser.nu (Swedish Laser Medical Society)

• http://www.healinglightseminars.com/librar

y.html

• http://www.walt.nu (World Association for Laser Therapy)

• www.naalt.org (North American Association for Laser Therapy)

Low Level Laser Therapy (LLLT)

Applications, Case Studies and Low

Level Laser Research

• MUSCULOSKELETAL PAIN

SYNDROMES (CHRONIC AND ACUTE):

– LLLT has been shown to be effective in a

variety of musculoskeletal conditions and

associated pain presentations.

http://www.pubmed.com/

http://www.medscape.com/

http://www.laser.nu/

http://www.healinglightseminars.com/library.html

http://www.walt.nu/

http://www.naalt.org/



Acute low back pain with radiculopathy:

a double-blind, randomized, placebo-

controlled study

• Konstantinovic LM, et al: Photomed Laser Surg.

2010 Aug;28(4):553-60

• RCT, double-blind, placebo-controlled trial was

performed on 546 patients.

– Group A (182 patients) was treated with nimesulide

200 mg/day and additionally with active LLLT

– Group B (182 patients) was treated only with

nimesulide

– Group C (182 patients) was treated with nimesulide

and placebo LLLT.

– LLLT was applied behind the involved spine

segment using a stationary skin-contact

method. • Pts treated 5x/wk, for a total of 15 treatments, with the

following parameters: wavelength 904 nm; frequency 5000

Hz; 100-mW average diode power; power density of 20

mW/cm(2) and dose of 3 J/cm(2); treatment time 150 sec at

whole doses of 12 J/cm(2).

• The outcomes were pain intensity measured with a visual

analog scale (VAS); lumbar movement, with a modified

Schober test; pain disability, with Oswestry disability score;

and quality of life, with a 12-item short-form health survey

questionnaire (SF-12).

• Subjects were evaluated before and after treatment.

Statistical analyses were done with SPSS 11.5.

LLLT and acute LBP with

Radiculopathy – 2010 study

• CONCLUSIONS: The results of this study

show better improvement in acute LBP

treated with LLLT used as additional

therapy (Group A).

Konstantinovic LM, et al

Photomed Laser Surg. 2010 Aug;28(4):553-60



LLLT for acute neck pain with

radiculopathy:

• Pain Med. 2010 Aug;11(8):1169-78

• The objective of the study was to investigate

clinical effects of low-level laser therapy in

patients with acute neck pain with radiculopathy.

This was a double-blind, randomized,

placebo-controlled study.

• The study was carried out between January

2005 and September 2007 at the Clinic for

Rehabilitation at the Medical School, University

of Belgrade, Serbia.

60 pts received a course of 15 treatments over 3

weeks with active or an inactivated laser as a

placebo procedure.

LLLT was applied to the skin projection at the

anatomical site of the spinal segment involved

with the following parameters:

• wavelength 905 nm

• frequency 5,000 Hz

• power density of 12 mW/cm(2)

• dose of 2 J/cm(2)

• tx time 120 sec at whole doses 12 J/cm(2).

• The primary outcome measure was pain intensity as

measured by a visual analog scale.

• Secondary outcome measures were neck movement,

neck disability index, and quality of life.

• Measurements were taken before treatment and at the

end of the 3-week treatment period.

• Statistically significant differences between groups were

found for intensity of arm pain and for neck extension.

• LLLT gave more effective short-term relief of arm

pain and increased range of neck extension in

patients with acute neck pain with radiculopathy in

comparison to the placebo procedure.• Pain Med. 2010 Aug;11(8):1169-78



Effect of low-level laser (Ga-Al-As 655 nm)

on skeletal muscle fatigue induced by

electrical stimulation in rats

“We conclude that LLLT doses of 0.5 and 1.0

J/cm2 can prevent development of muscular

fatigue in rats during repeated tetanic

contractions.”

Rodrigo Álvaro B. Lopes-Martins,1 Rodrigo Labat Marcos,1 Patrícia Sardinha Leonardo,1 Antônio Carlos Prianti, Jr.,1 Marcelo Nicolas Muscará,1 Flavio Aimbire,2 Lúcio Frigo,3 Vegard V. Iversen,4 and Jan Magnus

Bjordal5

J Appl Physiol 101: 283-288, 2006. First published April 20, 2006; doi:10.1152/japplphysiol.01318.2005

8750-7587/06

The effect of 300mW, 830NM laser on

chronic neck pain: a double- blind,

randomized, placebo-controlled study

-Chow RT et al. Pain. 2006 Jun 23

• 90 patients with chronic neck pain for at least 3

months up to 15 years (mean duration 11 years)

were given 14 treatments with laser over 7

weeks.

• At 1 month after treatment, 82% of patients in

the active group achieved a positive response

vs. only 29% in the placebo group.

Low level laser therapy before eccentric

exercise reduces muscle damage

markers in humansBaroni BM, Leal Junior EC, De Marchi T, Lopes AL, Salvador M, Vaz MA.

Eur J Appl Physiol. 2010 Jul 3. [Epub ahead of print]

• After LLLT or placebo treatment, subjects performed 75

maximal knee extensors eccentric contractions (five sets

of 15 reps.

• Muscle soreness (visual analogue scale-VAS), lactate

dehydrogenase (LDH) and creatine kinase (CK) levels

were measured prior to exercise, and 24 and 48 h after

exercise.

• LLLT treatment before eccentric exercise was effective in

terms of attenuating the increase of muscle proteins in the

blood serum and the decrease in muscle force.



Effects of Low-Level Laser Therapy (LLLT) in

the Development of Exercise-Induced Skeletal

Muscle Fatigue and Changes in Biochemical

Markers Related to Post-Exercise Recovery

• J Orthop Sports Phys Ther. 2010 Apr 12. [Epub ahead of

print] Leal Junior EC, Lopes-Martins RA, Frigo L, De Marchi T, Rossi RP, de

Godoi V, Tomazoni SS, da Silva DP, Basso M, Filho PL, de Valls Corsetti F, Iversen

VV, Bjordal JM.

• CONCLUSION: We conclude that pre-exercise

irradiation of the biceps with an LLLT dose of 6 J per

application location, applied in 2 locations, increased

endurance for repeated elbow flexion against resistance,

and decreased post-exercise levels of blood lactate, CK,

and CRP.

Effects of superpulsed low-level laser

therapy on temporomandibular joint pain.

• Marini I, Gatto MR, Bonetti GA., Clin J Pain. 2010 Sep;26(7):611-6.

• OBJECTIVES: A randomized double-blind study was

conducted to compare the efficacy of superpulsed low-

level laser therapy (SLLLT) with nonsteroidal anti-

inflammatory drugs in the treatment of pain caused by

temporomandibular joint disorders.

DISCUSSION: Mandibular function improved in all

SLLLT patients proving the effectiveness in the

treatment of pain, as demonstrated by a significant

improvement in clinical signs and symptoms of

temporomandibular joint disc displacement without

reduction and osteoarthritis at the end of treatment and

stability over a period of 1 month.

Clinical Evidence and Guidelines for Laser

Phototherapy

in Tendinopathies and Arthritis

NAALT Conference 2011Jan M. Bjordal

Professor ,PT, PhD,

Bergen University College & University of Bergen, Norway

Leeds Metropolitan University, Great Britain



Pessoa et al. 2005 Photomed Laser Surg

14 days after injury

LLLT Steroids

Optimal LLLT enhances tissue repair,

while steroids inhibit tissue repair

LLLT vs. Steroids

Conclusions1. Most musculoskeletal pain treatment guidelines are confounded

by authors´ conflict of interests with the drug industry

2. Pain treatment guidelines should be developed by authors

without conflicts of interest with any manufacturer of drugs or

pain relief devices

3. Optimal LLLT has greater short-term efficacy than NSAID and

greater long-term efficacy than steroid injections in

tendinopathies

4. In neck pain, there is no evidence in support of NSAID use,

while LLLT efficacy is supported by firm scientific evidence

5. LLLT is at least equally effective as NSAID in low back pain and

osteoarthritis

6. LLLT has superior safety over NSAID and steroid injections in

musculoskeletal pain

Pessoa et al. 2005 Photomed Laser Surg

Use common and

clinical sense

when reviewing

research!



FDA Approved Uses• Chiropractors and CTs who have taken an

approved continuing education class are allowed to use cold laser and light therapy to treat patients for conditions within their scope of practice “but only if those uses have been approved by the federal Food and Drug Administration.” (FDA)

• The FDA approves a cold laser or light therapy device with what is known as a 510(k) form.

• It is important that the device you are utilizing within your office have a 510(k) approval and that you know what indications have been approved.

Examples of FDA Approved

Uses• Example – one specific modality received

approval in 2002 “to provide topical heating for

the temporary increase in local blood circulation,

temporary relief of minor muscle and joint aches,

pain and stiffness and relaxation of muscles; for

muscle spasms, and minor pain and stiffness

associated with arthritis.” It is also approved for

the temporary relief of hand and wrist pain

associated with carpal tunnel syndrome.

Examples of 510(k) Approvals:

• “for the temporary increase in local blood circulation; temporary relief of minor muscle and joint aches, pains and stiffness; for relaxation of muscles; for muscle spasms; and minor pain and stiffness associated with arthritis.”

– Approval # K031329

– http://www.fda.gov/cdrh/pdf3/K031329.pdf



• approval in 2003 for the indication of

“adjunctive use in the temporary relief of

hand and wrist pain associated with

Carpal Tunnel Syndrome.”



“adjunctive use in the temporary relief of

hand and wrist pain associated with

Carpal Tunnel Syndrome.”


Examples of 510(k)

Approvals


“adjunctive use in providing temporary

relief of pain associated with iliotibial band

syndrome.”



Examples of 510(k)

Approvals

• approval for the indication of “elevating

tissue temperature for the temporary relief

of minor muscle and joint pain and

stiffness, minor arthritis pain, or muscle

spasm; the temporary increase in local

blood circulation; and/or the temporary

relaxation of the muscle.”

Examples of 510(k)

Approvals


“adjunctive use in temporary relief of hand

and wrist pain associated with Carpal

Tunnel Syndrome.”

Examples of 510(k)

Approvals

• ….intended to emit energy in the infrared

spectrum to provide topical heating for the

purpose of elevating tissue temperature for the

temporary relief of minor joint pain and stiffness,

minor arthritis pain, or muscle spasm, the

temporary increase in local blood circulation

and/or promoting relaxation of muscles.» FDA approval K043586



510(k) Approval

• Before buying a laser or light therapy device, ask

the vendor for a copy of the FDA 510(k)

approval to be sure that the device has been

approved for the indications which you (the

doctor) intend to treat within the office.

• Always treat within your scope of practice –

regardless of what the modality is approved for.

Application Considerations…

“Dosage”

• Dosage is often measured in Joules per

unit or in Joules

• Time is dependent upon the power of the

modality being used.

• Too much, too little, poor contact, lack of

absorption…. All reasons for poor

outcomes

Irradiance vs. Time as

“dosage”…

• Irradiance (W/cm2)

Often called Intensity, or Power Density and

is calculated as

Irradiance = Power (W)/Area (cm2)

More accurate representation of dosage than

just “time”



Pulse Structure• Peak Power (W)

• Pulse freq (Hz)

• Pulse Width (s)

• Duty cycle (%)

If the beam is pulsed, then the Power should

be the Average Power and calculated as

follows:

Average Power (W) = Peak Power (W) ×

pulse width (s) × pulse

frequency (Hz)

Arndt-Schultz

Principle

• There is an optimal amount of energy

absorption per unit of time that is

beneficial.

• Too much, or too little, loses therapeutic

benefits.

• Too little stimuli will not produce effects,

whereas too much stimuli may actually

have harmful effects.



Q: What happens if too

high of a dose is applied?

• A: May have a non-optimal

effect, or worse, a

biosuppressive effect .

• For example: The healing of a

wound may take longer time than

normally expected.

• Very high doses on healthy tissues

will not damage them.

Cosine Law

Radiant energy is more easily transmitted to

deeper tissues if the source of radiation is at

a right angle to the area being radiated.

Law of Cosines



Conventional Treatment Protocols

• Treatment parameters are designed to get the required amount of photons to the target tissue

• Given the same amount of J/cm2, a higher dose over a shorter period of time is preferred.

• Typically treatment will be directed at the injured area. Apply Laser or Light:

– Over the damaged tissue

– Over the affected nerve roots

– Over the muscle insertion

– Over trigger points or tender points

– Over acupuncture points related to the condition



Conventional Treatment

Protocols

• When treating points, push down with the laser

or probe to move the blood out of the way to get

better/deeper penetration. (Be careful if using a

high-powered laser that may cause heat!!)

• When treating edema – treat the proximal part

first in order to promote drainage before treating

the distal part.

Conventional Treatment

Protocols

• In order to get the desired amount of therapy

into a target tissue, the probe or cluster needs to

be stationary.

• If the probe/therapy head is moving, then the

treatment time needs to be changed

accordingly.

• In other words, treat multiple points instead of

moving the probe.



• Treat proximal areas

before distal regions

Conventional Treatment Protocols

• Frequency of Treatment: Light therapy

has been shown to have a cumulative

effect – every other day to 3x/wk for the

first 2 wks is recommended.

• Chronic conditions may be aggravated in

the first few treatments

• Acute conditions usually respond quicker

than chronic.

Dosage Recommendations

• Refer to user’s manual if backed by research

• Per World Association for Laser Therapy:

– For LLLT of 904nm

http://www.walt.nu/images/stories/files/Dose_table_90

4nm_for_Low_Level_Laser_Therapy_WALT-2010.pdf

– For LLLT of 780-860 nm:

http://www.walt.nu/images/stories/files/Dose_table_78

0-860nm_for_Low_Level_Laser_Therapy_WALT-

2010.pdf

http://www.walt.nu/images/stories/files/Dose_table_904nm_for_Low_Level_Laser_Therapy_WALT-2010.pdf

http://www.walt.nu/images/stories/files/Dose_table_780-860nm_for_Low_Level_Laser_Therapy_WALT-2010.pdf



Reminder!

• The State of Wisconsin restricts the use of

a Light Therapy device to the purpose

specified on the FDA 510(k) statement.

• You should have a written copy of the

510(k) statement from the manufacturer.

• The state will not accept “ignorance” as an

excuse.

Applications

• Refer to your User Manual

• Be sure to check the 510(k) FDA approval

• Class Examples:

Specific Examples:

• Neck / Shoulder Pain

• Lateral Epicondylitis

• Soft Tissue Inflammation

• Cervical Radiculopathy

• Other conditions: TMJ, sinus pressure, migraine/headaches, plantar fasciitis, tight muscles, etc.



Specific Examples:

• Lateral Epicondylitis (Tennis Elbow)

– Using Light Cluster Probe or Laser

– Treatment Areas:• Insertion site – extensor muscles at the lateral

epicondyle

– Dosage:• 1-3 J/cm2 per point

• 1-2x/wk for 3-6 wks.

• Consider treatment of cervical region if slow progress

Specific Examples:

• Soft Tissue Inflammation (including bursitis,

tendonitis, etc.)

– Treatment areas:

• Points along inflammed areas – treat proximal

before distal

– Dosage:

• 4-8 J/cm2 per point – select dosage based upon

depth of the target tissue (deeper needs higher

dosage)

• 2-3x/wk

• Review of modalities used for

demonstration in this class:





Neck / Shoulder Pain

Neck / Shoulder Pain– Direct skin contact

– Treatment Areas:• Paravertebrally from C5-T2


• 1-2x/wk for 3-4 wks

– Also consider treatment over trigger points especially in the trapezius muscle, rhomboids & levatorscapulae

– Chiropractic adjustments as clinically indicated.

Lateral Epicondylitis

Lateral Epicondylitis (Tennis Elbow)– Using Light Cluster Probe

– Treatment Areas:• Insertion site – extensor muscles at the lateral epicondyle and

then distal through the extensor muscle

• Cervical and cervicothoracic muscles, trigger points, etc.


• 1-2x/wk for 3-6 wks.

• Consider further treatment of cervical region if slow progress

– Include chiropractic adjustment to subluxations at elbow, wrist and cervicothoracic regions as clinically indicated, ice massage & extensor stretches/exercises.



Soft Tissue Inflammation

Soft Tissue Inflammation

(including bursitis, tendonitis, etc.)

– Treatment areas:

• Points along inflamed areas – treat proximal before distal

• Include trigger points if indicated

– Dosage:

• 4-8 J/cm2 per point – select dosage based upon depth of the

target tissue (deeper needs higher dosage)

• 2-3x/wk

– Chiropractic adjustments as clinically indicated.

Cervical Radiculitis

Cervicobrachial Radicular Pain– Direct skin contact

– Treatment Areas:• Disc level (4J)

• Paravertebrally from C5-T4-5 bilaterally if indicated

• At trigger points, tight points– include scalenes, traps, rhomboids, levator scap

• Along dermatome


• 3x/wk for 3-4 wks

– Chiropractic adjustments & treatment as clinically indicated.



“The sun with all those planets revolving around it and dependent on it, can still ripen a bunch of grapes as if it had nothing else in

the universe to do.”

Galileo Galilei (1564-1652)

Cold Laser

and Light Therapy

By:

Dr. Wendy L.C. Varish, DC, FACO, CCSP, CCOHC

Documents

Cold Laser and Light Therapy