cHt,PTilfl CONTENIS

a,lol hiolaty '71

o,ftnlllo.n:t ind nomonol1turo 172 Low-intensity laser

pnyolcol prlnclplo, 172
Ughl omhsslon nnd ab101pllo11, nnd 1hu
therapy
p1odue11on ol ,,Hot racMaUon 172
Cnar•alr,r'.Jt!oti orln:ior 1n<1/t1llon ,1,1
u•a,..t!aouo fn!or4c11on 175
Dn Pid Bnxlt'r
concop!Ynf bMfa 011a,01
pt,c,1oblomodul11llon· lho Arndt-Schult, 1111v t 76
llologlc•I and phy1I0I01Jl•11 ,11001, 176
Col!ulni roat!nrch 176
,\rllmal •tudl.. 1n
C4t1l1c;lqd SIUdlo:; 111 humans 178

Cllnlcol llMdloa 178

wound '1oi1lin9 t 79
MMllt oondlllcns 179 BRIEF HISTORY
uu,cuJ0,ko!o101 dlsorda,, 1eo
Pain 180
n,c term ·1,1s-er' lS i11' ,l crony m for l.Jght
Princlp!H of cfln!eol appllcnllon 180 ,\111phfic,1Hon by Sbntulate<i Emi.<Sio~ of
lndlcallon• 180 R,,dialian. Alt.hough AIUcit Em!ih?.ln ong1maJJy
OotaQG nnd lrmdliillon paromorors 18 1
lmportonco ol lho uso of contact I011t,.nIque 1s, ontlmed 1he pnnciples underlytng ~11, genera-
Tu1a1rr1onl ol open wounds ond ulco1s 182 tion of ~u<h li5hun Lhe ei'\rly part oi ilib ~l!ntu"'··
r,oaImoI,t ot u11Iu1 c,ondillons 184
l(oy polnl s on lnsoI uotumenl or somo solo-ctod
II w.,s nol unttl 1960 that Theodor!' ~laiman
condll/o,n• 185 produl:'<'d the lirst burst of ruby la._<cr light a l
Hughes L.1hc11+rtories in th~ USA ln the iinter•
Hllerdo 186 vcning dec,1di:.,~, \'anous laser de,-iices based
C!us!tlc.ali~n ol losors aod oc.u111r h1tzord 186
Co11l,al11cf1C!'lli0r'IS 186 upon Mai1n;in'!'i- original prototype hav~ r'ounJ
O!hor sa.lotycoMlctorat!ons 186 .1pplication.s ranging from ln~r po111t.?rS and bar
ccid~ readers r1, mllllary range 6ndt!rs and ~t
acquislllon systems.
Sine~ their inception. lasers h,we fo und appl.t~
c.,tion in medicinE.• and particularly in surgery:
tiphlh3lmic surgeon.< wen? 1he first speclailJ te•
use 1hc pulsed ruby las,•r succeSSiull)· for the
lrc,,tment of d~tached retina in humans. In
geiwrol, n10~1 medital applitJlions to date have
reliocl upon the photothermal and photooblative
Interactions of li:tscr ""th tissue; thus Jasen,. are
routlnell' ust>d to cut, ll'Cld and even de.'l'trov
tissue. The us~ of Jasers as ,,ltemative3 to m\'.! 11'1
S('J.)~1.5, J S wol I as for nimuur iJhlation and
tnttoo removal, .are all oased upon , ud, tls,,'tte
re.1ctions. In corntra:st, lnh~rc~t h a" also foruscd
on U1e potential cllnic,11 applications of the non,
Utcrmal inl~ractions of la~r light· \\1th tis;;ue.
principally based upon initial work carried out
by Profo~sor Endru ~!ester's group in Budapest
during the l,11e 1"160s and eMly 1970s. Results of
lh is work indk.)tt!d the pot~ntial of relatively

171
 112 El,KT1lOMAGNETl AliEHTS
:__ _ _ _ __ _ _ _ _ _ __ _ _ __ __ _

tow-,n1rns1t1· l:..~r UT,1d1>tton app lied USA wlwr,· 1he term iN ,umet1m c, abb
Jirectl)' rev1aled
to tis,u e · to modulate c,,rt1in biol IO 'blo ,tim ' The use ol ,uc h terminul
og,c•I ogy ,,
p ~ m pan icul M to pho tob1ost1 l'Sscnh•lly bas ed upo n the !'orly ubs en 1
1nu latc atio ns or
wow1d-healing p = = (Mr,;tcr, Ml'!-l<'r Ml"l'll'r's gro up and other.., whi ch ,ugg c<t
and cd the
Mester, 19S5). B,1sed upo n M..,,1er 's 1,·or potl'nrial of s uch dev ices 10 ncce lera tc scle
k in cll v1cly
an,m.1ls and in path.>nlS, the t!n.,-uing d= var iou s wou nd hea ling proc esse s and
de saw cellular
the pmm ouo n ol He--1\c lase r radiation funct'inn s. 1lowcvcr, the u·rm Is lno ppr opr
as the ialc tu
treatm1'Ilt 01 ch1>1c,, for a VMiCt)' ol cun defi ne thl' mod ality for two reas ons . I~
d1boru. the l1rs1
thro ugh out the cou ntn e> 01 the fomier iru.t,mce, th<1 app llc, Hon s of the mod oltt
Sov u>I y exceed
Union. and u, the for East, particularly ml'n-ly the trea tme nt of wou nds . fur the
Chi n• rmore,
\\'it hm the last 10-15 years, the 1ntroduc110 ami more imp ortantly, losers also hav e
11 of the
sm.111, com pac t lasei-.,mitting pho todl ude s potential, eve n at ther •pc utic inte nsit
has i~, t?
pro duc ed an inn-ease in the "-"' ol thb ther mhihit cellular procl'sses li.c. lase r ptmlubi
apy, ot11/1il11 -
kno wn .lS low-level or low -lntcn.sity 1,.,.,
.. thrr· tion; see sect ion on Arn dt-S chu ltz law
bel ow),
ap)' (LILT) m the W., ;t. Althoug h 1he Foo
i.l and thu s a mo re acru ralc gcn cnc term for
Drug Adminlstr.ition (FDA) ln the US/\ the blo -
h as still logiral e_!fecls of low lnt,ns1ty lase r irra
to app ro,· e laS<?r therapy, 1hc mmlal11y ha, diat ion
found is laser pho tob iom oJ ulat ion.
increasing application by phy ,iot her api,
ts (for
hum an and anim al use), Jentist~. a,-upun
ctur-
ists, pod iatr ists, and some phy sicians,
(or a
rang e of con dlt,o ns incl udin g the tr~atme
nl of
PHYSICAL PRINCIPLES
OJ"'n wou nds , soft tissue injuries ,
arthritic Light emission and absorption, and
ron diti ons and pain ass.iciated with
actlologi.,.: (sec Baxtt r rt 11/., 199 I).
van ous the production or laser radiation
"l'lw bas is of produc tion of stim ula ted e
mis sion
is sum mar ised in Figu re 12.1.
DEFINITIONS AND NOMENCLATURE
low -int ens ity 1:..~e r therapy (Baxter, 1994 • In non -las er sou rces, light is typ1
1 or call y
luw-(reacth·c)lcvel llse r ther apy (Ohshir produc ed by ~po11l~11ro1tS emiss,on of
radialio11
o and (Fli,;. 12.IA). In such circ;ums lan ccs, the
Calderh,•nd, 1988). is a generic term that ato ms
defi nes anti molecu les com pris ing th<! cen tral em
the ther.1pcutic application of rcla11vel itte r in
y \,1w - such devices (~.g. the elem ent /fil ame nt
out put (< 500 mW ) laser~ and mon nch in a typ ·
tomatic k,,t hou seh old ligh t bub ) are stim ula
sup crlu mm ous dio des for the treatml' nl ted w 1th
ol dis- (d,• ctrical) ene rgy so that the elec tron
ease and inju ry a t dosages (u~ually , 351 s shif t lo
/cm 2) lug hcr ~ne rgy orbits. Once In suc h o
gen eral ly con side rec to bl' too low to effr rbit s, the
rt a.ny electrons a~ ,_nhe rent ly uns tabl e and fall
dete ctab le hea ling ol the ir1adia1cd s pon ta•
tissu es. ncously w1thm a short peri od o l h me
Low-mtens1ty lase r 1herapy i~ thu s an ath to low er
cm, al en,•rgy levl'ls and in >v ,lol ng rele ase the
trea tment mo dali ty. For this reas on, this iY ext r~
mudal• energy :.., pho ton s of ligh t. The p ro per
ity has also ,;omellmes (ina ppr opriate ties ol th~
ly) bee n emi tted pho ton s are dete rmi ned by the
term ed 'sof f or ·c11l d' la~c r ther apy to dilf cr-
dl stin• ence in cne r~ leve ls (or ,,ate nce bnn ds)
gui sh the devicl.'l' (and the r~su ltin g thro ugh
app lica - whi ch n_n exc,tcd elecJrcn 'dro ppe d', as
tions) from hig h-powe r sou rres of the the dif•
typ e use d fcrcnce ,n ene rgy will be c~a ctly the sam
in surgery and in other med ical and e as the
den tal qua nlal ene rgy of the photo11 pro duc ed
applications; howeve r. such term s are . As, for a
mis lead - giv en pho ton of ligh t, the qua nta \ e ner
ing and map pro pn, te, and are therefor gy (speci-
e bes t 1,ed in clcctro_n -vol ts) Is inversely rela ted
avo ided . to the
Thi s mod alit y is also freq uently rde ned ';"v elcn gth (~ nm) . the wav elen gth
to ns ,s elfec-
l,,se r (ph oto) bios hmu lation. par ticu larl tavely dete rmu ,cd by the diff eren ce in
)' in the valence
bnn ds; and in lum , mok-cules pro d
ucc ty pica · I
p

I T.I
I.01\1,INTENSITV LASER THERAPY

p
/ C
A B

fl e,0 10<1 el•c tn"'

a11m ulu1ed omlss,o ,, o1 I,ghI A. SponcaoOOUJ t01, »-0
Agure 12. 1 Sponmn~ous emissio
n, ObS -Orp i.on and ,;I l)y ro51lng elecrr011 .
!on (P). B Abs orption · lncldtnl pholon Is abooroo
om.
tel drops lo lower /n!SIJtlg) lc-,el, Stim fling o sing le pho 1ee1 !W'tron 10 produCE two
ulat ed emi ssio n lncldoru pho!Of'I lnceracts w,111 a.ha dy e-.0
v.-ttich mov~s to higher level. C.
i<let,ocal pnolOns (P l , P2)

~ure 12.ICJ.
spectra when cxdleli nnd res ting sta tes (s"" F1 . tJ,c eJ,-c-
ra11ges o( wavelengths o: l!'mi~s ion Under these cxo,p1ional circums1a
nce
appropria1ely sti111ulalcd. i1, g1v"s vrr
lron, m rctumrng lo iL> original orb l,gh1 wrth
en a ph oton
• Absorptio11 of mrf1otio11 ocrurs wh its excess energy .,, , photon 01
molecule In
of light interacts with 211 atom or exactly the sanw properll~ ;,s the
incident pho-
the val ence
which the di(ference in energy of ton, and completely in phase. In
laser de vice,~.
ried by the
bands tx,1ctly equals the energy car the un iqu e arc umstances which
give rise to
sequen ces:
photon (Fig. 12. IB). 111is has lwo con stimulated emiss ion o/ radiati on
are produ ced
rgy (and thus
lor a pholon of a given quanta! ene through the selection o( nn approp
riat e material
s will be capa-
wavelength) only ccrtaill molecule or substance which , when electr
icallv stimu-
converse!)',
ble of absorbing the light radiation ; la1ed, will produce larg e numbers
uf 'identical
quanta! ener-
lor a gi1•en mo lecule, only cer tain phr,tons Lluough the ropid excitat
ion (If the
be absorbed
gies (and thu s wal'el crg ths) can medium. In order lo produce suc
h stimulated
ctrum for 1he
llhis b 1ermed the ab,~rplim, spe emission of rac.Uativ 11, laser
Lrc atnu-n l d(.•vic.c-s
lo be ll'1111<'·
molecule ). Thus ,,bsorp lion is said rely upon three essential mmpo nen
l~.
lmgtlr SfNCific. This is an impar
tan l concep t in
th specificity
LILT applira lions, as 1hi, ,va veleng 1. A /asmg merfi11111 is capabl
e of being
o( obsorplio n effectively det
ermines which 1ypcs tely produce
orb incidt•nt ·pumped' wilh energy lo ultima
of tissue will preferentially ,,bs stimulated emission; for 1herapeut
ic S)'Stem s, the
pen~lratio n
radiation, and (in turn) the depth of enN S'' soul'ct' is invariably dectn
~al, and the
of a particular treatment un it. 1ypic·aUy trom
a uniqu e ene rgy is ddi1·ercd lo the medium
• Sti11111/att,I ,·111i~sio11 of rn,linlicm is thl' ma ins or (Jes.-, commonly) from
a baI1c, y (see
ident photon
cvenl which occurs when on inc below). The lwo media IIID>t commo
,1ly use d in
e,,dy excited
interacts with an atom which is alr LILT npplic.itions me the ga,;co
us mb tur e 0 1
(Le. where the •l• rtr on (s) an> alre
od y in a higher rating al a wave-
,1 I energy of (od ium and neo n (J-1,:,..:,J.-.) ope
energy orbit); audilio naJ,y, the qu,1111 lcnglh of (,J2.8 nm (i.e. red
ligh t), or gallium
1hf inciden1 photon mu st e~actly equal tho., dif- ium-arserude
the clecLro n's ar..enid,• (Ga- As ) or 11allium-.tlumin
ference in energy level~ between
 174 ELECTROMAGNETIC AGENTS

(GaAIAs) sem ico nductors t)'picaUy producinis
rndi;,tion at ~950 n111 (i.e ,.;siblc red 10 lh(•
near infrared). Although He-Ne systems WNl'
lhe firs t lo be used for LILT appl,,ation,;, and a
sig nificant percenl~g• of the papers pubbshecl
with111 tlus orca are based upon such dc,·lces.
th,,Jr use hds dlmlnished cons,dcrnbly over the
and so me cases) to anow several w3 \\•.
(iJ1
lengths of radiation lo b~ used in paraiJ,I
(fig. 12.2). Such multisource cluster unlts 1nav
be usefully rcg,1 rded as the ' third generatiu~·
of development for 1lwrapc111 k lasers_ Ma,.
recentty, sevt.>rill manuforturct:; have introd uced
'fo urth-gencr~tion' flexible multisource •rr,,ys i, 1

last d ecade; thus, very few He-Ne l,1sers, wluch .illow more cffiaenl delivery of ligh1 to tissu,
t,111 be regarded as the 'first generation' of laser s urfaces with ' hands-free' ,1pphc,1tion.
therapy systems, rurrently l1nd applicai-lon in II should be noted th,, t, fo r He-Ne based sy,.
routine physiothcrapE'utic prai:tice, at le.:ist 111 tem$, because Lhl' reson.illng cavity is usualh 1

Flritain or l.reland. This is due lo tl,c r,;Jative more cumbersome to appl)\ the laser radia tion
I
•••
I
experuc uf such u1ul!,. Jnd the ,ornpar,llively from the 0U1pu1 cuupler is normall)' deli\'ered 10
low power outpu l a:,.S()ciatcd with He-Ne SYS· U, o 11ssue 10 be created by mc•on, of a fibre-op lie
I I ,
tcms. In add1t10n. the relat,vcly greater colllma• applicator. T],is allows the oprr,1tor tu direct tl,e
111111 (sec bdnw ) oi tl,esc units when ,1pplied rndiation 10 l'he target tissue more c..isiJy.
witho ut film:•opllc applicators puses d signifi• 3. J\ 1101oer sourre to 'pump' the lasing medfa
cant h.1wrd 10 the unprolec1cd eye compared to produet! stimulatt!d emission, In most i:as~s.
wi lh 1hr avcr,lj;!e semicondactor-•diodc~l'ct!)-Cd tht!rapcu1ic dt.>vicec; ha\'t! tended tu be m;tins
1reJtm rml unit. " ' Jlplied and intorp1>r,11e a base unit tu contain
2 A resatmtmg c,wrt-:1 or ,:hamber consisting of lhc tran,former ~nd conl.rc,I unit (F,~. 12.2), Morr
11 :-tructurc to cont:1 in the la~ing medium and recently, however. a number of manufat.."'turcri
incorporating a pair of p,,raliel " ' fleeting sur• h,we produced rech,1l'gcable and bat1ery-powe11?tl
focc,-. or mirror-s. Wlthm Ll1i.-, du.1mbt:r, photun!t 0( units 1u enham,.. the portability o f ~1elr las.-r
lighl produco,d by the med ium arc reJlectt!d bad ,!evices (e.g. for spnrls iJ1j,11ics applications ).
and forth bctwwn tl,e 'mirro rs' Iv ultim ,1ely
prod uce Jn inteno;e photon n:•:,,onance. :\s one of
the reflectlllS surface, (also termed lhc outpul Characteristics of laser radiation
i.:ouplcr} is not n 'pure· mirror and :;o due'- nol Tiie r,1dfation genernied by ther.tpcutic laser
rcOect J00% of th,: light striking its surface, some devices differs fro111 chat p roduc~d by other
of the rad iation 1s ,,Unwed tc:i pass 1hrough '" lhe
o ulpu l· ot the device. While 1he resonating c2vity
for Ml J le-:slc unil c.,n be relatively large and
cumbersome. those fo r dioJe-bascd unils are
tiny, being the laslng medium itself (1c. th e
semko nduclM d iode), the ends of which M,·
ca.refu Ily p,, IL<hed lo for m reflecting surfaces .
• Thi, has import,,nl imphcatio ns for the roul inc
j. use o f these unils in clinical practice, as the lreat-
,. mcnl ' he,1d' o r ' probe' is us11aUv nor much lar~,·r
Lhan the Sill' of a pen o1nd represents ano1her
• reason wh\' diode-based units, which may [,p
-
regil r<lt:d 11$ the 'second gener.1Uon' of l.1ser
.
therapy $)'51~111 develormenl, are SU pl•pular

f with dinki.tns. Furthcnn<1re. several manul.1c-

turers mcorpvrate" number of diode~ (u p lo 180
d iod es) rntu rnultisource 'clus ter ' ,tr ray, in 1mle1·
to ,1llow simultaneous treatment , ,i lar,i;cr lesion~
Figure 12.2 A moda,n 1use1 lrea,monl umt (Phaiograp!'
courtesy ot Central Mechcal Eqrnomont, No111n.gham.)
, 10,uar sou rces (e.g. infr ared lam ps)
in the ln',l lmo nt uniL,, lncorporat111g , orn e
dio des wt1uld be prohib!Uvely exp ens ive
JO o r -10
(01· mu -
'
;,,Jlon,ini, thre e resp ecL<. hin g oth er
tine din ical use 1f they comprL<ed not
c 11nlts typic.:il ly
Lhan true la.-..:1· dio des : thu.., tlres
Mon och lom atic ity Jn,...r dio des,
inco rpo rate no mor e than -.cver,,I
des.
!he Jigl ? pro d~c e~ by a lase r
i, 'sin gle the rem aind er beir,g sup erlu m ino u, dio
coloured . the ma1 onty of the radi atio n emi tted
und
by the tIN tment dev ic~ bcin g clu ster arobM d
ed
0 ,Ingle
wa, ·ele ngth wit h a ver y nar row Las er- tissue int era ctio n
bv othe r
..~du1 . In con tras t, ligh t g,rnern ted .As alre ady ind k,,t ed abo ve, l,,se r tiss
u, • in1c r·,ic·
sources comprises a \vid c variety oi wave•
lion is typic,11Jy asood,1ted wit h the
pole ntid tly
let
lengths, som etim es ran gin g fron , the ultr avio on of d<'structive effects of irra diat ion at rela tive ly
in the sen sati e circ um -
to the infrared , whi ch resu lt high pow er and ene rgy leve ls; in thes high ly
kes the 1•ctinn
rh,• coln ur w hite whe n the ligh t stri st,,nces, high den sitie s of lase r ligh t from
0 ( a hum an obs
erv er. Wa vele ngth is n oiti cal coll ima ted or focu sed sou rces wit h out
put in the
effe cts o toth crmHI
/Jctor in dete□ni rti ng the ther npe utic wal l ron ge ca.n easlly pro duc " ph
ame ter or e>.plo-
reactions in tu,ues, incl udin g abl. lth· c
par
produced by lase r trea tme nts, as this
detcm1i nes w hich spe cific bio molecu
les will ity lase r
sivc effects. However, in low-lnle.ns
thu s the bnsic upo n the
obsorb th.: inci den t radi atio n, and ther apy, the emp h,,s is is by def init ion t wilh
unc l"rly ing anr l) reac tion s of ligh
photobiologicoJ inte ract ion non•therrnru (or athe nn.r
och rom ,llic ligh t
ghe n 1:n>.1tment eff,: ct. tissu<'. Lig ht from a lase r or mon h
ract wit
thcr.:ipy I.J·eatmenl dcv ire cn n inte
irra diat ed tissu., in two way~·
Collimation
1. Sca tter ing of inci den t ligh t. TI,i
s is esse n-
pho tons
In l•se r ligh t, the ray s of light or tially • cha nge in the dire ctio n of pro p,,g
dtio n of
ice for all prac tical
P"'d ucc d by the J,1se r dev Me
the ligh t as it pas ses thro ugh the ti,su cs, and is
no dive rgen ce of
purposes para llel, with alm ost due to the vari abil ity in the refr acti ve
ind ices oi
s prop erty
the ~nutted r.1diation ove r disr anc e. Thi Sucl1 ~cat-
'bu ndle d ' 1:issue coin pon~nts relative to "''atc r.
keeps the opti cal pow er of the d.,v ice teri ng will cau se a 'wid enin g' of rhc !,.,a m " S it
on to a relati ve!}' small area ove r
cons ider able ue, and resu lt in
pas sing pas ses th roug h u:ra dial ed tiss
tlist.inccs, and, to a deg ree, even whe n th., rapi d loss of coh eren ce.
by a
lluough tiss ue. 2. Abs orp tion of inc ide nt ligh t
olec ule
cbro mo pho re. A duo mo pho re is a biom
ic or alon \ic
Coherence which is cap able, thro ugh ils elec tron
indd ,•r,t
also fn configuration, of bein g excited by thi,
Th, lt~ht enti tled by lase r dev ices is pho ton(s). _Light at the wav elen gths
t)•pically
uni gue
pha"•· so ln con junc tion wit h the two emp loye d m ULT are readily abs orb
ed b y a
"e, the trou ghs
prop,:rtit-< alre ady out lin. ,d abo ,·ariety of biom olec ules includi ng mel anin and
mat ch per•
and P'-'aks of the emi tted ligh t wav es hae mog lobi n; as a con sequ en ce, the pen
etra tion
in spa ce
fectly in time (tem por al coh eren ce) and dep th asso ciat ed wit h trealrnC'nl dev ices
1s lim -
\sp,,tial cohe ,.,nce). The biol ogic.:il
and clin ical . It sh oul d
(e.g . ited lo no more than 5<:,•cral rnill irne Lres
reJt.,...,,,,. ot thh pro per ty is still deb ated end ent
9), not kas t be not ed that, •s the abs orp tion Is dep
se,• J-.Mu. 1998 ; 'fun cr a nd Hod e, 199 tht- d ept h
d 's up., r- upo n the wav elen gth oi inci d ent ligh t.
"<'c~use 01 the a,·a llab illty oi so-c alle epe.nd<'nt.
pos sess all the qua lllie s of pen etra tion is sim ilar ly ,vavelen gth d
lurn1 11ou ~ diod es' whi ch ion, abs orp tiou
th" coh eren ce, bu~ 0( tJ,es e two mod es of inte ract
"' •1 ' tru~ · las.-r dio de, less in term s
of the latt<!r. may be rei; arde d as the mo st imp orta nt
~- reI' ar~ a fr,1ction of the cos t
"·h npy, ,,s
on dus tf'r of the pho tohio logic~I bns i• of l.,se r ther
· ·lultlsou1t•e thir d- and four th-g eoe rMl
 171 El£ Clll 0\IA GN ETI C AGENTS

w11hout ab5orptlon no photobiological.

and thus
-
cllnacal. effects would b~ possible.

I
Conceptual basis of laser
photobiomodulatlon: the
Arndt- Schultz law
Th r photoblologlc•l d!ecL< of lase r
or mono-
chromatic light upo n ti<-<11~ .,re ma
ny and
complc_s, and to a large drg rtt still
poorly A 9 C
unde_r,,tood, pamcu.l.uly in tern,~ of the
variable
stimulative/ inhibitory reactions whlch tnlantlty 01,tltn.Mdon
may be
effected b)' such irra,1iaUo n. In pro
viding a
theoretkal basis for the observed biolog f igure 12.3 Ille Amdl- S<hultl law A
ical and biological ac1M1t1on (1ctU1ruJ 8 8 /0s1l
P1omrn!oll01d no
clinical effects of Otis modality, tlw muJat1on activalfon or
Arndt- biologlc.>l p,OC8sses C Bormbi-on mb
Schult,: law h,15 btt n pro posed as itlo n d blo log al
a suit,1ble ptoc-use s
mod!'I ; the maill tenet.s of this law are
illustrated
in Fagun' 1l.3. II should be stressed,
however,
that although this model can accoun
t for such Cellular research
phenomena as the ' inverse' dos, ge dep
endency A range of studies have examined the
reponed 1n some papers (e.g. Lo we d 11/., effec~, of
1994 ) it low-intensity laser rrudJauun ,n a v,,n
essenllaUy ,1ppl1es to rndiant exposun, (or eiy 0 1 cell
energy IJnc>s nnd c•xplan le<l cells 10 establish
dens11y-see bolow); the putabvc rele the phollt•
vance of biological bases for the chnac,,I u o;e of
manipulation of oth ,•r irr,1dialion par thb mo d,,I •
am,•tcrs lly. especially for th" promo tion
,uc h as pulse repelllion rate or pow of wound
rr output healing. In these stud ies a nuanb<,r
remain,, al lcn, 1 for the time being, ., nf posi;,t,I,•
m.attN of indicators have b..'<'n US<.>d to i\SSeS.,
debate . th,• pho h•
bio modulato ry effceis 0 1 laser
lrrad inllun.
incl udi ng cell prolif,•1,lt"an (Bolton,
You nfl ,mJ
BIOLOGICAL AND PHYSIOLOGICA Dyson, 191)5; 0mallun ,md MMSha
L ll, 19~1>;
EFFECTS I f,,llm,,n (I al., 1981!, 1.ocvsch,,11 and
Arunhnll ·
Investigations o' the biolog ical and phy Ulndslcv. 1994 ), col l,ge n pro duction
siulogk.11 (Castro
effect, of low•lntcmHy IM<'r rndi.ali ,·1 al., 1983; L.1111 rl 111, 19llo) ant
nn c,111 i ultr,1structural
usefully be con,ldcn>d under thn'I:• mai chani;,•s Ulo<atr.1 fl 111 . 19114; M11n1cllel
n al\' a,: and Karu,
cellulor studJ...,, involving the use 1'J'l2), llt~·aaco;e of their Importance
or well• in wound
~tabh,he<l cell tin"5 and C)(pl•nted rell wp.1lr, the cells most cummonly used 10
-. i,tu<l11•, dat e have
,n various spt•ci,'< of ani ma ls (in vivo llnJ bt'en flbrublasts anJ m,1r ruphag1.,s (l'.g
In vitro). , O'K on,·
• nd fin,illy ,.... ..ud , in hcollhy hu111.m rt al.. 1994; rogn•I. l'h" n and Zon
volunll'<!ts g, 1997).
Whilst the folluwlng provid, s an overvie Howt'ver, 11 should be <trcs,cd tha
w nf t allh ough
the findings to date in these areas, a findings from ,uc h studies are genera
full an.t lly pn, i·
comprehensive wview of the literatu live, the finding~ are nol cxclu.sive ly
re on th,• favourable
I biologico\l and physiologica.1 l'lfe cl.• nor stra ightforward; n?5Ults In some
of low • cell type,
intensity laser radiation is beyond the have lendcd 10 be more variable- for
scope of ln~ tance.
thls book; for further detail the reader is research on lym phocytes has sho wn
directed varl.abl ,·
lo the reviews of Basford (1989, 199 effects as a resolt of laser irradiahon
5), Bruder (Ha llman
(1994), K"ru (1998), King (1990), r l nl., 1988; Manteifcl & Karu, 199
Kitchen and 2; Oht,, el 11I,
Partridge (1991), Shields and O'Kanc (19 1987; Yam.iguclu, Trukam oto and MA
94), and lonn, 19941
Tuner and Mode (1999) Cellular stu dies s uch as those outline
d above
Me important in two respects In
lhe f11,1
 -
=•l:N.:.TENSITY:: ....-SER THERAPY 177
OW
- -- ----- - - - - - - - - ---~L:: ~
ahcy pro ,•,de a ,c,e nhf ic b= s lur th,· rnjurt<'!- tEm wm ~f..• ,., t1/, 1'191)1 ,rnd
"P"" sl-111
IJ"'"' Lyc1 11, J nd
;,(JI dpp llca llon of low -inh ms ity l,1,ser, for
th., \\•ou nd,. of ,•.1nous typ c, (Ab cri;e l,
1\1,-stcr
.,,.u i•s• nwn l 01 w oun ds, thro ugh dem ons
tr.it ion C.lStcl. 19S7. H,un.1 ,., ul, 1982: Me,.tcr,
AJ1houglr
hr pho1ob1oloi ;,ca l ml'c han ,sm s und erh,ing ,lnd /\'1.-,m,r. 19SS; W.ill.cr ,·t 11/., 2000).
rt,-d pas itiv,•
➔ ~ 11.,atm cnts (Ka ru , 1998). Sec ond lv. bi 0 ;;, 08 thes e .<tudll•, h.w c t)'Pi c.1lly n,po
"arch tech - i11c-n,ascd
.,,d, .,,ell -con trol led labo rato rv rcs.- dfo·cts of J,1St'r Jrr.1dlation (in terms uf
ed t;ran•
~ ,~, syst erna uc Jn \ll'S h' gnt1' ons b}' som e gro up,
ni~u rllh.---s ot he-L1fmg. wound dosu..re. t!rulnnc
crin u,n tJI
,,,-., dcrnoru.trah,d tJ,e m1porla11re of la~
r irra - u l.,tio n tis.sue fom,atio n, etc. ), lhe ""p
to rcp re•
dosage. lesion.< m tht's e arum .,ls are cons ider ed
Ji,,aon par ame te~ suc h as wav elen gth, ,n humans
d effects srn l a poor mod'-'f for \vow ,d!,
,rd pub e repe l1t1on rnlc to the obs...rvc in tei; ument
. 1994; b,.•causc o f tJ1e sped.,,_ di/ for en~
, ~· Ag,uby ; t al. 1996: 01< .ine ,·t uJ 9; Kin g,
,t,j,1fi11nol111. Bolton a nd Dy~ on, 199
4; ,·,m Brcu geL com p.1red "~lh hum ans (D.is ford . 198 a tor;
ce. ,om e inv ,
- stig
1990). As ., con seq uen
[ngel• and 11.ir. 19'.13). d hea ling as
hav e pn• lcrr ed 10 us e por cine w oun
n,1, no1w1th!.tandlng. the c.,.trapolation ol s tud )'
clinical • more .ipp rop ri,u e e..-J"'"m enta l assa y to
r nil1ng, irom thi> typt , o( s tud y to the ioti on for
ce ol the thl" p oten tia l benefit,. of lilser ,rr.u:t
-.,1w,g ,s diff icul t . .is the prec ise rclev,1n hum .1ns ., ,,,it h m o re
1menr,. is m.u1ugement of wou nds i.n
n port ,'<I ob.. .,n·a hon , 10 clmicnl tre.1 Cas tel.
n,pl e. where v,iriable find ings (Ab crge l. Lyo ns and
,ut Jlw.-iy.s c.nll rt!ly cl..-ar. For ,•Aa ugh find -
at a l9Si ; Hun ter ,•1 nl . 198-1). Thu s, aJtJ, o
,•hotobioshm ulat ory ;,{(e rt,, are repo rted ly dem on•
a labo rato ry ing~ from i\JlJm aJ rese nrch ha,. gen eral
,w.,n t t!Apo,ure o( I 5 J/ cm~ in upo n wo und
of arlif i• stra ted bios tim ulat i"e effe cts
•uJ, ,n,·o h mg th,• d1n>c1 1rrad1,111on hc,11ing , part icul arly in rod ents, the find
,ng s ,ue
•lik e cell
,,,11,· m~ ln1.,1 n-,d mun11c mac ruph nge not e..,clusi"ely pos itiv e. The clfects
of lnsc r
n,-.. wh.tt dire ct rele ,·.in a, has thi, for dos.1ge 1rradio11on upo n 11.•sue rep au m .,, per
ime nta l
ven ous ulcer
.....ll'Ct1on m lh~ Ja....,_.r tn•a tn,1.•nt of ..1 inv es uga tcd . w ,1h
pro bkms, mus cle lesion., has .1lso bee n
n • 6i•y e.ir-.1ld pati ent ? G1n •n ouc h pos itive n-su lts (Mo rron e el nl. 1998);
tJ,15 rep re-
the cell
p~rt1culnrly the va,1 d llforcnc(' bctw <>ell ,en t,; an imp orta nt find ing, par trcu larl
v giv en
'nviron-
,,,.... • nd th.- high ly com plicated micrO< th;, wid espr ead u,.._. o r l..se r lher apy
,n spo rts
;, num ber 01 grou p!t
nwn t o( the cl 1nac,1I wou nd, n>habilltiltion.
c -<pt.'ri men t.il
n.u e emp loyc J animal -.tud11.•., ..ind Pc.-rh.,ps thl' mos t inh .•~b ng ..upe ct
o r this
furt her
,tud ies on h,,a lthy hum ,,n volu ntee rs tu typ< ' of ..t nu1'hll wurJ... has b\.'\.
'n repo rts, pnn o-
••-.-.s the b1ulugical and p lw,1 nloi:1r.1I d rec1, nf pall y by Rochf..m d ' ~ gro up, o l tJ,,, pot
enti al of
,h,, mc,J,1hty In thL· r.1born lon· laS<"r irrMflattnn lo ilcre lc.r,llt• rege
ner.1tion of
io-
trop hys
ncn•,-s. to~e lh,•r \\~t h .is._<oc:iat"d dcc
r var ious
Animal stu die s lo~tc.11 ,1nd function,,I rccov(•ry. llfte
ent.11 lesio ns (,•.g . KJ1ullM rt nl .
con ccn tr..ltL.ad on ty pe:, 01 •'>.p<'J'Jm
lh Jdte, ,1n1m n l stu dic , hav4: 1994, Roc hkin d £ 1 11/,. 1989 ). It suc h
effe cts M\'
11,0 main Med ~ 0 ( n.•scatch : thl' photnbio,!iltim ulll- tion s for
nd hNI • .,lso pos sibl e 111 hum an:,, th,• Imp lica
""' cffoct,, ol los er irra dia tion up<ln wou ced futu re ,1pplica11ons of thi,. m oda lity wou ld be
tal ly indu
u,g ond tl<su e repa ir ,n c"p eri mcn eno m1o us; inte rest ingly, Roc hkin d 's
gro up has
1~ •ons, nnd the ne u roph ysio log, cal and m par- in hum ans
irr-a dra • con duc ted som e limr ted clorrical worf..
~rular the anti noc ,ccp tivc effe cts ol s uch JOO J / cm2 ) witJ ,
usin s l'l'latrvely high dos age s ( >
°"
11 For the form er s tud ies, sm.11l loos e-sk inne d
.,s r.Hs and ,nice hav ~ bee 11 most enc our ngm g pre lun mar y resu lts tn bot
h per iph -
.inarn.ils such nd ct nl.,
; Mes ter, eral and cen tra l nerv<' lesi ons (Ro chio
~•~• n1only use d (c,s Lyo ns <'I al., I987 199,fo. t,)
cies, a
ester a11d Mes ter, 1985); in thes e spe effoct~
und s hav e bee n Neu rop hys tolo gica l and anti .noc ,ccp tive
f.,1"~.: of c,~r im~ nta l wo stig ated
(r,.1 est~r of Jas.,r. rrr.1diat1on . hav e also _bc.-en inve
'-'~ pfovr-d includinA mus cle infu nes ticu lar. wit hdr awa l
1989). tend on rn a van etv of spe aes . 1n par
' 1975) bums (Ro dlk rnd ,t Ill..
1
 178 ELECTROMAONETIC AGENTS
a.nd ,w n1dance behavto ur:: s uch us tJ,e t.liH1k k
,1nd hot-pl.ate tt'~Li.; hnve been used to .J5:ie~!-l
hy po a.lgesic dfc..:t~ <:1( l,1scr irrad iation, its mech•
ani,:;1n o( action arn.i dependence upon t.h ~ pu lse
repet11ion r.11 c u sed (~.g. Po nnudurai el t1I, 1\/88;
Punnudurni, Zbu7,ek a ml Wu, 1937; Wu, 1983}.
These s1111Ju.is cons is tently demonstrated a s1g-
n1tk anl hy poaJgesic effect of laser irrad iation, in
terms of increased latency to tail nick or paw lick,
which ,eos found to be most pronounced
a, lhc lower pulse repetition rates (4 Hz;
l'<Jnnudur,,i, Zbuzek and Wu, 1987). l' urther•
.
, :
• ••
more, th e hypoalgesla w• s found not •~ be
r~vcrsiblc when thQ opiate r111t.agonls1 n.1lchone
w;is administered, -\,•hjch susscsts lh,u th·c
observed pam relief was nol med iated by
endogeno us opiates (Ponnud11r,1i d al.. 1?88).
tlowevcr, the hypoalgcsic c Uects oi laser irrodi>•
d o n, at least in .1niJr1als, are not straig ht forward,
as one group has also reported l;iscr•mcd1a1ed
l1yper11lgcs,c effects tn experimental mice usins a
hot-plat<· paradigm to assess pain relief
(Zarkovic , , al., 19S9).
It can thus be seen that Animal sludies have
provided some evidence of benefk,al effeclS of
laser irradiation upon experimental wounds and
pain. Although studies in animals such as those
outllned above do go some way towards bridg-
1ng the gap between cellular work and clinical
practice, som e of the problems in cxtn,polnling
and apply ing the findings to humans remain.
As a consequence, scvern l g:roups have used con•
troUed studies in healthy humnn volunteers as a
uscfuJ means o( investigation without rccoune to
patients and the considerable problems inherent
on undertaking conlToUed clinlrnl research,
Controlled studies in humans
Stud ies in this area have focused princi pally on
the physiological and hypoalgesic effecls of laser
rad iation. This ;1pproach has been partiruJarly
u~eful in on,•esliga ung the effects of laser upon
penpheral 11<,n,es. while earl)' studies provided
contradictory tu1dingi; (e.g. Greathouse el al.,
19 85; Stwder-~fackler and IJork. 1988; Walker
aml At--hanjce. 1985; Wu ct af, 19~7). more
fl't.t'.111 ~tudit:s have d emonstr:i.ted significa nt
effects upon periphe ra l nerve conduction 1n ,
median and s uperficia l radial nerves wle
would appear to be critically dependen l up,.·
t·hc d osage and pulse repi,u tion rate of th1; I,,. ..
source (Basford el al., 1993; Baxter <'I ,r/,, IY, 1
Lowe ,•I t1I., 1994; Wa ls h, 1993). Although th<-,,,
papers typically reporl changes in ner.,
conduction latencies or velod1ie" in re.po,,,,., •
laser irradiation applied to the skin overlym~
the course of the nerve, the precise rele vance r.1!
such observations lo the clinical applic:atiom o!
this modalily are debatable. Of more dircu
relevance to d inic.JJ pr.1elicc, n nu.rnber or
studjes have assessed the effects of laser upon
various types of experimenlnlly Induced pajn in
humans. These studies ruive essentially relied
upo n hvo main 1ypes o f pain i_nduct:ion: thermal
pain threshold and the submaximal cffor1
tourniquet technique. Noxious hco1 stimulation
h>s been used by several groups lo assess th~
efficacy o( single-diode laser application,
applied d irectly to Lhe si1e of noxious s llmula,
tion or to ilpproprfotc acupu:nctui e points, w ith
VMi~ble fi ndings (e.g. ll rockhaus and Elg,,.
1990; Seibert and Gould, 1984); in particular the
latter s tudy found the hypoalgesic effccls oi
needle acupuncture to be significantly superior
10 laser acupuncture. Variable findings have al,o
been obtained with experimentally induced
lschaemic pain; s igni ficant hypoalgcsic effeet•
upon this model of pa,n have been reportc-d
with combined phototherapy /low-inten>J~•
laser therapy uslng a multiwavcl.e.ngth, mulu-
source ' cluster' array at radlanl exposu,es o:
over 30J/cm2 (e.g. Mokhlar ct al., 1992 ), but no•
with low-Intensity laser applied usmg a sin gli.
(830 nm) diode (Lowe el nl., 1997).
CLINICAL STUDIES
1\lthough a large number of clinical s tudies have
been completed and published in thJS ,11ea, i~
the main with positive resul ts, reviewers have
consistently noted the followini; problems with
the literature :
• most s tudies ha,,e been published in fo reign
language journals, often without Engllsh

~-ll'•cts, makrni: the work m,1cccss iblc to
,1orhon~ r("S('a:r.-1,~~ ,inrl chnioJn~
,1,~s1tJ<i1<S rep~rred in Lhe litem tun,
o!ten J><:'Orly
ll\'l?"fi<«<S of lmgu,1ge) J~
,\"ntn1lil•d with only very Limited blinding;
Jt'-"I a <15111/i:'..lnt proportion of the
'.~udies is mcrrly anecdotal in natu ,·e
, ~f ,rr.,diallo n parJmell'rs and
tn•allncnt
rroiocnll used •re frequent ly ln~dcquatl'ly
'l"'afied, thu , hmi!m~ comp.1n ,on of result,
aoJ rendenng rephc.,uon ,1nd opplica Uon in
the ctuiic•I selling 1mpo,;stblc. h ·cn where
111adJaaon par.
imelcrs .ire ,pedfled. the
i,.,,,,Jdenng numbt,r of ~si ble J)<!nnutdllons
•rd com binaUons oi wavelength, irradi,mcc,
rut~ rcpebllon rdte. etc. will often mean that
rreci,c rrphcalion is problcmahc
f!,i, 11otw1tl1~t.1ndmg, it is 1mport,u11 to
Mn.'<~
w: :J,e pub ~heJ database or clinical ,tudJes on
'" mlcns1ty las.r thcr,1py rt,pres.!nts a s,gnifi•
"r
,.,,,, tx,d)' an"<lo!al evidence in favo
ur of thr
m,,J,1btv: while tl,~ con,trnints of the cum.'11I lexl
r11\iud~ ,i1 .,.h.u~1i\'e fC\' IC\\' or lhi, literature,
w OJ
1h,, !Cll!owing al lt!aS L proVId~ an o,·erv1c
,,,,. oi tilt, n1'>St rele,";Jnt papers to date.
Wound healing
fn f'Opularitv o' t= cherapy among phy,io·
therJ p1,ts for U\l· lrcatmenl of var.i(lus types
of
.<ound, i< w, rn ~ bv the results oi ihe only
•"•r,e s.:ale , urvey ,,f current clinical practice in
·•~ udJ tf!J,tcr u .1!.• 1991 ) Tl"l'<ltment oi ,·ari·
01 1 types ,,1 duo nic ulceration l\',1S the first
i:::,liutioo for low-inwn~itr laser to be !rlnlled
'" hurn, ns du rint the late 1960s and eacly 1970,
,.,,, 11r.5!er and ~foster. 1939), using He-
:,./e
••n:c,, anJ dos;ge , of up to ,l J/ cm!: ,t was
e early
••><J upun the n>ported , ucce,.srateofs thes of wou nd
,tuJrc\, m t,trm , t,,t enh i'mced
~,•,!~ng and J'1in r(.Judlon. that the modality
.'"'"'1~ •due\'cd populdrilv in this ,1pplicatton.
Ji U i,• "":•um1-- d<'l.4J"·"' J.,;~r t.herapv has been
' .
or wounds
~ /~$ti,J 1n Lhe tri:Jh nen t of c) \-'Mie r,,•
~<t
~Ile 1.t]
~
•
Ct.r:Jh:J le•,fons with pos iti \'C' resull!,:,
,,;"'rd •II;- wt,.,.,, applied in mor~ chro11ic,
ctrtbll' t.\, 1!1;. 1e,t:, K i.HU 19ti5: Lasan, Ba'\: lt:r
,
Jn:I Ashford, 199S; Robmson and \Vulters. 19\ll
Sugrue ctn/,, t99il/ Howo,·e t 8""" lhJt ma,w
of
tlw reports 10 date are poo rlr rnn1 rollcd and
bJ;<)d upon rclalively , m.ill numbers, •nd /ur-
thcrmor~ tJ,a1 re~ults a.n> not c~cluSl\'cl}' posmve
ill.<,
(e.~. 5.JnnoaMi ti ,,i, 1984 ). Jddmo11JI stud
.ire warrant~cf ICI cstabli< h detiruLl\'el~
the bene-
fit of this rnocfal,ty for tJ,e prornonon of wouncJ
h·
he•ling, and particularly th~ r('J~,·anr~ of irr,1<
at,on parameters to such rfrn t•
Arthritic conditions
-i'he p<'l l~nhal benefit- or lao;er therapy in the
manc1ge mm r ot ~1Jch cun dili on, as rht-•
uo,.,toid
s
arthntis, oste0,1rthritis and arthrogenic pam h,1
van •·
~n a s ~ by a numbt!f of grou p; with
·
ing degrees of 51rcc,,ss reported . Alth\Jugh ;~,
era! papers h•ve repo rted decrc.JSed JOln l pain
t•
and inflarnma11011 coupled with tncre.a,~d hm
tioadl status in rhcumat\Jid 1omt; .lite r tn?•lmc
,1t
wilh a lo"' output Nd- Yi\G laS<!r (Goldm
an
et .i. I9SO; Vido.-ich and Olson. 19871, it
i;,
imporl,1nt to stres5 that such unit s. wh· ch .ire
;i
trpically used at higher output Je,•cl,. iv, suri
u .. ,
cal opplacations, art> not suitable for routine
in phj•Sinthcrapeullc laser therapy. Usin
g th,,
e~
mo:e common l)' avai lable H...-Ne and diod
lrkd
ha~ d unu,, .J. nom l,r,r of grou ps han~: n."Jh
s1g1116cant decrrases in pain w1tl1 con cmn
it,lnl
t
unpro,·ements m function as a n~i.ull or J,,,c.
o.
treatm~nl of these patients (lon,1uer, 19ii
Palmgren , t al.. 1989; 'lrel le, ~, /JI,, t99'1 ; 'Na!
kcr
el rJ.. 19S7). Equally, howe1cr, S<'•·eral
i;mu r•
or
have failed to find any significant 1,cnetit
laser treatmwt an 1,·,,fl-amtroUed ,lnd nl"l ne,I
hi.Ls (llasford ct al., 1987; Bliddal cl al. 1987
:
Jcnl'!n, rfaneb}' .nl<I Kjer, 19S7) 1\'hdc 1'1.,
prerlse reasc,ns t"r ,uch di.screpanr.ies JN not
entirdy clear, ,t may Ix, due in part to the dtli
rr•
,·
encrs in lnser paranwtcrs employed In the~
low -
stud1t'> ,,nJ in particular th" rd abn ,ly
r
pow er outpu l units uS<·d in >om~ uf tJ,, Lllle
11h inr,
,tudies (<1 rnW) lhu ,, d<Sp1te some pro.
w·r
l:inclings, this is ,1not:Jtl1r .lrC'.l in ·which lurtJ
res<'l1n:h would appear lo be ill<llr•tc
J he/or?
mnn: dl'!ftnihn~ pronounccm~:nt...1. on 1.-·ffic,·cy
~•rr
1
 180 R ECTROMAGNETIC AGENTS
possible (Bt0sseau ,1 nl., 2000; :-.larks .u,d de
_
Paltnn, 1999:.
Musculoskeletal disorders
Given the evidence oi the pokntial bio,;timula-
tive effect, o( laser irrJdiation at the cellular and
... d mical Je,•el, it is not surpnsmg that a munber of
groups h;wc ,lS$CS.Scd the effic.lcy oi these dcvk,~i.
in thl! m,,na~emerll' of a nmge of musculoskclelal
'h i
disorders. Ldser therapy /or lend.inopatlues has
been investi&,l tCcl by several groups \\; ti, both
positi\'e (England el al.. 1989) nnd neg.,tivc
(Siebert cl irl., 1987) findings bclJ1g reported.
However, the dispMalc findings bctw~n these
• • two s t1Jdics 111,1y in part be explained by the irr,1-
' ' dlation rechr.iqucs used, in that· the invcs1igators
.. in the latter study inappropri1ttely employed a
non-contact tcduu,1ue (see below), using the
l,1scr 50(1.rce at a disrance ol some JO cm from
the target tissue; this wouJd have significantly
reduced the intensi1y of rdruation on the tissue
(i.e. irradiance) and thus 1hc ct'fccliveness of 1he
applied l.lscr 1rcatrnent in this trial Similar!)•, the
use of inappropnately low dosage levels may in
part explain the non-significant results rcpurtcd
by 5(>n1C 1;:oups in the laser treatment of
olhcr musruloskclclal condillons such as myo-
tascial pain (\\'aylonis cl al., 1968) and lateral
epicondylitis (lundeberg. Haker and Thomas,
1937), compared with the typically positi\'e find-
ings .11 01.h cr centres (Choi, Srikantha and Wu,
1986; Glykoiridis ,,nd Di,,mantopoulos. '1987;
U, 1990). However, it should be stressed that,
although Llie former studies m,t)' be criHcised on
the basi, of tl,eir use of mappl'Opriate lrraruation
parameters. these ~tudics were in the main
betrer rlesigned am1 conlrollc,I 1han many of the
c.1sc-series type of p:,per typicallv published in
;
this area.
..• Pain
Early observations of concomitant reductions m
rer>ortcd pnin in wound p,1Lients trea lcd with
laser li:d to a:tempts at exploitation and investi-
~••ion of the analgesic e[fect.s (>( this nmdaUtv.
Apilrt l:ron, d~creases in pain .J$SOciated with the
la.ser-mcdrnteJ trciLrnen1 ,:ffcc:ts ducuml'Oh•~I 111
those ,;tudil'!, alri:,,1dy mdic;i lcJ .»bovc,, a numb,.,
oi groups h,l\'C nloo rl!pOrlcd analgesic dle,I,
o( laser 1rrr1d1al.ion in v,,rlou~ Lypcs t if c._hrnn1,
pau, 11s well as in ncuropathic nnd ncuro>\t'll1r
pain syndromes (Amoib nnd Kues, 19'11,
I
lukc1shcvich, I985; Muore r!I nl., I9118: Shlro10
Ono and O11shl10, 19$9: Walker, 1983). I lowcv..(
.:tnd de-s pjte s uch positive raporlt,, the l rc:,11111:01
of pain remains one of the most contcnli1.11J'I
arcos of laser apphcatfon, parc lcularly in term,
of the manag=ent of chronic pam sy11drnmc,,
1,•fulc the reasons for scepticism ., rn cssentiall)
those al ready iclenl:iffed, lhc lack of an obvioll•
mt.!charusm of .1ctio, furlhcr confound~ accep-
tance of the pain-relieving effects nf thi;, modal
ity (sec Devor, JWOJ, l'hh nmw,th , tauding. thr•
moJ aUty has become ., popular lrcatme111
me~1od wl lh phys,otheraplsts for the relief ,.f
pain., and one which is lughly rntcd ag,1 ln,1
ahcrnati\'e electrotherapcutic mc>dalltics (l:laxtc,
er 11/., 1991), Fu1lhcm1<lrc, a recent report fmm
Basford's centre Indicates P"lcntlal benefit, m
the n,;in,, gemcnl or ow bi'lck pain, at least with
the use or dcfocuS!d high-power souxce, at
thcr,,pcutk Intens ities (Bas ford, Sheffield and
Harmsen, 1999).
PRINCIPLES OF CLINICAL
APPLICATION
Indications
l aser therapy finds a variety of applications ,n
clinical practice; thc,e can be usefully ~urn·
ma1ised under the following headings: ·
I stimuJation of wound heali ng in various
types of open wounds
2. treatmc.nt o( various ;1_rthritic- cund ihow,
3. treatment of soft tissue injuries
4. cclicl' of pain.
These an' considered in outline below, after ·' "
o,·erview of the principles underlying cllect1• •
las~r treatment . As a basis for subsequenl sc<·
tions an d to a.id the reader in mon.• critJc~I revie\\'
oi 1:hc work publJshcd in this area, the method "1
 lanng dosage- nnd the impo rt,mce o f atiwr
c.,Jr_u. don poci-lmeters n rc presented below.
ti13\ 1JO
ge and irradiation parameters
0058
1 (ronl wavelength, which is detern,ined by
,,po< · m ttSt?<I 1n
the lasing med1u · th
· c devu::e, the other
~:,t
. adintion p.ira m~ters that appear 10 be 11npor-
ht l;iser trcatn,e nl$ are us follows.
power output
Tiir powt!r output of :i unit i,; Ul'.-Uall)r expressed
m,tu,,.,t1s (mW). or thousandths of a wnt1.
~us is u:--ually fi-x(•d .,n1.i invariable. lJowev~r,
·omc machines allow operator sclcdion of the
~cr, t•nt,,r;<' of lhc tota l power outpu t (e .g. 10%.
25r 1
, ctr.}; in add ition, w l~erc pulsing of :J1e
uutput j-. pn.1v ideJ ..1s ,1 n option by the m:inutnc-
turN, this. can h.ive p rofou nd effects upon t·hc
powll:r outp11 t of the unit in some insttinces.
over the lu~t dt:>c·;iJ 1::, the trend in Lommcrclally
,wJ.ildl'lll"' unib has been t(w.•a rd.:-. higher-o utput
dc.vke~ (~11-200 .u ,\'\f ), r ,,thcr than L·hc o nce•
populru- 1- IO n,\N device,. 1101 lcosl bec:-use
luc:hc.r•c.mtpu l unit~ c1,m ddi\lCI' a spec1f1cd
L~;tmcnLin ..i m uch sh ,Jtter period of ti m e.
lrmdlanco (power density)
The p1_,w~r per unit area (r_nW /<.·n, 2) is an impor-
1.mt-irr;idiilth,n parameter, wltid 1 is usually kept
JS high .,s pl!sitibk fo r " g iven w ut by lhe
!-O•callt'd ' l11•con tact' trcatn,ent tccluuque, nnd
~ppl}•inp. a firi:n pressure through the treatment
h.l,., d d u dn!Z ucc~tn, cn t. lt shouJd be n o1cd that,
1,vpn with Lh~· s mall dPgr~cs of d iv~rgence il~,;o-
l'idlcd w·ith laser t reatrrwnt device~, tn?atmenl
out of conl.lct \,,ilh lh~ t.i.rget ti~su e wi.Jl signifl-
c.1.ntJy tcdu L'.~ the cffecti vc.ness o f treatnlent a5
1he irr~1d la ncc foll~ owin g to the inver!)C sqmu':
la,,,. (sec Fig. 1.1.1-l, p. 168) and bccal.L<;e 01
lno-,tu.scd l't.•flel'tton fro m t1u:- ski.n o r tissi:1c lnll•r'-
rac@. For in~c,mt,'ld tnwtments, the irt;iCUance ii:;
simply c.tlu1.lat1:1d by dividing the power l)Utpul
:o~ ;i.v-..:r.J)~i:- p c1\ V L"r u u tpul for a p ulsed unit). by
h1: spot :-.izc- t1f Lhe trea tm ent headi typu:a..l
\'ch.Jc.:: Ir,r t tw loll,..-r ilre 0 .1- 0 .125cnr.'
£:oorgy
LOW-INTENSITY LASER THERAPY
This is given In joules 0) and is us ually specific~
181
'
per poillt irrndialed, or s ome times for the ' tolal
ll'eiltment where .., numb.!r of points ore. trt!ated .
It is <•kulated by mu ltiplying the power ? u ~ut
in walls by the time of ir radia lion or apphcnti~n
in seconds. ·nms a 30 n,W (i .e. 0.03 W) dev,cc
applied for 'I minule (i.e. 60s) will d eliver 1.8) o~
c-nr.rgy. Dosage is re corded u, joules per point, as
well l\S 101.:il Joules (or IJ,e treMment.
Radiant exposure (energy density)
This is gelleraUy considered lo be the b-,st mean_s
of specifying dosage, a l lea61 i?r re.search p ape':'.
and is given in joules per urut are~ (I .e . I/ an'),
typical values for routine treatments m ay range
2
from le,;s than one to over 30 J/cm ; however
1- 12) / cm2 would be most common ly used (sec
below). Energy dei,s ily is usually cakuln1ed by
di\'iding the ene,·gy delivered (in jou l~s) by t h.:
spot size of the tJ•catmcnt un jl ( in an )
Pulse repetition rate
Althm,gh , large pe rcentage or the laser w tlls
•r-outincly use<l in clinical practke .a.re continuous
w..1vc (C\>V) output (i.1!4 the outpu t power is esse.n•
tially invariable over time), most u nlts currently
available in the UK nllow som e form of pulsing
of :heir o utput. f'or pulsed units, thi! pulse rep" -
titiun rate is expres.secl in he.rt:< (Hz, p ulses per
second). Typical values for pulse rcpctitioi, rate
c.:w vary from 2 t.o tens of thous onrl.s of Hz.
Allhough t he potcnlfa l biological and d.inical
re levance of pulse repetition rate is stilt f-M from
being wUve rsa..lJy ctcccp tcd.. cc-UufaJ· research
would .susg~st t hat this parameter is critical lo at
le,,sl some of the binlo1,-ic.tl ;,fieds of I.hi., modality
(e.g. Rajaratnam. flolton and Dyson, 1994).
Importance of the use of contact
technique
Altl,ough the method of application nrny ,·~ry
depen ding on the presenting condllion, w her -
ever possible lhc treabucnt head or p robe
 182 ELEOTRSMAGNETIC AGENTS
sho uld be applied with a Arm pressure to the
ttrea of tissue 10 be lreilted (Fig. 12.4). In Lhc
first instance, this mnkcs the laser treatment
inherently safor by reducing the potential for
~ccidcntnl intrabe;,m vie.wing,. as lnd1coted
elsewhere. However, Lhc primary reaso n for
using so-called cont,1ct technique is to maximise
the irradianrc or po wer densiiy on the tissue
surface, and thus the light Oux within the larget
I' tissue, which are important in i.'nsud ng the
elfecti venoss of laser trea tment. Where the
treatment head is used out of co nlncl, the light
flu.x within the tissue is reduced (lwing to
': s-evcrnl factors; most impt.1rt.1ncly, the inverse
square law applies to such non-contact ,l pplica-
tions, lcadlng lt1 reduced incident irr.1diance on
' surface of the icradiatcd tissue. Furthe.rmorc,
111ore roleclIon oi incident photons will lJCcur
where the probe is not maintained directly in
contact with tlw tissue (Fis 12.4).
Apart from producing the hii;hest .levels of
light Dux within the tissue. npplication of
contact technique will also allow the operator to
press the treabnent llrobe into lhe tissue, to treat
deeper-Seated lesions more effectively. As well
as compensating for the relatively limited pmc•
!ration of therapeutic laser devices by approxi-
mating the tre,11111en1 probe with the target
tissue, the deep pressure will drive red blood
cells from the area of tlssuc dJreclly under th,•
I
I - - -
l'--=7
• - --
t s::::;,:::
0
A
◄I-----Targ-01 o, uo
Figure 1i,4
Con1ac1vcr&us non-conl
ac tee n qu(I. A: Non-con1act •~hnlque. 9: Conlact technique.
probe head and thus reduce the a ttenuation of
light due to absorption by such cells.
Application of Lhc laser trca l.ment probe al..,
affords the opporlur\ity o ( applying pressure
treatments to key pob1ts (e.g. trigger 01
acupoints) and thus effeclively combines lase,
with acupressure-type l·reatments; indeed, ' la,e,
acupuncture' has long been proposed as a viable
alternative (and non-invasive) means of stimu.lat,
ing acupm1rture points (Wong and Fung. 19911
De.spite the above, there are siruations when,
las4.'r treabnent c.-,nnot be applied using contact
technique; principally these are where such
application would be too painful or ascplrc
technique is required (e.g. in cases or op;,n
wounds), Less conunonly, the contours of the
tissue to be treated !nil)' not allow use of a so-
ca lled 'cluster' head in full contact, thus non•
contact technique must be u~cd. 'A'herc this is lhr
case, lite treatment head sh ould not be held motf
tl1,1n ll.5-1 cm from the surface of the target tissu•.
Treatment of open wounds and
ulcers
Th~ tn,atment nf open wounds and ulcers repre-
sents lhe cord.in,tl •pplication fo r low-intensitr
las.,,. dc,•kes, anJ combined phntothcrapy)
low-mtcns1ty lnscr ther,,py units (Pig. 12.5). f'or
comprehensiv., ITeatrnent uf such conditie111,
- l aser p~cbo ----►
i
~¼in~ --
- - -- - , ~
t h 1 a

{\ --~~
'jf10\ UQlillltOfll ol YJ<JUHd nmrgln s
1
•
01111l11ny 1ochn1QUO tor wounc.J bad
1
Tteatmon1ot wound mo,glns and bod with 'clusrnr array
Tren1mon1ol wounct mar·gJns and bod wll.h 'cluster array
Figure 12.5 Loser treatment ol wounds. wound margin is
ht!aled wl1h single probe using conla01 technique ( 1 cm from
wound; 2 c.rn Intervals); wound bed Is treated using non-
t0mac1 techn!quo, using either griddlng or scanning toch•
niquo (nlnglo•dioao p robe) or mullldiodo 'cluster' unit.
~7•dlation is applied in two stages: t.he fi.rsl using
lh• ndarcl contact technique a.rowid 1he edges of
• wound, the second during w hich the wound
~· .
I& treated using non-contact techi11que.
Trea1menr ol wound margms
. applied in sequence to each of tl,e ho les overly-
ro, thos • single-diode probe is the lclcal unit 10
' 1PP1y t.re;itrnent. ~round the circumference of
LOW•ll'ITENSITY LASER THERAPY 113
•~ 1'. w1d
,,I 11pprnxi111alo•ly I 2 cm from it, edge•.
I rnnts ur appl lc,111011
shuul,1 be n u m<m: th11n
2- 3cm npurt, und the trc:olmcnt unit ~hould be
applied wllh n firm prc.. uro., tu tht: int~ct ski n
within Jh., pnllent' s Julcrancei,,
Por such lrcnlml.!nl.s uf the wound margins,
dosagc.s should be of nu more lhan l / pe r point
or approxima tely J()l/cm 2•
Treatment of the wound bed
A~ already lndicaled abo ve, treatment of the
wo und bed will Invariably be completed using
non•contact technique. As 1hc wound lacks the
usual protective layer of dermis, the dosages
applied during trcalmenl wil l be much lo we r
than during application o ver in tnct skin, and
typically ci led radinnt exposures are somewhere
2
in the range or 1- 10J/cm2, ,,,;th 11/ / cm being
most co mmonly recommended ~s the so-called
•Mester protocol' based upon the pio neering
wurk or Professor Endre Mester's group.
However, the problem of applyinf; su d , a
dosage in a standardised fa shion across the s ur-
face of an open wo und I~ obvious and has led 10
several means of application being recom-
mended 111 these Clmditions. At the simplest
level, where only a single probe or fibre•optic
applicator is availab le, the wound may be
'mapped' with a hypothetica l grid of equal-sized
squares (typically l-2 cm square), each of which
may be regard ed as :,n incbvidual area of target
tissue and treatmenl applied accordingly al tho:
rccon1rncnded dosage. In order to standardise
the 'grid', some therapists ha ve employed
acetate sheets marked with a !,'1"id, upon which
the oualine of t.hc wound can also be traced at
regular intervals as a met hod of record.ing the
progress of the patient's lesion to treatment.
1\ltem ,1tively, a clear plastic sheet wit,h holes
drllled in a regula r grid has also been success-
fully used in some units as a means o r standa rd-
ising wow1d treatments; in such cases, the size
of the holes con·csponds to t.he circumference of
the tip of the laser treatment probe, which is
ing the wound, for the time required to deliver
the prc$crlbed dosage.
 114 ELECrnOMAGNETIC AGENTS
Apart f.rt1m such gricld ing, ~umc the rapis t~
have a lso employed som e v1iri.i11t o f s<.-anmng
1cd 111ique lo treat th-, "'Ound bed w here slni;k ·
dlodl' o r fi bn.H>ptiC' applica lors are used. In lhc><!
cases, the pwbc 1:, m<,.wed sluwly ove.r t.ht!' dl\.'tl o (
lhc les io n us ing ,1 non-contact leclmi<JUC wh,k
1aklng car<' 10 d clivc,r a s1a11dard ised rad fa nl
.. exposure to all areas, ilnd to mn_intain the head i'lt
a distance o f no m o r-, tha n I cm from th e wo und
bed. Perhaps nol su rprisingly, m os t therapis ts
,,, .
l• find this tcclmiq ue difficull 10 perform, and thus
ii is Jn c.reaslng ly rare to find unit$ where m anual
i-;rann.ing trc~r1,w-nts ar~ pcrformt!d
' '.
I •
Special dev,ces for rt earment ol wounds
·"
J Given the proble ms inherent m perfo rm ing
.. ~ffcdive standardised laser 1rr.:id i:\tion o f w ound
beds~ n n umber of s pccinl d l'vices have bctn pro-
d uced a n J m arketed in an atte mpt to s implify
11nd i_n,pro vc the e.fflc.icy o( such crc:u.mcnt.s, Ln
the first in.slance, several rnanufncturcrs have
p roduced s,dJllUJlg de vices thnl may be used In
confunc1'io n w ith their trea lmenl units; thes<'
sca nner,, m echnnically direct the o urp ul of th<-
,kvicc over an area defined by the o pe ra to r by
mean, of contr ols on the scanning unll. While
su ch d evices hnve been popular Jn some circles
in offering a ' hands off' approach lo providing a
well-standardised treatment across tJ,., whnlc
w ound a rea, p articularly In cases of more <'X ten-
s lve wo unds (e .g. bur ns), the rclatJvcly high cost
and po tentia lly greater hazards associated with
these units have prevented them becomh\g ns
popu lar as they perhaps might o therwist• be.
As an nlte.mntivc to scanners, a number ur
manufacturers now p rovide the option o f so
called ' duster ' units, typically lncorpornting .1n
arr.iy o( d iodes Jn a s ing le hand •held unit. Th<'
,. numhur of d iodes pro vided in these clus ters
varies between 3 and almost 200, but It is gener-
a lly true tha1 the larger un its inco rporate a mix-
tu re of s uperlumlnous (m o nochrom alic) d iodes
.as w d l as (tru e ) lase r sources I,-, their arrays, d ue
,., di< prohibitive cast of the latter. Snch duster
muts allnw sim u.ltoneous treatment o f on oren of
t·issu e, tlw exte nt of which Is decided by the nwn•
bcr • nd ,·o nfig ur•llun of th e d iodes lnducled in
the array. Fur the rmore, '-;ev cral manuiact&JII-',
h,wc i.nt:t.lrporated diodes o pcr;ibng al a v,i, ,♦ 1 ,
c,( wa velengths (Le. mul lisou rce/mu it,w,"'
length arrays) in thcfr clu; lcr unit, . clr11ni,n;
enhanced clinical effects thr o ug h parallel tan,i
possibly synergis tic) wavdeng th •spccl.fic elle11 ,
In rou tine dlnlcni practice. the relative di((ic11111
in treat I11g extens ive ulccra11o n with s lni;I,
diode unils has led 1u d us ler uniis bcin1:1 it,
qu~n1ly cited as the m osl po pulnr un its b1
1herapists (see Baxter cl nl .. 199.1). In lrcaun1,
wo und beds, cl uslN units can be usod In isola
lion o r in conjuncllon with sing le probes 1,
access deeper or recessed ;.rea.s, ;111d in eith, ,
case present .J more lime efficicnl means of trent.
nwnt tl,an s ingle probes unit~ used i11 iso lat.io n.
Treatment of other conditions
A s already lndica1cd, when t-re,,lmenl ls a ppli,•.I
10 rnl>cl skin, co nt-.cl technique is th e npplic.,
lio n of choke. For such 1rentmen1 of i;cner;,I
musculoskcletal co nd ili o 1, s, laser 1hernpy i:,111
usefull)• be npplied Inn n umber or wny, .
Dlrecr rrearmenr of the lesion
In s uch c,1.ses, the lnscr probe i, ,1pplicd tllrcr lh
lt1 the lesio n (nr<>n of bn1is lng, site of pain, eh ,
U!-ling .i 11nn pres:-lure within the patient', tult·,
.,nee. Where l'Xtt'nsh,(• bruisi nH/hnc mnturna 1•
prPscnt, an 'in tont nl't' ver;Gion or w o und trv,11
m cnl (.is al ready s umm.irised abo ve ) Is npplh-•I
for these c11ses1 dosnges npplied are corrc~pn11J
lngly higher th nn those used for the t.rent mcnl " '
open wounds, given the prrs~ncc of th(! ~kin ,,,, •1
bnrricr to l,, ser irrad iation.
Treatment of acupuncture and trigger points
In d lina nnd Japan. !he m ain m et.hod of Jo,.·•
appJJc-«tion is as an alkrnntivc tv m:cd lci; 1• 11
acupuncture . Altho ugh the comp,trnliv~ cfh<•" 1
of s uch application with respecl lo m><•<II"
o r o ther non-invasive a ilerna livcs (e.g. TEN'•
1
acu pressure, etc.) is s tilt lo be dcl<•md11•·•
det'inltiveJy and is a m a tter for inlcns(' clch••1•'
 ,1,. ,ire ni an y
re po rt s in th e
I' ,
- - -- • l OW-fHTEHsr,y LA
SER THERAPY t '5

pl ic at io n of la se r •111 1 lc ra tur,,. nf
h•. ,
llti11<in,um .,1 lOJ / r Wh<'rt• pu l"-.f 'Y'"'"" an ·
ii• -sSful ap 94; W on g il nd Fu is M• l•a (s.· ,• I m
,tv,1 il"•bl,•, l 'J t} I •,,Iffll!nls ,h uu fl f ht· m11t,lfed
11·' ' '9 · El l '• 19
• , ~r, 198 • 11,'. ng, 1991d). IVilh r,•I arl v,• lv rtI r,11,- .
1
us cl es w it h a ss o ci at ed• w eI1- ·
loc 1ISC H ) • uw pu1"' n •p ,,l t!iu n rJ no t•
flJ r m .
c,· t . a (<: lOO 10 ,f •nru th,• kt lu he
r t1:
J,1u of pnU1 up on p a lpa ti on -~ . ng ge r · n
,. _ L • tf tnm•f1w "
,_ ; en t pn ,
• W I h,1l"rn,1 tu 1n,a or
tr ea te d w iu ;° in ls m
1
..., w at rt•
JI '- al so be br u · .• .. _ >g w ~• "· W
1'cl U 'ln •• lh,•
~.,I.try. 19 93 ) m ;iy la se r is tn g 15 pr es enl, II sh ou ld bl! ln,,,1 "
.,d ia lio n; al th ou gh n o de fi ru H ve re co m m en d a ra J pr i · I 1re ad y ou tl10< 'tl /o r th ,· ln•,11
d tr:i • ge ne na p l'S a
do sa ge for su ch ough in thL, , ,,..,•
.,
irr
U<'IL'
f',utl
ca
tlt
.
11
er
be
ap y,
~
. m
a
th
e
e
on
au th or 's el ep er ie nc e
thes:;; ;en• of op en wound~. alth
rm contact lechnique rli sh ou ld b,, used w11h
1n 1h
.iun
<•
el h· h pa rulMly w he re 1lw J,-
lt'>"J1$ ar e ac hi20 ev ed w he•n a re la liv Y 18 ·p ow er r pa tle nr's lolernnce,
0 W ) 1s em pl oy ed to d ep.
15 relatively de
· -n
un11 (1.e. :,.,-, m e iv er • in th,·
nd 2- 3 Jpe r point. al dosage~ sh ould Ix
.., :ial d05age s of ar ou Reco m m en ded in1iti ol the
n o( 4- -8 JI cm ar ou nd the m ar gm., ll•
re ~o
d us in g a gr id lechni qu e or ., mul
lesion. an the bn us e
pl ie d ov er th e ce nt re of
ro ot s, trunks, ei c. so ur ce ar ra y ap
ar s an d in ju ri es, las(
'r
•-radiation ov er ne rv e In the tr ea tm en t of m us cl e te
raling th e
lm en l of pa in sy nd
ro m es , or in
er ~p y ca n be hi gh ly effective in acccle func•
the la se r lr e~ lh e re lu m to nom tal
1t1 m aj or feature o( an d th us th
c.lSE~ w he re pa ui re pr es en t,. a be repair pr oc es s
with its abillly 10 bt
• applil.'d
nt at io n of th e co nd it io n to lion. This, coupled mt'<f,.
:l;e clinic al p re :.e pl ie d to st ag e- -i n so m e cases lm
on m ay us ef ul ly be ap ea rl y in th e ~r ul e
r m od al ity
treal e~ , l.r ra da ar _i
pr op ri at e ne rv e
ro o1, m akes ii n po pu la
m g th e ap alely airer iniu.ry-
L'ie skm O \·c rly up pe r orts m ju ne s.
tr un k. F or elea m pJ e, in tr ea ti ng in th e trealmen! of sp
plexus or pp lie d ov er
b pa in . la se r th er ap y m ig ht be a ac lti al
hm rv e ro ot s, tht> br
nl ce ,·v ic al ne
~I f rek va >l.l as urogenJc pa in
by ir ra di ,,t io n ov er Ecb's po in t, as wt Neuropathic an d ne
plexus m ar e rela- c ne uro-
in ts w he re th e n er ve s in lh c ar the pa tie nl pr es en ts w ith ch ro ni
10 po ia n or Whe re
is typicaUy ap pl ie
d
pe rf ic ia l s uc h as th e ra di al, m ed , la se r ir ra di at io n
1,vely ~u ge ni c pa in e rooti.,
e lb ow o r w ris t. io n to all relevant ne rv
!l!nar ne rv e, ar th e in a sy sr em at ic fa sh
g a m id dl e- ra ng e
do sa ge
d tr un ks , us in
pleJCUs an 2 re tr ig ge r
0- U j/ o n ) to in itial!!' 1reatmen1. W he
(1 also
entified, these ar e
in ts o n la s e r treatment o f or te nd er po in ts ar e id
al Jeasr
Key po initial do sa ge of
nditions us in g an
some selected co
lr' ea ted, hi evl! de se n•
/c m 2, w hi ch ls increased 10 ac
10 -2 0J n. lrrad1a •
th e po in t up on re pa lp at io
Solt tissue in ju ries at ed
si lis at io n o(
ie d di .rectly to an y ,trea
s or
11 1ent sh ou ld be in iti tion ls al so ap pl <', ei c
:it SUch co nd iti on s, trc at
th e_aa ,l e an d to the affected de rm ar om
y possible within re ferr ed pa in ,
ls pr ac lic aU
as early as region of
. in g re la ti ve ly lo w do sa ge s in th~
srag., us
ly to th e si te of UlJW}' an5t
d
2 pl ie d di re ct
H l J/ on ap in. W ith in th e 6.r
s of pi 1l pa bl e pa A rthrogenic pa in
any area tr ea tm en t m_ay be • df rc •
72·96 ho ur s af te r inju ry , su ch gi a of ,·a ri ou s dl 'li olog i.-s n1.w b..
k of A rt hr al
1J ue e ti m es d ai ly ,-.ri th no ns 1J gt !d w ilh J.1 ~r 1re.11m..-n1 wh,•11
th at do sa ges ?re
''PPlicd up to k~pl liv ely m ,11 10 th,•
pr ov id ed in J co m pr eh
en <f re m Jn n, ·r
tert re at m en t, ,,p pl ie d 1.11...-n
rt an t to reiterate thal /o
w -m le ns ily
3n d jo in ls ; r., r 1h ,
,_ , ,·. tf \' ,h ou lJ b..•
:: :· h is im po rm al , ((e cl ed 1, .,n 11 1g) 10
by de fi ni tio n at her in th - 1
w ,r h n• gJ nl "' p.111enl po ,1
., ·r fn>atmen t is ea tr nen
(e s~ "C i.illy ~,~s tl--m,1tt•
1nt .1~
~ t>mine nl ly su it able fo r tr l..'ru-ui·e th .It ._ ,JI J:--p-.•d:i- ,)t lhr... 1l)
th e co nd it io n re solve!', th ed
e freJ·
an
"'ltia hons . A s d \'.'illlJ tn .•.l ft•t.f
uc lo ,1
ru cv o f lase r ·tr ea tm en t m il J be 4re up
: "n
•O sao y inCCC"~""•
"" co rres po nd in gl
• 186 ELECTFIOMAClNETIC AGENTS
HAZARDS
Classification of lasers and
ocular hazard
Under a.n internationally agreed cl•ss,ncJtion
system which grades la..<t<r devices on " scale
from 1 to 4 according to the ilSSociat,1d dangers
to the unprotected skin and eye, the units
••• typiC.Jlly used in l.IT.T are classed as cfoss 3B
,, lasers, aJtl1ough much lower output dJSS 1 and 2
devkcs ha,·e also been used in the pasL This
II ► essentially means, for the majority ,,f sy;,1ems
, I[ used in physiotherapy applications (i.e. class
'•: 3 B units), that .utl,ough the laser's ou tp ut
•• may be considered harmless when directed
on ·10 tJ,e unprotected skin, it poses a po/i:unal
hazard to the eye if ,~ewed along the axis of
.. the beam (i.e. intrabeam viewing) owiJ1g 10 the
high degree of collimation of the laser light.
For this rc,1son the use of protecth•e goggles,
which must be appropriate for the wave•
lcngth(s} used, is re,ommended for operator
and patient. Care is also recommended in Ensur-
ing that tl1e beam is ne,·er directed towards
the unprotected eye; the palient should be
speci6c,1Uy wamed about the ocu.lar hazard
,1ssociated with the device nnd asked not to stare
d irectly at the treatment site during npplication.
Furthermore, the laser Lreatmcnt unit should
ideally be used only in an area specifically desig-
nated for this purpose; outside this area, ihe
appropriate laser warning symbols should
l•c dcarli• displayed. Having outlined these
fundamental safety rules, it is impOrtMt to
stress that the ocular hazard associated with
ther,1peu t·ic units is (for all practJcal purposes)
negligible, !!specially where the treatment head
• or probe is used wjth tl1e recommended ' in-
j contact' technique (see •Principles of applica-
tion'), In addition to tl:tc above, the outpat oi
the treatment unit should be regulal'ly tested
to ensure the C1ptlmal operation (and thus cffec•
liveness) of !he device: this is particularli1
important ,1$ rcci!nt research would Indicate
that " large proportion of laser units in rontiJ,c
use may not be p roviding adequate power
oulpu: to be effoctiv~ (Nus$baum, VaJ1 Zuylen
,md B,,xter. J99<J). · ti,1115. Principally these include tl1e foUowiJlg.
Contraindications
(Sec Chartered Society oi Physiotheraphy (199,
S~fdy of eleclrot/1erapy g11idnr1r,, for addition:;
infonnation. )
Apart from direct treatmcm of the eye (for
whatever redson}, I.he use oi low-intensity lase,
therapy is also conlraindicateJ in the following
<:asc..~.
• In patients with active or suspected
carcinoma. (With the exception of treatment 1n
hospice care.) Studies at the ceUufor level tesltfy
lo tl,c potential photobiostimulatory effects of
laser radiation; given tlus, it is possible t.ha·
therapeutic laser application could accelerak
carcmogencsis in patients where carcinoma 1s
prcSe.nl Despite this potentfal clanger, it shouJcJ
be stressed that laboratory studies in normal
cells have coru,i.stently failed to demonstrate any
c.i.rcinoge,uc effects of laser radiation; u1dce<l.
recent results would suggest that laser irrad ia-
tion might affect DNA repa.ir mechanisms
[Logan, Craig and Barnett, 1994).
• Direct irradiation over the pregn,u,t
uterus. In the absence of hard evidence to show
no associated haznrd to fetus or motl,er, avoid-
ing treatment directly over the pregnant uterus
represents a prudent and stand.ud precau tio~
that applies to a.II forms of electt'otherapy.
• Areas of haemorrhage. This n?presenls a,
,1bsolutc contraindication to laser treatment due
to the possibility of laser-induced vasodilatauon,
whkh would exacer bate the condition.
• Cognitive difficulties or unreliable patient.
The patient should be able to understand the
explanation and. mandatory warnings, and ro
comply with instructions.
Other safety considerations
\ll,~1ilst the above are usually regarded as the
cardinal contrain,licatio11s to treatment wiih lo•,•:·
intensity laser therapy, the Chartered Society o/
Physiotherapy's Safety of Electrotherapy Equip:
mcnt Worki11g Group ha,•e also recorrunendeu
the ex~rcisc of caution in a number of other sJrua·
 -~~~--~~L~OW'.:-t~liTEN~~SO'Y~~L. ~
~~S~E~R~T~H~fAAP'Y~~~8
1~~
7
----==~:==~~~----~- . ( n ca n ce p~se nt an
fect ed ti ss ue le ·po&· •n ~cted cftect·s up on c.1.rd ,a c ru nc no
, rr r. it rn ~• of inse r li gh t has th e r these pa tie nt s
,n wou nd s)b. As la. r- .. •
1entJaJ to W\acceptable ns k fo photos rnsilive •r
ea.s .
tf . L-
c ac te a a =<h,mc/1in coli in cu lu re
I •. Trea tment over y ol pho1osens1tivily (e.g.
uo o,
n" 'u li tr )
an d O ' J<ane• 199,' • 11 w ou ld Patients with a hist t) should be treate
d
·, ~ J()98; Shdie ld s th ac tio ns to su nh gh
,~
en l to re co m m en d ca u tio n in e •~ ve rs e re th e us e o f a te st do
ch ca ,e s
se
•,,111 only pr u
er apy to infected ssue
ll. w ith care. an d in su di tio n, th e cu.rren
l us e of
,rrucalio n· IIof ._ lase r th d • m m en de d. In ad .
• y 1r
,
ne ct e op en w ou nd s · H ow ev et
'
ls reco
m g dr ug ~ sh ou ld aJ .o be e><duded
aa . ( ,_ llS
•.,nd es pe. ts om cl ea r, as th er e is evi.d cn ce photosensi it h epil ,p sy. Car e
ti en t w
t. , situabon t th
.u rr
li ni . ccessful! • Trea tm en t of pa treating patients w
ith
at c C la ns ha ve su ex em se d w he n
ug g~ s an d i~ sh ~ ld be
:~ 5
io ns w it h la se r thernpy, y.
11>'->=~ su ch co nd it io n as an a rustory of epileps ,.u of al te re d sk in sm sa li on .
e p rese nc e of in fect • T tt •lm<n l of an
,ome cases re ga rd th en t (Baxter el al.• 19
91 ).
tr ea bn en t is athc rrnic, ;i nd
Is
fo r su ch tr ea tm Althougl1 la._< er pe np he ra l
,:,{.u/NJn n&J.i •, th e treatment of
1
ov er !h e sy_m pa th et ic ga ith re co m m en de d in ch
• Tr ea tm en t
fa c re g, on in p.it ic nts w s. ca re sh o ul d bi.' ex ercise d in su
o. cd n en·e le si on
,·,gus netV es an d
he po ss ib il it y of la se r• m
ed ia te J
hu rt di se as e. T rs e cases.
ne ur al ac tiv it y re su lt in g in ad ve
,:wra nons in

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l appro. r;,y1:01J;,,;tpv 77h :71 wt', Ali d a.L ( l.9~N)
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'-o ft u, .,,
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to ld u thn1b, S i:11r1d
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