LASER

Photobiology
Cellular effects of phototherapy can be classified into primary (light-induced),
secondary (which occur in response to the primary effects) and tertiary effects
(Dyson, 2006).
Primary reactions are generally restricted to the absorption of photons while
secondary effects are not unique to phototherapy and, because their occurrence
depends on the sensitivity of the cells, are less predictable than primary effects
(Dyson, 2006). Tertiary effects are the least predictable since the response is
influenced by the internal and external environment and by intracellular interactions.
In primary responses:
1. photons emitted by the laser reach the mitochondria (Theralase, 2003) and
cell membranes of low lying cells (fibroblasts, keratinocytes or endothelial)
where the photonic energy is absorbed by chromophores (mitochondrial
cytochromes, porphyrins and flavoproteins) and is converted to chemical
kinetic energy (Matic et al, 2003) within the cell.
2. This causes changes in membrane permeability, improved signaling between
mitochondria, nucleus and cytosol and nitric oxide formation.
3. Increased oxidative metabolism to produce more ATP (Yu et al, 1997).
4. Normalization of cell function, pain relief and wound healing (Figure 1)
(Dyson, 2006)
Secondary reactions:
1. Various physiological changes at the cellular level such as changes in cell
membrane permeability (Figure 1) (Dyson, 2006).
2. Calcium is released from the mitochondria into the cytoplasm with changes in
intracellular calcium levels (Tunér and Hode, 2002) which:
Stimulates cell metabolism and the regulation of signaling pathways
responsible for significant events required for wound repair such as:
 Cell migration
 RNA and DNA synthesis
 Cell mitosis
 Protein secretion
 Cell proliferation (Kiepeis et al, 2001).
Tertiary effects (Systemic effect):
1. Induced in cells at a distance from the cells in which the secondary events
occur (Dyson, 2006).
2. Irradiated or energized cells communicate with each other, and with non
irradiated cells, through increased levels of cytokines or growth factors
(Vladimirov, 2004) resulting in inter-cellular communication (Tunér and
Hode, 2002).
3. There is an increase in the immune response with the activation of T-
lymphocytes, macrophages and number of mast cells (Hamblin and Deidova,
2006).
4. An increase in the synthesis of endorphins and decrease in bradykinin results
in pain relief.
5. Certain molecules such as porphyrins can be converted into a long-lived triplet
state after photon absorption. This triplet state can interact with ground-state
oxygen with energy transfer leading to the production of a reactive singlet
oxygen species (Hamblin and Deidova, 2006).
6. Alteration of mitochondrial metabolism and activation of the respiratory chain
by illumination, which would also
7. Increase production of superoxide anions.
8. Reverse the inhibition of cytochrome c oxidase by nitric oxide (NO) and thus
increase the rate of respiration with consequently more ATP synthesis
(Hamblin and Deidova, 2006).
 (Fig. 1) Cellular effects of phototherapy (Tunér and Hode, 2002).

Therapeutic applications:
1. Reduces pain in a large variety of acute and chronic pain entities including
pain related to abnormalities in nerves, soft tissue, muscles, tendons, joints and
bone.
2. Reduces swelling and inflammation associated with acute injuries in
superficial muscles, tendons, ligaments, bursa, and sheaths (Woodruff et al,
2004).
 3. Improves wound healing of slow-to-healing or non healing wounds in soft
tissues, tendons and bone due to improved tissue oxygenation and nutrition
(Woodruff et al, 2004).
4. Improves absorption of interstitial fluid (anti edematous) and increases
lymphatic circulation and drainage which results in better tissue regeneration
(Takac and Stojanovic, 1998).
5. Improves local and systemic blood circulation which is useful in blood-related
conditions such as Buerger’s and Raynaud’s diseases and torpid leg ulcers.
6. Enhance autoimmune response in immune deficient conditions such as
psoriasis, rheumatoid arthritis and atopic dermatitis (Woodruff et al, 2004).
7. Controls hypertension by increasing flow rate and increasing the diameter of
the vessels (Gabel, 1995).
8. Restores normal pigment in abnormally colored cutaneous lesions.
9. Laser therapy also has benefits for patients with Bell’s palsy, psoriasis and
unhealed donor areas following skin grafting (Baxter et al, 1997).
Phototherapy for superficial wound healing:
1. Clearance of necrotic or slough tissue, reduced signs of infection, reduced
amount and odor of fluid in highly exuding wounds, reduced pain and
resumption of the immune response initiated by the inflammatory phase.
2. He-Ne laser (5 J/cm2 ) stimulates mitochondrial activity, which leads to
normalization of cell function and stimulates cell proliferation and migration
of wounded fibroblasts to accelerate wound closure (Hawkins and
Abrahamse, 2006).
3. Ga/As diode laser (3 J/cm2) (120 mw) stimulated fibroblast proliferation
without impairingprocollagen synthesis (Pereira et al., 2002).
4. For open wounds or ulcers, the laser probe is normally held 1-2cm from the
wound while the periphery is treated with the laser probe in direct contact. The
open area of the wound should receive a lower dose than the skin periphery
(Tunér and Hode, 2002).
5. In the treatment of a chronic ulcer for example, a higher dose such as 3-4
J/cm2 will be used on points along the periphery of the wound followed by a
lower dose of 0.5 J/cm2 over the open wound (Tunér and Hode, 2002).
6. Special precautions such as holding the probe close (non-contact) to the wound
and cleaning the probe with an alcohol wipe have to be used to reduce
contamination during laser treatment (Tunér and Hode, 2002).
7. Phototherapy using a wavelength of 630 nm (1-20 J/cm2) results in bacterial
inhibition which may be an important consideration when selecting the correct
wavelength for infected wounds (Nussbaum et al, 2003).
8. An infected ulcer can be treated twice weekly until the infection clears.
 9. Patients on prescribed medication or who have conditions known to cause
photosensitivity reactions should also avoid LLLT.
10. It is unlikely that a combination of laser and drug will trigger a
photosensitivity response however patients should be patch tested with a small
dose and examined after 24-48 hours to determine if there is a hypersensitivity
reaction. (Lucas et al, 2003).
11. Acute wounds should be treated daily while chronic wounds should be treated
1-2 times a week.
12. Chronic tissue conditions require more treatment intervals where two or three
treatments a week are considered as the maximum.
13. As a general rule, it is better to use 3-4 treatments a week with moderate doses
than using higher doses and fewer treatments (Tunér and Hode, 2002).
Phototherapy for pain relief:
1. Laser therapy provides relief for musculoskeletal pain, post fracture pain, pain
at origin or insertion of any muscle or tendon, haematoma, and neurogenic
pain
2. Most acute musculoskeletal injuries should be treated daily over a short period
whereas chronic musculoskeletal injuries should be treated over a longer
period every week if palliative or every 2-3 days if there is low grade
inflammation (Tunér and Hode, 2002).
3. An infra-red probe has a penetration depth of several centimetres and is used
for musculoskeletal injuries, acupoints, neurogenic pain and trigger points
(Theralase, 2003).
4. The most frequently used laser for pain therapy is the Ga/AI/As diode that
emits coherent light in the near infrared waveband, usually 820-840 nm, and
with a continuous wave power output of 60 mW(Moore et al, 2002).
5. A near infrared (810 nm) laser probe can be used to treat pain while a cluster
probe can be used for soft tissue inflammation and pain trigger points (muscle,
tendon and ligaments).
6. Anti inflammatory by lowering, in a dose-dependent manner, levels
of prostaglandin E2 (PGE2), generated through the arachidonic acid pathway,
increases the sensitivity of nociceptors during inflammation; the counteracting
effects of LLLT therefore inhibit this sensitization(Ferreira et al., 2005).
7. LLLT produces dose‐dependent reduction, interleukin 1-beta, tumor necrosis
factor-alpha (acute inflammatory states), the cellular influx of neutrophil
granulocytes, oxidative stress, edema, and bleeding(Bjordal et al., 2006).
8. Laser suppressed nerve conduction in nociceptive fibers and caused a variety
of neurotransmitter effects such as increased serotonin, beta‐endorphin, and
acetylcholine esterase activity (Chow et al., 2007).
Precautions:
1. Patients should wear laser‐protective glasses. Laser beams, can similarly cause
ocular damage when reaching the retina (Teichman et al., 1999).
2. In addition, LLLT should take place in a controlled area with minimal access
to avoid inadvertent exposure to passersby.
3. One should remain vigilant about avoiding laser reflection from mirrored
surfaces.
Contraindications:
 Absolute contraindications to LLLT the following three conditions: direct
treatment of the eye, cancer, hemorrhage, and a pregnant uterus.
 Relative contraindications include treatment over open epiphyses, autonomic
ganglia, the heart, reproductive organs, infected tissue, photosensitive skin or
tissue, and in patients with impaired sensation or responsiveness.
 (Fig.2) Key aspects of phototherapy that can be used to establish an effective therapeutic regimen
for the treatment of superficial wounds or skin conditions and musculoskeletal injuries
 LOW LEVEL LASER THERAPY

Students learning objectives

Following completion of this chapter, each student should be able to;

1. Define LASER.
2. Describe the mechanisms of Laser production.
3. Mention the characteristics of Laser Beam.
4. Identify the different types of LASER.
5. Explain physiological effects of LASER.
6. Describe indication & contraindication of LASER therapy.
7. Be aware of the precautions for low-power lasers.

Fig: 19 Cold Laser device

Definition

The word LASER is an acronym for Light Amplification by Stimulated

Emission of Radiation. Laser can be considered to be a form of light amplifier - it
provides enhancement of particular properties of light energy. Laser is a form of
electromagnetic radiation that's classified within both the infrared and visible light
portions of the spectrum. Laser light will behave according to the basic laws of light,
in that it travels in straight lines at a constant velocity in space. It can be transmitted,
reflected, refracted and absorbed.
Lasers are either high power or low power. High-power lasers are used in surgery for
purpose of incision, coagulation of vessels, and thermolysis, owing to their thermal
effects. The low-power, low level or cold laser produces little or no thermal effects
but seems to have some significant clinical effect on soft tissue and fracture healing
as well as pain management through stimulation of acupuncture and trigger points.

Physical Principle of Laser Production:

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 tiny “energy packets” called 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 (figure 20).

Fig. 20 Production of Laser light.

Properties of laser light
The laser light is emitted in an organized manner rather than in a random pattern as
from a light bulb. Three properties distinguish the laser from incandescent and
fluorescent light sources: coherence, monochromaticity, and collimation.
 1. Coherence
Coherence means all photons of light emitted are 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 (figure 21 a & b).

Fig. 21a Incoherent Laser wavesFig. 21b Coherent LASER Waves

2. Monochromatic (figure 22)

Monochromaticity refers to the specificity of light in a single, defined
wavelength; if the specificity is in the visible light spectrum, it is only one
color. The laser is one of the few light sources that produces a specific
wavelength.
1. Wavelengths of less than 400 nanometers—ultraviolet spectrum.
2. Wavelengths of 400 to 700 nm—visible light.
3. Wavelengths between 700 and 100,000 nm—infrared spectrum.

Fig. 22Monochromaticity

3. Collimation
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.
On the other hand, white light is composed of many wavelengths (colors) that
superimpose their phases on one another and scatter in all direction (figure 23).

Fig. 23Collimation difference between normal light and Laser.

TYPES OF LASERS
Lasers are classified according to the nature of the material placed between two
reflecting surfaces. There are potentially thousands of different types of lasers, each
with specific wavelengths and unique characteristics, depending on the lasing
medium utilized. The lasing mediums used to create lasers include the following
categories:
1. Solid state lasers (Ruby or Crystal lasers): this consists of a small synthetic
ruby rod made of aluminum oxide and chromium.
2. Gas lasers: the helium neon (HeNe), argon, and carbon dioxide (CO 2).
3. Semiconductor or diode lasers: The gallium arsenide (GaAs) and gallium
aluminum arsenide (GaAlAs).
4. Liquid lasers: are also known as dye lasers because they use organic dyes as
the lasing medium.
5. Chemical lasers: are usually extremely high powered and frequently used for
military purposes.
Lasers can also be categorized as either high or low power, depending on the
intensity of energy they deliver. High-power lasers are also known as "hot" lasers
because of the thermal responses they generate. These are used in the medical realms
in numerous areas, including surgical cutting and coagulation, ophthalmologic,
dermatologic, oncologic, and vascular specialties.
The use of low-power lasers for wound healing and pain management is a
relatively new area of application in medicine. These lasers produce a maximal
output of less than 1 milli watt (1mW= 1/1000 W) work by causing photochemical,
rather than thermal, effects. No tissue warming occurs.

The two types of low power lasers used by therapist are:

1- The helium-neon laser (He-Ne) and gallium-arsenide laser (Ga-As). The HeNe
gas laser uses a gas mixture of primarily helium with neon in a pressurized
tube. This creates a laser in the red portion of the electromagnetic spectrum
with a wavelength of 632.8 nm and direct depth of penetration to 2-5mm,
although there may be some indirect effect up to 8 to 10mm.
2- The GaAs lasers utilize a diode to produce an infrared (invisible) laser at a
wavelength of 904 nm that is directly absorbed in tissues at depths of 1-2 cm
and has an indirect effect up to 5 cm.
Laser Tissue Interaction:
Any energy applied to the body can be absorbed, reflected, transmitted, and
refracted. Biological effects results only from the absorption of energy, and as more
energy is absorbed, there's less available for the deeper and adjacent tissues. When
laser radiations interact with matter the effects are the same as any other equivalent
electromagnetic radiation i.e. absorbed, reflected, transmitted, and refracted. In this
way collimation and coherence are diminished or lost.
The extent to which this happens will depend on the nature and density of
matter present so that laser radiations will pass unaffected through space and be
only slightly altered in air but is markedly altered on entering a more dense material
such as the tissues (figure 24).

Fig. 24Laser tissue interaction

Depth of Penetration
Any energy applied to the body can be absorbed, reflected, transmitted, and
refracted. Biologic effects result only from the absorption of energy, and as more
energy is absorbed, less is available for the deeper and adjacent tissues (figure 25).
Laser light's depth of penetration through the tissues depends on:
1. Wavelength and frequency of laser beam.
2. Angle of incidence.
3. The nature of the medium the light propagates through i.e. tissue type.

Fig. 25 penetration of different Laser wave length

Regarding the type of laser, absorption of HeNe laser energy occurs rapidly in the
superficial structures, especially within the first 2 to 5 mm of soft tissue. The
response that occurs from absorption is termed the direct effect. The indirect effect is
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. HeNe laser has an indirect effect on tissue
up to 8 to 10mm.
The GaAs, which has a longer wavelength, is directly absorbed in tissues at depths of
1 to 2 cm and has an indirect effect up to 5cm. Therefore, this laser has better
potential for the treatment of deeper soft tissue injuries, such as strains, sprains, and
contusions.

Physiological Effect of Laser

1-Facilitation of Wound and Fracture healing:
Laser therapy promotes the healing of chronic and acute wound (figure II.10); such
as surgical wound, ulcer, bed source and burn through;
  Improving circulation and inhibiting bacterial growth.
 Stimulation of angiogenesis
 Stimulating Leukocytic, phagocytosis and fibroblast proliferation
 Enhancing cellular metabolism and ATP production.
 Increase collagen synthesis and procollagen RNA levels.
 Increase tensile strength of the wound.
While regarding accelerates of bone healing, Laser therapy enhances:
 The rate of hematoma absorption.
 Bone remodeling.
 Blood vessel formation and calcium deposition.
 Fibroblast and chondrocyte activity.
2- Pain Control:
Laser therapy has been thought to be useful in the treatment of acute and chronic
painful condition as musculoskeletal pain, post-surgical pain, and neuropathic pain
through its analgesic, myorelaxant, tissue healing, and bio-stimulation effects (figure
26). The analgesic effects of laser may be due to:
 Increased endogenous opoid production.
 Increase the local release of neurotransmitters such as serotonin.
 Decreased sensory nerve conduction velocity.
 Indirect effect through Hastened healing and Anti-inflammatory effects.
 Reducing interstitial swelling by stimulating the activity of lymphatic.

3- Anti-inflammatory and anti-edematous effects:

 Enhance the natural defense mechanism through stimulating phagocytosis with
a destructive effect on the irritant products.
 Decrease the level of prostaglandin (PGE2) that promote reduction of edema
and “wash out” of pro-inflammatory molecules.
 Dilatation and modulation of permeability of capillaries and lymphatic vessels
with fast reabsorption of oedema.
4- Immunologic response:
Laser therapy stimulates the immune system through:
 Activation of phagocytes,
 Stimulation of macrophages and
 Stimulation of mast cell degranulation.
5- Bio-stimulation effect through:
 Alteration of cell membrane potentials.
 Improving nuclear activity.
 Increasing cell metabolism.
 Increasing cell proliferation.
 Increasing cell motility.

Fig. 26 Physiological effects of laser

Indications of Laser Therapy:

1. Non- infected and infected skin wound and ulcers.
2. Non-united fracture.
3. Acute and chronic inflammation of musculoskeletal system as osteoarthritis
and rheumatoid arthritis.
4. Acute and chronic soft tissues injuries, such as tendon, ligaments, muscle and
nerve injuries
5. Neuropathic pain such as, trigeminal neuralgia, post-herpetic neuralgia and
carpal tunnel syndrome.
6. Trigger point and acupuncture point stimulation.

Contraindication of Laser Therapy:

1. Cancerous tumors
2. Direct exposure into the eyes
 3. Pregnancy
4. Hemorrhaging regions.
5. Gonads.
6. Over the thyroid gland

Precaution of Laser Therapy:

Lasers deliver nonionizing radiation, therefore, no mutagenic effects on DNA and no
damage to the cells or cell membranes have been found. No deleterious effects have
been reported after low-power laser exposure, including carcinogenic responses,
unless applied to already cancerous cells.Tumorous cells may proliferate when
stimulated. , but yet;

Low-power laser is not recommended for patients with:

1. Epilepsy
2. Fever
3. Malignancy
4. areas of decreased sensation
5. The gonads.
6. Epiphyseal plates of children.
7. Sympathetic ganglia.
8. Vagus nerve.
9. The operator should not attempnt to stare directly into the beam. Suitable
protective goggles to attenuate the wavelengths would be used by both
the operator and patient.
10. Some patients are on drugs known to cause photosensitivity reactions.

Penetration Depth
Laser light emitted in the near-infrared band penetrates
soft tissue deeper than light emitted in the visible
red band (see Fig. 11-6). Why is it so? As shown in
Table 11-4, the depth to which a laser beam of light can
penetrate soft tissues depends on two factors: absorption
and scattering. First, the greater the absorption of photons
by superficial tissues, the fewer the number of photons
the deeper tissues can absorb. In other words, penetration
depth (P) is inversely related to absorption (A), meaning
that the greater the absorption superficially, the lesser
the penetration depth (P = 1/A). Biophysics indicates that
visible red laser light is absorbed much more by superficial
tissues (skin and blood) than is infrared invisible light
(Nussbaum et al., 2003). Second, for any laser light to
physiologically and therapeutically affect tissues, it must
first be able to penetrate the skin and underlying targeted
soft tissue before being absorbed by the wavelengthspecific
chromophores buried in the layers of this tissue.
When a laser beam of light hits soft tissues, a significant
portion of its photons is scattered, or deflected, in various
directions away from the original direct path to the
targeted area. The biophysics of laser indicates that scattering
is inversely related to wavelength (S = 1/l). It is
greatest at short wavelengths and gradually decreases at
longer wavelengths (Houza et al., 1993; Nussbaum et al.,
2003). This means that photons of red lasers will experience more scattering than
those of infrared lasers when penetrating
soft tissues. Biophysics has also established that
penetration depth (P) is inversely related to scattering (S),
meaning that penetration depth decreases as scattering
increases (P = 1/S). As stated earlier, scattering is more
pronounced with shorter-wavelength lasers (red) than
with longer-wavelength lasers (infrared). Compared to
red light lasers, infrared light thus penetrates deeper into
soft tissues because it presents less superficial absorption
and scattering (see Table 11-4 and Fig. 11-6). Penetration
depth value is defined (Low et al., 1990; Baxter, 1994) as
the tissue depth, measured in centimeters, at which the
laser beam energy is reduced to 37% of its original value
(100%). This value is derived from the following formula:
Penetration depth value = 1/e, where e is a constant value
of 2.718. Penetration depth values for human tissues are
approximately less than 1 cm for red light lasers and less
than 5 cm for infrared light lasers.

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