Photomedicine and Laser Surgery

Volume 26, Number 5, 2008

© Mary Ann Liebert, Inc.
Pp. 419–424
DOI: 10.1089/pho.2007.2160

Effect of 655-nm Low-Level Laser Therapy

on Exercise-Induced Skeletal Muscle Fatigue in Humans

Ernesto Cesar Pinto Leal Junior, M.Sc.,1,2,3 Rodrigo Álvaro Brandão Lopes-Martins, Ph.D.,4
Francis Dalan, P.T.,5 Maurício Ferrari, P.T.,5 Fernando Montanari Sbabo, P.T.,5
Rafael Abeche Generosi, P.E.,6 Bruno Manfredini Baroni, P.T.,5
Sócrates Calvoso Penna, Ph.D.,4 Vegard V. Iversen, Ph.D.,8 and Jan Magnus Bjordal, Ph.D.3,7

Abstract

Objective: To investigate if development of skeletal muscle fatigue during repeated voluntary biceps contrac-
tions could be attenuated by low-level laser therapy (LLLT).
Background Data: Previous animal studies have indicated that LLLT can reduce oxidative stress and delay the
onset of skeletal muscle fatigue.
Materials and Methods: Twelve male professional volleyball players were entered into a randomized double-
blind placebo-controlled trial, for two sessions (on day 1 and day 8) at a 1-wk interval, with both groups per-
forming as many voluntary biceps contractions as possible, with a load of 75% of the maximal voluntary con-
traction force (MVC). At the second session on day 8, the groups were either given LLLT (655 nm) of 5 J at an
energy density of 500 J/cm2 administered at each of four points along the middle of the biceps muscle belly,
or placebo LLLT in the same manner immediately before the exercise session. The number of muscle contrac-
tions with 75% of MVC was counted by a blinded observer and blood lactate concentration was measured.
Results: Compared to the first session (on day 1), the mean number of repetitions increased significantly by 8.5
repetitions ( 1.9) in the active LLLT group at the second session (on day 8), while in the placebo LLLT group
the increase was only 2.7 repetitions ( 2.9) (p  0.0001). At the second session, blood lactate levels increased
from a pre-exercise mean of 2.4 mmol/L ( 0.5 mmol/L), to 3.6 mmol/L ( 0.5 mmol/L) in the placebo group,
and to 3.8 mmol/L ( 0.4 mmol/L) in the active LLLT group after exercise, but this difference between groups
was not statistically significant.
Conclusion: We conclude that LLLT appears to delay the onset of muscle fatigue and exhaustion by a local
mechanism in spite of increased blood lactate levels.

Introduction the capacity to generate force by contractile proteins in the

muscle).3 Muscle fatigue can be divided into a central com-

S KELETAL MUSCLE FATIGUE is a common experience in daily

life, although the mechanisms of its action, development,
and prevention are not fully understood. Commonly seen
features of skeletal muscle fatigue are decreased muscle
strength, impaired motor control, and subsequent muscular
pain.1,2
The mechanisms that contribute to muscle fatigue during
a sustained submaximal contraction include several pro-
cesses (e.g., input from the motor cortex, transmission by
spinal motor neurons, local neuromuscular activation, and
ponent and a peripheral component. Factors that affect force
production during muscle activity include the type and in-
tensity of exercise, the muscle groups involved, and the lo-
cal physical and biochemical environment.4,5 In this sense,
muscle fatigue is a complex and multifaceted process in-
volving physiological, biomechanical, and psychological el-
ements.6 Age and gender are also important factors deter-
mining our ability to contract skeletal muscle and to
withstand fatigue.7 There are some indications that exerted
force declines rapidly in male subjects during the develop-

1Laboratory of Human Movement, 2Sports Medicine Institute, University of Caxias do Sul, Caxias do Sul, RS, Brazil, 3Section for Phys-

iotherapy Science, Institute of Public Health and Primary Health Care, University of Bergen, Bergen, Norway, 4Laboratory of Pharmacol-
ogy and Phototherapy of Inflammation, Department of Pharmacology, Institute of Biomedical Sciences, University of São Paulo, São Paulo,
5Faculty of Physiotherapy, 6Faculty of Physical Education, University of Caxias do Sul, Caxias do Sul, RS, Brazil, 7Bergen University Col-

lege, Institute for Physical Therapy, and 8Section for Physiology, Institute of Biomedicine, University of Bergen, Bergen, Norway.

419
420
Lactate post-test
Exercise test
Stretching
Lactate
pre-test
Day 1 Day 2 Day 3 Day 4 Day 5
FIG. 1. Time flow chart of the study protocol.
ment of skeletal muscle fatigue.8 In clinical settings, skeletal
muscle fatigue may also subsequently contribute to the de-
velopment of muscle pain.9
There are several different types of muscle fatigue and the
contribution of each to the overall decline in muscle perfor-
mance depends on the muscle fiber type and the intensity
and duration of the activity.10 One type is caused by the
build-up of potassium ion in the transverse-tubular T sys-
tem in the immediate vicinity of the muscle fibers. The other
major type of fatigue is metabolic fatigue due to direct or in-
direct effects of the accumulation of metabolites such as
inorganic phosphate (Pi), ADP, magnesium ion, and reactive
oxygen species, and a decrease in substrates (ATP, creatine
phosphate, and glycogen).10
The decrease in force generation under anaerobic condi-
tions such as during strenuous exercise inevitably generate
a large amount of reactive oxygen species and disrupt mi-
tochondrial function, which is known to cause muscle de-
polarization and reduced force.11 Lactic acid accumulation
inside the muscle fiber may not be responsible for decreased
muscle performance,10 and its physiological role in muscle
fatigue remains controversial. However, in most high-level
sports modalities, monitoring of blood lactic acid concentra-
tions is still the main tool used to plan training programs.
In a previous animal experiment, we found that low-level
laser irradiation could delay the inevitable decline in maxi-
mal contraction during repeated electrically-induced tetanic
contractions.12 Specific doses of low-level laser irradiation
reduced muscle creatine kinase activity levels, thus indicat-
ing a decrease in muscle damage, when compared to non-
irradiated groups.
In clinical settings, low-level laser therapy (LLLT) is being
used in the treatment of muscle pain, and some positive find-
ings have been seen for neck muscle pain,13,14 and conditions
related to skeletal muscle fatigue.
In the present study, we investigated the effect of LLLT
on skeletal muscle performance and lactic acid levels in a
clinical model with professional volleyball players.
Materials and Methods
The study was approved by the ethics committee of
the Vale do Paraíba University (protocol number
H141/CEP/2006). All subjects signed informed consent. The
volunteers were recruited among professional male volley-
LEAL JUNIOR ET AL.
Lactate post-test
Exercise
test
Laser/placebo
treatment
Stretching
Lactate
pre-test
Day 6 Day 7 Day 8
ball players from Rio Grande do Sul State at the same train-
ing level, and they were randomly divided into two groups:
Group A, the placebo group, and group B, the laser-treat-
ment group. Randomization was performed by a simple
drawing of lots administered by an assistant not involved in
the experiment. The allocation to groups was blinded to both
the participants and the observers.
Sample size calculation
To our knowledge, there are no existing human trials that
have been performed to evaluate the development of skele-
tal muscle fatigue. This makes sample size calculations un-
certain. We set the least detectable difference to 8 repetitions,
and we calculated a probable SD of 5, using data from the
animal study, establishing the statistical power of 80% and
a significance level of p  0.05. Our calculation estimated the
minimal number of participants to be 6 per group.
Inclusion criteria
The inclusion criteria were: male volleyball players, who
had been playing volleyball professionally for at least 2 y,
who were aged 18–35 y.
Exclusion criteria
The exclusion criteria were: any previous musculoskeletal
injury to the shoulder or elbow, participation in less than
80% of the regularly scheduled physical training and vol-
leyball sessions for the professional volleyball team, and
players using any kind of nutritional supplements or phar-
macological agents.
Procedures
In order to provide stability for the elbow, we used a Scott
chair with an inclination of 45°. For the measurement of the
time of irradiation and total time of repetitions, a chronome-
ter accurate to two decimals was used.
Maximum voluntary contraction (MVC) test. The athletes
were familiarized with the flexion-extension exercises with
an adaptation and standardization period of 2 wk. After 2
wk, we performed a maximal contraction force test that con-
sisted of a single repetition in total range of motion for flex-
ion-extension of the elbow in order to evaluate the strength
LLLT IN SKELETAL MUSCLE FATIGUE IN HUMANS 421

of the biceps muscle while the subject was seated in the Scott
chair. Free weights were used, and an individual-specific
percentage (75%) was established for each subject.

Period of evaluation. Care was taken to standardize the ex-

ecution of the exercise protocol. Exercises were performed in
a standard sitting position at approximately the same time of
the day to control for the circadian rhythm. Also, muscle
strength training was performed in the same manner each time,
at 75% of maximal load. The performance and evaluation of
the exercises were performed in two sessions (on day 1 and
day 8) on the same day of the week (Monday) in the same pe-
riod of the day (between 8:30 and 11:00 AM). No strenuous
physical activity was allowed on the weekend before testing.
The timeline of the experiment is shown in Fig. 1.

Fatigue protocol. At the first session on day 1 and second

session on day 8 of the study, basal lactate measurements were
obtained for each subject by taking a blood sample from the
second finger of the hand of the arm involved in the fatigue
exercises. Immediately after this, all 12 subjects submitted to a
series of muscle stretching exercises involving all the major
muscles of the upper extremities (two rounds of 60 sec for each
muscle group), and finishing with the flexor muscles of the el-
bow. Then each subject was seated in the Scott chair with the
knee and the hip flexed at 90°. Using a free weight halter, each
subject performed his previously defined personal weight load
(75% of maximal load). A goniometer was attached to the
Scott chair to measure the flexion angle.
The number of repetitions done in the exercise fatigue test
was counted by one observer, and the total time to complete
the effort was measured by a second observer. Both observers
were blinded to the participant’s group allocation (LLLT or
placebo). The repetitions began at the position of maximal ex-
tension of the elbow (180°) for the non-dominant arm. FIG. 2. The laser irradiation points (white circles) used for
LLLT or placebo LLLT.
LLLT protocol
At session 2 (on day 8), 1 wk after the first session, the Blood samples and lactate concentration
participants either received a single treatment of active LLLT
In order to measure blood lactate concentrations, follow-
or placebo LLLT according to the results of the randomiza-
ing aseptic cleaning of the finger, a qualified nurse (blinded
tion procedure. Active LLLT or placebo LLLT was adminis-
to group allocation) took one blood sample before, and an-
tered after the stretching regimen, but immediately before
other blood sample 3 min after, the exercises were com-
the exercise fatigue test. LLLT and placebo LLLT were ad-
pleted. The finger from which the blood samples were taken
ministered by a technician who was restricted from telling
was on the same side as that holding the free weight for the
the subjects or observers whether active LLLT or placebo
biceps contraction in all subjects. Accu-Chek Soft Clix®
LLLT was being administered. Blinding was maintained by
lancets were used (Roche Diagnostics, Mannheim, Germany)
the subject’s use of opaque goggles. To maintain similarity
and the samples were immediately analyzed with a portable
of the two procedures, a small protective shield was placed
Accutrend Lactate® (Roche Diagnostics) analyzer.
over the tip of the probe for those receiving placebo LLLT,
thereby blocking the laser energy from reaching the subject’s Statistical analysis
skin. The biceps muscle belly was marked at four points
Group means and their respective standard deviations were
evenly spaced along the ventral side of the muscle belly, so
used for statistical analysis. We used a two-sided t-test to test
that the LLLT irradiation could be delivered to most of its
if there was a significant difference between active LLLT or
surface (Fig. 2).
placebo LLLT. The significance level was set at p  0.05.
The irradiation was performed in contact mode with the
laser probe held stationary with slight pressure at a 90° an-
Results
gle on each of the four treatment points. Each subject re-
ceived only one treatment session. The laser parameters are Twelve healthy male professional volleyball players were
summarized in Table 1. recruited who met the inclusion and exclusion criteria. Af-
After LLLT or placebo LLLT had been administered, the ter randomization, there were six men in each group. Their
participants were immediately repositioned and they began average age was 22 y ( 3 y), their body weight was a mean
the fatigue exercise protocol within 60 sec. 90 kg ( 10 kg), and their height was 195 cm ( 8 cm).
422 LEAL JUNIOR ET AL.

TABLE 1. LASER PARAMETERS ings in an animal study,12 and must be considered as only
the first step in this novel area of LLLT research, as many
Wavelength: 655 nm (red) questions remain unanswered. The clinical impact of our
Laser frequency: Continuous output findings is also limited by the fact that the observed effects
Power output: 50 mW
were measured within a few minutes after irradiation (400
Spot diameter: 0.06 cm2
Spot size: 0.01 cm sec of LLLT, 60 sec for repositioning, and 38–53 sec for ex-
Power density: 5 W/cm2 ercise fatigue testing).
Energy: 5 J/point The doses we used in our previous animal study were in-
Energy density: 500 J/cm2 on each point situ doses, because the muscles were dissected and the ani-
Treatment time: 100 sec on each point mals’ skin was removed. Light penetration through human
Number of points: 4 skin is poorer with the red laser than with the infrared laser,19
Total energy delivered: 20 J and among other things we considered using an infrared
Application mode: Probe held stationary in skin contact at laser in this study. Only pragmatic reasons such as the laser
a 90° angle with slight pressure equipment we had available governed our selection of the
type of laser we used to perform this study. Taking this into
consideration, we decided to increase the power output from
2.5 mW to 50 mW, the power density from 0.031 W/cm2 to
The exercise fatigue test performed on day 1 showed no
5 W/cm2, the dose at one point from 0.4 J to 5 J, and the en-
significant differences between the two groups in the num-
ergy density from 1 J/cm2 to 500 J/cm2, delivered to each of
ber of repetitions performed. On day 8, the fatigue exercise
four points, in order achieve sufficient irradiation of the hu-
test (performed immediately after LLLT or placebo LLLT)
man biceps muscle.
revealed a significant difference in the number of repetitions
Clinical studies have previously demonstrated that active
performed in favor of the active LLLT group (p  0.0001).
LLLT with a dose greater than 8.9 J increased post-exercise
The results are summarized in Fig. 3.
microcirculation, but did not reduce spontaneous pain, in the
The time required to perform the exercises on day 1 and
day 8, respectively, showed a significant increase, from 38.7
sec (95% CI: 31.1, 46.3) to 53.8 sec (95% CI: 46.2, 61.4) in the
LLLT group, but not in the placebo LLLT group, in whom
it was 38.6 sec (95% CI: 30.9, 46.1) to 41.1 sec (95% CI: 33.6,
48.7). The difference in change between the groups from day
1 to day 8 was statistically significant (p  0.0022), in favor
of the LLLT group. The results for time are summarized in
Fig. 4.
The results of the blood lactate tests showed that both
groups increased their blood lactate levels from the baseline
assessments to the post-exercise assessments. However,
there were no significant differences between the groups for
this outcome. The results are summarized in Fig. 5.

Discussion
In this small trial, LLLT appeared to delay the fatigue re-
sponse in the biceps muscle and allowed the participants to
perform a significantly higher number of repetitions than
controls, thus improving skeletal muscle performance. The
lack of differences in the blood lactate levels between groups
indicates that the mechanism behind LLLT’s effects is prob-
ably not associated with a delayed shift from aerobic to
anaerobic muscle metabolism. Several authors have reported
that the decline in muscle force or power output leading to
impaired exercise performance is not associated with lactic
acid or hydrogen ion accumulation .10,15 Previous animal
studies have indicated that local mechanisms of LLLT can
prevent ischemic muscle injury by reducing release of reac-
tive oxygen species (ROS) and creatine phosphokinase ac-
tivity, while increasing levels of antioxidants and heat-shock
proteins.16,17 These results are interesting, since the previ-
ously described results by Ortenblad and Stephenson18
showed that stimulating a highly aerobic muscle under
anaerobic conditions would generate large amounts of ROS,
leading to muscle depolarization and reduced force. In this
way, LLLT may be useful in preventing fatigue and in im- FIG. 3. Number of biceps muscle contractions performed
proving muscle performance. Our findings of delayed onset on day 1 (without LLLT or placebo LLLT) and on day 8 (im-
of skeletal muscle fatigue are consistent with previous find- mediately post-LLLT or placebo LLLT).
LLLT IN SKELETAL MUSCLE FATIGUE IN HUMANS 423

condition in which fatigue and oxidative stress appear to play

important roles. In two clinical studies, researchers have al-
ready found beneficial effects from LLLT in fibromyalgia pa-
tients.26, 27 Exercise therapy has been used with some long-
term success in fibromyalgia, but the level of exercise intensity
must be increased slowly in order to avoid episodes of in-
creased pain and set-back.28,29 Exercise-induced fatigue is of-
ten associated with painful reactions in fibromyalgia patients,
and LLLT may have a potential role in reducing post-exercise
pain in these patients.

Conclusion
We conclude that LLLT can delay the perceived onset of
muscle fatigue and exhaustion, probably by local mecha-
nisms including a reduction of oxidative stress or a decrease
in the production of ROS. Blood lactate concentrations were
similar in both groups immediately after the muscle perfor-
mance test. Still, the accumulation of lactate may have been
slightly delayed by LLLT, and further studies are needed to
clarify this point. The clinical impact of our findings may be
limited by the experimental model we used, which only mea-
sured the immediate effects on muscle performance within
2 min of irradiation. However, it is the first study to dem-
onstrate the effect of low-level laser therapy to improve mus-
cle performance, and it opens a clinical window into treat-
ment of musculoskeletal conditions in which muscle fatigue
is a precursor to pain.

FIG. 4. Time required to perform biceps muscle contrac-

tions on day 1 (without LLLT or placebo LLLT) and on day
8 (immediately post-LLLT or placebo LLLT).

masseter muscle.20 A positive effect of delayed onset of mus-

cle soreness has also been described in one trial with an opti-
mal LLLT dose,21 while others have failed to find such effects
with sub-optimal doses.22,23 In our study, we made to mod-
ify the LLLT protocol to optimize its clinical use in humans.
Our findings may be relevant to other areas, such as the study
of chronic muscle pain syndromes. Several treatment options
are available for the treatment of chronic muscle pain, but cur-
rently none seems to provide the ultimate balance between
benefit and harm. In addition, some disorders such as chronic
neck muscle pain and fibromyalgia may be recalcitrant to such
treatment, as no single treatment modality appears to provide
convincing results. There appears to be a majority of positive
results of LLLT in common muscle pain syndromes such as
neck pain,14 but the mechanism of its action remains poorly
understood. Our study primarily investigated the effects of
LLLT related to muscle tissue, and any possible systemic ef-
fects. Recently, another novel LLLT mechanism was observed
in an animal study, in which LLLT blocked the axonal flow
of small-diameter nerves.24 Common treatments for muscle
pain are often associated with transient pain, including mas- FIG. 5. Blood lactate levels before and after the series of bi-
sage and acupuncture, and pharmaceutical muscle relaxants ceps muscle contractions on day 1 (without LLLT or placebo
may cause addiction, and thus have a poorer prognosis for LLLT) and on day 8 (with LLLT or placebo LLLT irradiation
those with lower back pain.25 Fibromyalgia is another chronic before exercise test).
424
Acknowledgements
The authors would like to thanks Saul Zat for his techni-
cal assistance with the volunteers, and R.A.B. Lopes-Martins
would like to thank Fundaçao de Amparo a Pesquisa do Es-
tado de São Paulo (FAPESP) for financial support (grant no.
05/02117-6).
Disclosure Statement
No competing financial interests exist.
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Address reprint requests to:
Ernesto Cesar Pinto Leal Junior
Laboratory of Human Movement
Sports Medicine Institute
University of Caxias do Sul
Rua Francisco Getúlio Vargas, 1130
95070-560, Caxias do Sul, RS, Brazil
E-mail: ecplealj@ucs.br
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