Download Workshop - low intensity laser therap

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Meditech International Inc.
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www.bioflexlaser.com
415 Horner Avenue, Toronto, Ontario M8W 4W3
Low Intensity Laser Therapy
Science and Clinical
Applications
Slava Kim, MD
Clinic Director
Copyright © 2008 Meditech International Incorporated. ALL RIGHTS RESERVED.
Lasers – What comes to mind?
Sun Gods
Temple of Apollo
Greek Sun God
Ra
Egyptian Sun God
Belenus
Celtic Sun God
Healing with light is a common concept in
many cultures
Light as a healing force
Heliotherapy – Sunlight Therapy
University of Virginia Medical Center
Charlotteville, Virginia
Circa 1929
Samuel and Nettie Bowne Hospital
Poughkeepsie, New York.
Circa 1935
Absence of Light on Human Body - SAD
Seasonal Affective Disorder (SAD)
– Bright Light Phototherapy has
been shown to effectively treat
seasonal affective disorder
(SAD).
– Non thermal and does not
require specialized cells
Endre Mester - The Father of Laser Therapy
May 29, 1966
• Endre Mester working at
Semmelweiss hospital in
Budapest, Hungary publishes the
first paper on the stimulatory
effects of ruby laser light on the
skin of rats
Biological Photoacceptor Molecules
Plants
– Chlorophyll
– Carotenoids
Humans
–
–
–
–
Rhodopsin (vision)
Hemoglobin (blood)
Myoglobin (muscle)
Cytochrome (all cells)
The Electromagnetic Spectrum
Decrease in wavelength = Increase in energy in a smaller area
Damage with Electromagnetic Radiation
Two ways to cause damage
1. Ionizing radiation
•
Able to break bonds (i.e. DNA causing mutations)
2. Intensity
•
Thermal heating of tissue (i.e. microwave heating
food)
Wavelengths in the BioFlex Systems
• Red light at 660nm
• Infrared light at 840nm and 830nm
Cytochrome C Oxidase Absorption
M. Cope thesis
data modified
by M. Patterson
Red light at 660nm and Infrared light at 830/840nm
Published Absorption Spectra
Desmet et. al.,
Photomed.
Laser Surg.
24(2):121-128,
2006
Red light at 660nm and Infrared light at 830/840nm
Published Action Spectra
CuA
red
620 nm
CuB oxid
680 nm
CuB
red
760 nm
CuA
oxid
820 nm
Karu and
Afanasyeva,
DAN 392(5):693,
1995
Wavelength, nm
Red light at 660nm and Infrared light at 830/840nm
Biological Treatment Window
0.0050
0.0045
0.2000
Absorption Coeffiecient
0.0040
0.0035
Water
0.0030
Deoxyhemoglobin
0.0025
Oxyhemoglobin
0.0020
Cytochrome C
oxidized
0.0015
Cytochrome C
reduced
0.1500
0.1000
0.0500
0.0010
0.0005
0.0000
450
0.0000
550
650
750
850
Wavelength (nm)
Treatment Window
950
1050
M. Cope thesis
data modified
by M. Patterson
Laser Therapy Dosage - Arndt-Shultz Law
Physiological Activity
C
A
B
Control
D
Strength of Stimuli
A. No light gives no effect
B. Small amount of light also has no effect
C. Maximal effect at the apex of the curve
D. Inhibitory amount of light inhibits healing
Energy Production - Components
NADH
Dehydrogenase Cytochrome bc1
Complex
ATP
Synthase
Cytochrome c
Oxidase
Electron Transport Chain
H+
H+
H+
H+
H+
H+
ADP
ATP
Effect of Red and Infrared Light
H+
H+
H+
H+
H+
H+
H+
H+
H+
ADP
ATP
Laser Therapy Effects
Put title of slide here
Primary
– The light is absorbed by
cytochrome c oxidase
Secondary
– Release of NO into
endothelium of blood
vessels
– Small increases in free
radicals
– Increased proton
gradient in
mitochondria
Clinical
– Wound Healing,
Acceleration of the
Inflammatory Process
and Pain Influence
Published Effects of Light on Cells
• Increased ATP production
• Circulation
– Relaxation of smooth
muscles surrounding blood
vessels
– Angiogenesis
• Increased production of:
– Fibroblasts
– Macrophage
– Collagen
• Altered nerve conduction
• Increased metabolism of:
– Endorphins
– Acetylcholine
– Serotonin
• Increased synthesis of:
– DNA
– Proteins
• Stimulation of immune
response
Advantages of Laser Therapy
• Non-toxic
• Non allergic
• Non invasive
• Ease of application
• No side effects
• No complications
• Completely safe
• Cost effective
• Superior alternative to:
– analgesics
– NSAID’s
– other medications
•Surgery may not be
required
Conditions Treated I
• Acute injuries/trauma
– muscle
tears/hematoma
– tendon tears
– ligament
strain/sprains
– fractures
– subluxations
– sport injuries
• Musculoskeletal
– repetitive stress injuries
– rotator cuff tears
– carpal tunnel
syndrome
– reflex sympathetic
dystrophy
– fibromyalgia
– tempero-mandibular
joint pathologies
Conditions Treated II
•
Inflammatory
conditions
– tendonitis
– bursitis
– myositis
– fasciitis
– synovitis
– rheumatoid
arthritis
Autoimmune disease
• Degenerative disorders
– osteoarthritis
– discogenic and
vertebrogenic
radiculopathies
– calcifications
• e.g. bone spurs
– chondromalacia
patella
Conditions Treated III
• Other areas
• Wound management
– dermatological
– ulcers
• venous stasis
– plastic surgery
• diabetic
– dental (e.g. gingivitis)
• contact
– gynecological
• cervical pathologies
– Podiatry
• plantar fasciitis
• biomechanical
problems
• atherosclerotic
• Veterinary
– equine
– companion animals
Pain Mechanisms
Pathways for pain relief by
Red or Infrared laser therapy
Local photoradiation effects occurring in less than 24 hrs
Effects on biochemical inflammatory pathway
Reduced PGE
Levels (5)
Reduced TNF
Levels (2)
Reduced IL1
Levels (3)
Reduced COX-2
expression
(2)
Reduced
Plasminogen
activator
Levels (3)
Effects on cells and soft tissue
Reduced
Edema
formation (7)
Reduced
Hemorrhagic
formation (2)
Reduced
Neutrophil
cell influx (4)
Reduced
Cell apoptosis
(3)
Improved
Microcirculation
(4)
Inflammation
Acute Phase
Plasma derived mediators
- Bradykinin - complement (C3, C5a, MAC)
- coagulation (Factor XII, Plasmin, Thrombin)
Cell derived mediators
Preformed: Lysosome granules - vasoactive amines (Histamine, Serotonin)
Synthesized on demand:
- cytokines (IFN-γ, IL-8, TNF-α, IL-1)
- eicosanoids (Leukotriene B4, Prostaglandins)
- Nitric oxide - Kinins
Chronic Phase
Macrophage
- Epithelioid cell
- Giant cell
- Granuloma
Key Effects that Apply to Diabetes
Primary Effects
• ATP production and Membrane permeability
> Accelerated Metabolism
Secondary Effects
Clinical Effects
• Nitric Oxide Stimulation >
Angiogenesis
• Endothelial Growth Factor > Angiogenesis
• Endorphin Release >
Pain Reduction
• Elevated Immune Response > Wound Healing
• Increased Cell Metabolism > Acc. Inflammation Resp.
e.g. Fibroblast activity >
Increased collagen production
Evaluation of the degree of effectiveness of low level
light therapy on the treatment of skin ulcers and
delayed postoperative wound healing.
Iusim M, Kimchy J, Pillar T, Mendes DG.
Center for Implant Surgery, Flieman Geriatric Rehabilitation Hospital,
Technion, Haifa, Israel.
Orthopedics. 1992 Sep;15(9):1023-6.
Twenty-one patients with 31 postoperative delayed open wounds
resistant to conventional therapy were randomly allocated to three
groups.
Group 1 was treated with red low level narrow band (LLNB) light (660 nm);
Group 2 was treated with infrared LLNB light (940 nm);
Group 3 was treated with a placebo such as the Biobeam machine (no
light irradiation).
Group 1 showed a significant improvement compared to groups 2 and 3
(t-test).
Systemic effects of low-intensity laser irradiation on
skin microcirculation in patients with diabetic
microangiopathy.
Low-intensity laser irradiation has been shown to induce wound healing in
conditions of reduced microcirculation. We demonstrate low-intensity
laser irradiation on skin blood circulation in patients with diabetic
microangiopathy.
Patients are randomized; A) single helium-neon (HeNe, 632.8 nm) lowintensity laser irradiation with a dose of 30 J/cm(2) or B) sham irradiation
over the forefoot region in a double-blind, placebo-controlled clinical
study.
Skin blood circulation by means of temperature recordings over forefoot
regions was detected by infrared thermography.
A single dose of low-intensity laser irradiation = a rise in skin temperature.
The placebo group = a drop in skin temperature occurred.
Our data show a significant increase in skin circulation due to athermic laser
irradiation in patients with diabetic microangiopathy and point to the
possibility of inducing systemic effects.
Healing of Bone Affections and Gangrene with Low
Intensity Laser Irradiation in Diabetic Patients Suffering
from Foot Infections.
Schindl M, Schindl A, Polzleitner D, Schindl L.
Forsch Komplementarmed. 1998;5(5):244-247.
OBJECTIVE: Evaluation of low-intensity laser irradiation on the healing of bone
affections and gangrene in patients suffering from diabetic microangiopathy.
PATIENTS: Two consecutive diabetic male patients with gangrene, Osteomielitis,
and bone fractures.
INTERVENTION: Helium-neon laser irradiation (36 J/cm2 ) 50 min/day.
MAIN OUTCOME PARAMETER: Healing of gangrene and corticalis lesion as well as
remineralisation of bone affections.
RESULTS: Within a mean period of 14 weeks not only a complete healing of the
diabetic gangrenes but also a radiographically determined reestablishment of
corticalis and remineralisation of preexisting bone affections could be
achieved.
CONCLUSION: low-intensity laser irradiation should be further tested as an
additional beneficial therapeutic modality for the healing of gangrene and
bone affections in diabetic patients.
Diabetes Mellitus: infected dermal ulcers
Interim progress
Healing progressing
Initial:
Diabetic with 3 week old ulcer, previously
surgically debrided. The ulcer was deep,
painful and prior to treatment, resistant to
surgical and antibiotic therapy.
Final photo:
Total healing achieved
Patient, asymptomatic
and discharged
10 treatments over 3 weeks
Diabetes Mellitus: Gangrenous Leg
Dermal Ulcers
Initial
After 6
1 hour treatments
Diabetes Mellitus: Initial
Final, after 35 treatments
Diabetes Mellitus: Amputated III toe
Diabetes Mellitus
Pre-Gangrenous Right Foot
Initial
Intermediate
Intermediate
Final
Hemochromatosis
Dermal Ulcers – 2 Years
Initial
After 1 Treatment
After 5 Treatments
After 23 Treatments
After 36 Treatments
Final
1-Year Follow-up
Study: Achilles Tendons
Laser photostimulation of collagen production in
healing rabbit Achilles tendons. Reddy GK, Stehno-Bittel
L, Enwemeka CS.
Following tenotomy and repair, the surgical hind limbs of
the rabbits were immobilized in customized polyurethane
casts. The experimental animals were treated with a 632.8
nm HeNe laser daily at 1.0 J cm(-2) for 14 days.
Results: Biochemical analyses of the tendons
revealed a 26% increase in collagen concentration
with laser photostimulation indicating a more rapid
healing process in treated tendons compared to
controls.
Page 18
Left Achilles Tendonitis
10 treatments over 2 months
Tenderness,
Edema and
partial loss
of flexion
100% function,
asymptomatic
Initial
1 Month after final
treatment
Inflammation – Achilles Tendonitis
•
LLLT at a dose of 5.4 J per point can reduce inflammation
(PGE2) and pain in activated Achilles tendinitis.
Bjordal et al. Br J Sports Med. 40(1):76-80, 2006.
•
Low-level laser therapy accelerates clinical recovery from
chronic Achilles tendinopathy when added to an
Eccentric Exercise regimen. For the LLLT group, the results
at 4 weeks were similar to the placebo LLLT group results
after 12 weeks.
Stergioulas et al. American J. Sports Med. 36(5):881, 2008.
Muscle Tear/Hematoma
3 treatments over 5 days
Hamstring Tear/Hematoma
4 treatments over 7 days
Post-Traumatic Hematoma
Initial
After 4 Treatments
After 5 Treatments
Lateral Epicondylitis (tennis elbow)
•
A systematic review with procedural assessments and
meta-analysis of low level laser therapy in lateral elbow
tendinopathy was recently performed because other
reviews had found laser therapy to be ineffective.
•
LLLT administered with optimal doses of 904 nm and
possibly 632 nm wavelengths directly to the lateral elbow
tendon insertions, seem to offer short-term pain relief and
less disability in LET, both alone and in conjunction with an
exercise regimen.
Bjordal et. al. BMC Musculoskelet Disord. 29(9): 75. 2008
Subacromial Impingement Syndrome
•
A meta-analysis of the literature in Subacromial
Impingement Syndrome (SAIS) found that laser therapy is
an effective single intervention when compared with
placebo treatments, but adding laser treatment to
therapeutic exercise did not improve treatment efficacy.
•
The overall results of this meta analysis found that exercise,
joint mobilization, and laser therapy are effective physical
interventions for decreasing pain and functional loss or
disability for patients with SAIS. The current evidence does
not support the use of ultrasound.
Sauers. J Athletic Training. 40(3): 221-223, 2005.
Muscle Fatigue
•
Recently published study was aimed to investigate the
effect of low-level laser therapy (LLLT) (830 nm wavelength,
100 mW output, spot size 0.0028 cm(2), 200 s total
irradiation time) on skeletal muscle fatigue.
•
Concluded that 830 nm LLLT can delay the onset of
skeletal muscle fatigue in high-intensity exercises, in spite of
increased blood lactate levels.
Leal Junior et. al. Lasers Med Sci. Jul 23, 2008.
Joint Disorders
•
A systematic review on the effects of laser therapy in
chronic joint disorders found “Low level laser therapy with
the suggested dose range significantly reduces pain and
improves health status in chronic joint disorders.”
Bjordal et al. Aust J Physio. 49:107-116, 2003.
Osteoarthritis
•
Efficacy of physical interventions in osteoarthritic knee
pain. A systematic review and meta-analysis of
randomized placebo-controlled trials.
•
LLLT administered with optimal doses in an intensive 2-4
week treatment regimen, seem to offer clinically relevant
short-term pain relief for osteoarthritis of the knee.
Bjordal et. al. BMC Musculoskelet Disord. 22(8):51, 2007.
Thermal Burn (Heat)
5 Treatments Over 8 Days
Thermal Burn (Heat)
19 treatments over 2 months
Burns
LLLT of deep second-degree cutaneous burns significantly
increased the number of intact mast cells during the
inflammatory and proliferative phases of healing, and
decreased the total number of mast cells during the remodeling
phase.
Kaviani et. al. Lasers in Med. Sci. 21: 90, 2006.
•
A small pilot study used 400mW laser at 670 nm laser twice
a week over 8 weeks on 19 patients with burn scars who
were requesting laser therapy
•
Seventeen out of 19 lesions showed macroscopic
improvement after the treatment (expressed in points on
the Vancouver Scar Scale) with no scars becoming worse
Gaida et. al. Burns. 30: 362, 2004.
Fracture. R-Humerus.
Age: 66/M
Initial
Intermediate
Final
10/29/2006
11/04/2006
11/29/2006
11/01/2006
12/06/2006
10/25/2006
Bone Healing
•
A study performed in human osteoblast cells found “lowlevel laser therapy has a biostimulatory effect on human
osteoblast-like cells during the first 72 h after irradiation.”
Stein et. al. Wien Klin Wochenschr. 120(3-4): 112-117, 2008.
•
The results of a study carried out in laboratory mice
indicates “that the use of low-intensity laser promotes
better repair of bone injury”.
De Souza Merli et. al. Photomed Laser Surg. 23(2): 212-215, 2005.
•
A more recent study in rabbits found that LILT “may
accelerate the process of fracture repair or cause
increases in callus volume and BMD, especially in the early
stages of absorbing the hematoma and bone remodeling”
Liu et. al. Photomed Laser Surg. 25(6): 487-494, 2007.
Pain
Laser therapy in acute pain: a systematic review of possible
mechanisms of action and clinical effects in randomized
placebo-controlled trials.
•
The goal of the study was to review the biological and
clinical short-term effects of laser therapy in acute pain
from soft-tissue injury.
•
Laser therapy can modulate inflammatory processes in a
dose-dependent manner and can be titrated to
significantly reduce acute inflammatory pain in clinical
settings.
Bjordal et al. Photomed Laser Surg. 24(2):158-168. 2006
Case Study: Pain Reduction
Low level laser therapy with trigger points technique:
A clinical study on 243 patients.
(HeNe 632.8 nm visible red or infrared 820-830 nm continuous wave and 904 nm
pulsed emission.
There are very promising "trigger points" (TPs), i.e., myofascial zones of particular
sensibility and of highest projection of focal pain points, due to ischemic conditions.
Headaches and facial pain, skeletomuscular ailments, myogenic neck pain,
shoulder and arm pain, epicondylitis humery, tenosynovitis, low back and radicular
pain, Achilles tendinitis) to whom the "trigger points"
Results: rigidity decreases, the mobility is restored (functional recovery), and the
spontaneous or induced pain decreases or even disappears, by movement, too.
LLLT improves local microcirculation and it can also improve oxygen supply to
hypoxic cells in the TP areas and at the same time it can remove the collected
waste products.
Results measured according to VAS/VRS/PTM: in acute pain, diminished more than
70%; in chronic pain more than 60%.
Clinical effectiveness (success or failure) depends on the correctly applied energy
dose--over/underdosage produces opposite, negative effects on cellular
metabolism. The use of analgesic drugs could be reduced or completely excluded.
LLLT suggests that the laser beam can be used as monotherapy for pain treatment.
Page 29
Pain Reduction - Mechanism
•
830 nm laser irradiation induces varicosity formation,
reduces mitochondrial membrane potential and blocks
fast axonal flow in small and medium diameter rat dorsal
root ganglion neurons: implications for the analgesic
effects of laser.
•
Laser-induced neural blockade is suggested as a primary
candidate for the mechanism of laser-induced pain relief.
Chow et al. J Peripher Nerv Syst. 12(1): 28-39, 2007.
Peripheral-Arterial Occlusive Disease
(Frostbite 1992) – 86 yr. old podiatrist
Initial
After 5 Consecutive
Days of Treatment
11/29/2006
Acute for 6 months
Buergers Disease. Thromboangitis Obliterans
Initial:
Final photo:
June 11, color normal, one ulcer
totally healed, 2nd ulcer almost healed,
foot warm to the touch,
ready for weight bearing.
Interim (4-5)
12 treatments over 3 weeks
2 days after initiating treatments,
foot no longer in jeopardy.
Improved arterial circulation and venous
filling.
Venous Stasis
Dermal Ulceration
5 Treatments Over 9 Days
Chronic Lymphedema
After 10 Treatments
•
•
•
Cyanosis and induration gone
Good venous filling
Mid-calf diameter same as left
Neck Pain
•
A randomized, double-blind, placebo-controlled study of
low-level laser therapy (LLLT) in 90 subjects with chronic
neck pain was conducted with the aim of determining the
efficacy of 300 mW, 830 nm laser in the management of
chronic neck pain.
•
Low-level laser therapy (LLLT), at the parameters used in
this study, was efficacious in providing pain relief for
patients with chronic neck pain over a period of 3 months.
Chow et al. Pain. 124: 201-210, 2006
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