Laser and Light Therapy

PHOTOBIOMODULTATION:

Clinical Applications of
Light Therapy and Cold Laser
in Chiropractic

Wendy Varish, DC, FIANM(us),

DACO, CCSP, CCOHC, MCS-P “Live as if you were to die tomorrow. Learn as if you were to live forever.”
-Mahatma Gandhi

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Key Concepts What is Light Therapy /

Wendy Varish, DC, FACO, CCSP, CCOHC, MCS-P Photobiomodulation?
Howards Grove Chiropractic
516 S. Wisconsin Drive
Howards Grove, WI 53083
What colors/wavelengths
(920) 565-3922 affect the body and how?
fax (920) 565-2142
How is Light Therapy
wvarish@varishchiro.com delivered to the body?

What conditions are best

treated with Light Therapy?

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Chiropractic Scope of Practice

-Wisconsin

▪ Chir 4.03 Practice. The practice of chiropractic is the

application of chiropractic science in the adjustment
of the spinal column, skeletal articulations and
adjacent tissue which includes diagnosis and analysis
to determine the existence of spinal subluxations and
WISCONSIN CT associated nerve energy expression and the use of
procedures and instruments preparatory and
CHIROPRACTIC TECHNICIAN complementary to treatment of the spinal column,
skeletal articulations and adjacent tissue. Diagnosis
STATE REQUIREMENTS and analysis may include physical examination,
specimen analysis, drawing of blood, blood−analysis
and the use of x−ray and other instruments.

www.dsps.wi.gov

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https://docs.legis.wisconsin.gov/code/admin_code/chir/10.pdf
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TAKE NOTE!!!!
446.02(7) (a) Except as provided in pars. (b) and (d), a
chiropractor who is licensed under this chapter may delegate to
a person who is not licensed under this chapter the performance
of adjunctive services if the services are performed by any of
the following under the direct, on-premises
supervision of the chiropractor:
▪ (b) A chiropractor may not delegate to a person who is
not licensed under this chapter the making of a
diagnosis, the performance of a chiropractic
adjustment, the analysis of a diagnostic test or
clinical information or any practice or service that the
examining board, by rule, prohibits a chiropractor from
delegating to a person who is not licensed under this chapter.
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(1r) “Physiotherapy treatment” means the therapeutic
use of physical agents or means, including heat, cold,
light, air, water, sound, electricity, massage therapy or
bodywork therapy, and physical exercise with and
without assistive devices, to treat or manage injury,
disease, bodily defects, or bodily weaknesses.
(2) “Preliminary patient history” means the process of
taking patient vitals and gathering baseline data
regarding a patient, including the nature of the chief
complaint, family history, and medical history. The
“preliminary patient history” is intended to provide a
starting point for further inquiry by the chiropractor into
the patient’s condition.
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© Wendy Varish, DC
CHAPTER 446.02
CHIROPRACTIC EXAMINING BOARD
(7) (a) Except as provided in pars. (b) and (d), a chiropractor who is licensed under this
chapter may delegate to a person who is not licensed under this chapter the
performance of adjunctive services if the services are performed by any of
the following under the direct, on-premises supervision of the chiropractor:
1. A chiropractic technician.
▪NOTE: Subd. 1. is shown as affected by 2017 Wis. Acts
180 and 331 and as merged by the legislative reference bureau
under s. 13.92 (2) (i).
2. A health care professional.
(b) A chiropractor may not delegate to a person who is not licensed under this chapter
the making of a diagnosis, the performance of a chiropractic adjustment, the analysis of a
diagnostic test or clinical information or any practice or service that the examining
board, by rule, prohibits a chiropractor from delegating to a person who is not licensed
under this chapter.
(c) A chiropractor who delegates the performance of a service that is adjunctive to the
practice of chiropractic to a person who is not licensed under this chapter shall verify,
according to standards and procedures established by the examining board by rule, that
the person has adequate education, training and experience to perform the delegated
service safely, and is responsible for that person's performance of the delegated service.
(d) A chiropractor may delegate X-ray services only to a chiropractic radiological
technician or a health care professional acting within the scope of his or her license,
registration, or certification.
▪ NOTE: Par. (d) is shown as affected by 2017 Wis. Acts 180 and 331 and as merged by the legislative reference
bureau under s. 13.92 (2) (i).
Chapter Chir 10
DELEGATION TO CHIROPRACTIC TECHNICIANS
AND CHIROPRACTIC RADIOLOGICAL TECHNICIANS
▪ https://docs.legis.wisconsin.gov/code/admin_code/chir/10.pdf
▪(1) “Adjunctive services” means services
which are preparatory or complementary to
the practice of chiropractic.
▪“Adjunctive services” include the taking and
preparation of a preliminary patient history
and providing physiotherapy treatment.
▪“Adjunctive services” does not include
making a chiropractic diagnosis, analyzing a
diagnostic test, or performing a chiropractic
adjustment.
Chir 12.06 Prohibited practices.
▪(1) A chiropractor shall not delegate to any
chiropractic assistant or other person any
recommendations, analysis, advice, consultation or
dispensing with respect to vitamins, herbs, or nutritional
supplements. Nothing in this subsection may be
construed to prevent chiropractic assistants or
administrative employees from processing
sales of vitamins, herbs, or nutritional
supplements.
▪Chir 12.06(2)(2) After December 1, 2008 a
chiropractor shall not sell, barter, trade or give
away vitamins, herbs or nutritional supplements
unless the chiropractor holds a certificate for
nutritional counseling and except as consistent
with the provisions of this chapter.
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Chiropractic Technician (CT)

- Initial Certification Information What is Light??
▪ Wisconsin will now require a minimum 12-hour core • Light is actually Radiation:
course for initial certification as a Chiropractic
Technician. This new 12-hour course,
called Chiropractic Technician Certification, includes
topics that used to be covered in the “Patient – The process by which energy in various forms
History,” “Preliminary Exams,” and “Physiological travels through space.
Therapeutics Overview” classes.
▪ Note regarding the new rule: All current CTs are
grandfathered in and do NOT need any additional
coursework (beyond the 6 CE hours needed for
renewal).
▪ DSPS CT Home Page
▪ CT Application Form
▪ For additional information and a link to the current
application visit dsps.wi.gov.

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What is Light? What is Light?

• Light (radiation) is a form of energy which
behaves as both a particle and also a
wave.
• Light particles are known as photons.
• Photons are the basic units light. (Just as atoms
are the basic units of matter)
• Photons travel at 186,000 miles per second
(300,000km)– faster than any other known particle.

• Energy is emitted and transmitted in the

form of particles and waves
• Light energy is absorbed by matter.

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Electric and Magnetic

Properties of Light Waves What is Light??

• Terms used to Describe Light and Energy:

– Wavelength (width)
– Amplitude (Intensity - how high)
– Velocity (speed of light)
– Frequency (Rate = speed of light / wavelength)

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

waves are considered electromagnetic in nature; they have
both electrical and magnetic properties.

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Sunlight is composed of every color.

Major Concepts of Light Therapy
When sunlight passes through a prism, the
visible light is separated into a rainbow of
different colors.
• The sun emits energy in a broad spectrum
called the electromagnetic spectrum.

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However, this prism is also separating forms of

radiant energy that is not visible to our eyes .

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• The Sun emits almost every wavelength of Electromagnetic Spectrum

light, even light our eyes can't see.

• Sunlight your eyes CANNOT see(invisible)

• radio
• microwaves
• infrared
• ultraviolet
• X-Rays
• Gamma Rays

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Light and Energy

Velocity
• Velocity (speed of light = 300 million meters per second)
• Wavelength (width) • Electromagnetic radiation always travels at
– Defined as the distance between the peak of one wave
and the peak of the next
the speed of light. (~186,282 miles/sec or
• Frequency
~300,000 km/sec)
– Defined as the number of oscillations or vibrations
occurring in 1 second
– Expressed in hertz (Hz)
– (Frequency = speed of light / wavelength)
• Amplitude • For practical purposes we can say that
– (intensity – how high) radio waves always travel at the speed of
light.

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Wavelength, Frequency,
Amplitude The shorter the wavelength, the higher the
frequency of the radiation.
The higher the frequency, the greater the
Wavelength energy of the wave


Period t

Frequency = number of waves per second

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• Ultraviolet light -- 100-380nm

– Considered ionizing radiation
– This penetrates and breaks covalent bonds
• Visible light approximately 380-740 nm
• Infrared light – approximately 740-1000 nm
– Far infrared to approximately 10,000 nm

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Major Concepts of Light Therapy Effects of Photon Energy

• The photons in the
• Radiation (including visible light in the 380-740nm UV range (200-
wavelengths), is made up of individual packets of 400nm) creates
energy called photons.
chemical excitation
• The energy of a photon relates to its wavelength:
within the cells,
which leads to
– Short wavelength photons are very energetic
alteration of DNA
– Long wavelength photons have lower energy
and RNA
synthesis.

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Effects of Photon Energy

• The photons in the red
range (~630-660nm) are
strong enough to alter the
shape of certain receptor
proteins in the
mitochondrial cell
membrane …. But weak
enough not to damage
the cell (including its
DNA, enzymes, proteins,
and lipids).

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Mitochondria
• Power house of the cell

• Involved with cellular respiration; cell division &

growth; cell differentiation; cell signaling; cell death

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Cytochrome c
• Cytochrome c is highly
soluble protein found in the
intermembrane space of
the mitochondria

• Plays a vital role in cellular

oxidation in both plants and
animals.

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Cytochrome c

• It is an essential
component of the
electron transport chain,
where it carries one
electron.

• It is capable of
undergoing oxidation and
reduction, but it does not
bind oxygen.

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The main function of Cytochrome c in cellular

respiration is to transport electrons from
cytochrome c reductase (Complex III) to
cytochrome oxidase (Complex IV).

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• Cytochrome c is suspected to be the functional

complex in Low Level Light Therapy.
• In LLLT, red light and some near infra-red
wavelengths penetrate tissue and appear
capable of increasing activity of cytochrome c

• Increasing the activity of cytochrome c

increases the metabolic activity of the cell and
frees up more energy for the cells to repair the
tissue.

• Silveira PC, Streck EL, Pinho RA. (2005). "Cellular effects of low power laser therapy
can be mediated by nitric oxide.". Lasers Surg Med. 36 (4): 307–14.

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Cytochrome c Oxidase Cytochrome C Oxidase

It is proposed that Cytochrome C Oxidase (Cox) is
the primary photoacceptor for the red to near IR
range in mammalian cells (Karu and Kolyakov 2005).

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When LLLT (red light) is applied, Nitric Oxide is released from its
Nitric Oxide and Cox binding to heme iron and copper centers in cytochrome c oxidase.
Oxygen is allowed to rebind to these sites.
Respiration is restored and leads to increased ATP synthesis
• In stressed or hypoxic cells, the mitochondria produce
excess Nitric Oxide. (Brown 2001).
• The excess Nitric Oxide bond to Cox (Cytochrome oxidase).
This will competitively displace oxygen and will inhibit
respiration.

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

be measured in cell cultures and in animals.
• It has been proposed that LLLT works by photodiassociating
NO from Cox
– thereby reversing the mitochondrial inhibition of respiration due to
excessive NO binding (Lane 2006).

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Phototherapy

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

-visible red and NIR light absorbed by Cytochrome c
oxidase
• Karu (2010) speculates that photoirradiation may
intensify the transfer of electrons within cytochrome c
oxidase by making more electrons available

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

• Karu TI. (2010) IUBMB Life 62(8) 607-610.
• Silveira PCL, et al., (2009) Journal of Photochemistry and Photobiology B: Biology 95:89-92.

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Therapeutic Application of Red

light at 636 nm….. Therapeutic Window of Light
• Stimulates stressed cells
• Increases the mitochondrial membrane potential
• Increases activity of mitochondrial complex IV
(cytochrome c oxidase)
• Increases ATP and cAMP
• Directs cells into a cell survival pathway
• Restores homeostasis to cells

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Major Concepts of Light Therapy

• The 635nm photon wavelength has just

the right amount of energy to stimulate
mitochondrial membrane proteins.
• This results in an increase of cellular
energy ATP.

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Major Concepts of Light Therapy To Summarize…

• Small amounts of increased cellular energy

• In a clinical setting, we use radiation in the
(ATP) have significant influences on how the cell red (~635-740nm) and infrared (~740-
functions. 1000nm) wavelengths
• Red and infrared are on the opposite side
of the visible spectrum as ultraviolet
• Since the nervous system uses the greatest
amount of ATP energy, the greatest
improvement with laser/light therapy is seen in
neurological function.

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Cell Attracted to Infrared Light

• Ultraviolet (and smaller wavelengths) are

considered ionizing radiation and can be
damaging
• Red and Infrared (when applied correctly)
are therapeutically beneficial on a cellular
level!

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Cell turns and changes direction in response to light

Cell moving around obstacle to get to red light

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Increased Cell Mitosis Stimulated by Red Light

Clinical Benefits
of
Light Therapy

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3 Basic Effects of Light Therapy
• Tissue Repair
• Acceleration of Inflammation
• Pain Control
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Beneficial tissue effects of LLLT can include
almost all the tissues and organs of the body.
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Laser therapy effective for acute and chronic neck pain…
(Reuters Health, 11-12-2009) –Meta-
analysis by Dr. Roberta T. Chow and
colleagues from the University of
Sydney, Australia
• 16 randomized controlled trials (with
820 patients) that compared LLLT
with placebo or with active control
as a treatment for acute or chronic
neck pain.
• Reports that low-level laser therapy
(LLLT) provides rapid relief of acute
neck pain as well as sustained
improvements in chronic neck pain.
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Effects of Light Therapy
• Speeds up inflammation (i.e. the HEALING
process
• Speeds up wound healing / soft tissue repair
• Increases microcirculation
• Decreases pain
• Muscle relaxation
• Increases range of motion
• Increases lymph drainage – improves immune
system function
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APPROVED CLAIMS FOR INFRARED THERAPY
“Infrared therapy emits energy for temporary increase in local
blood circulation, temporary relief of minor muscle and joint aches,
pain and stiffness and relaxation of muscles; for muscle spasms,
and minor pain and stiffness associated with arthritis.”
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Chow, cont.: 11/13/2009 Online issue of The Lancet…
• Data from two of the trials showed that LLLT was
69% more likely than placebo to improve acute neck
pain.
• In five trials looking at chronic neck, LLLT was
roughly four times more likely than placebo to
improve pain.
• In 11 trials that evaluated changes in visual
analogue scale, LLLT was associated with a mean
drop in pain intensity of 19.86 mm.
• Data from seven trials, with up to 22 weeks of
follow-up, showed persistent pain relief for up to 6
months, with a mean reduction in pain intensity of
22.07 mm.
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Infrared therapy for chronic low back

pain: A randomized, controlled trial
George D Gale, MBBS FRCA FRCPC DAAPM, Peter J Rothbart, MD FRCPC, and Ye Li Pain
Research & Management. 2006 Autumn; 11(3): 193–196

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

pain relief obtained by applying infrared (IR) energy to the low back
MECHANISMS
in patients with chronic, intractable low back pain.
METHODS: 39 patients with chronic LBP of > 6 yrs duration were OF
recruited from patients attending the Rothbart Pain Management Clinic,
North York, Ontario. They were randomly assigned to IR therapy or
placebo treatment. 21 patients received IR therapy (800-1200nm) and 18 LIGHT THERAPY
received placebo therapy for 7 wks (1x/wk). The principle measure of
outcome was pain rated on the numerical rating scale (NRS). The pain
was assessed overall, then rotating and bending in different directions.
RESULTS: The mean NRS scores in the tx group fell from 6.9 of 10 to 3
of 10. The mean NRS in the placebo group fell from 7.4 of 10 to 6 of 10.
How does it work?
CONCLUSION: The IR therapy unit used was demonstrated to be
effective in reducing chronic low back pain, and no adverse effects
were observed.

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Clinical Phototherapy Terms

Defined as....
• The delivery of the optimum amount of • Photochemistry
photon energy to the diseased tissue or – How light energy is absorbed by the tissue.
tissues with the intention of modulating the
process of inflammation-repair and • Photobiology
through influencing the neuroimmune – How light energy is used by tissue.
endocrine system

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1st Law of Photochemistry/Photophysiology: Photochemistry of Light Therapy

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

• LEDs have a similar physiological effect on human cells as they

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

Light Emitting Diodes Aid in Wound Healing—

Harry T. Whelan, MD, Professor of Neurology,
Medical College of Wisconsin

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• Cytochrome c oxidase is
the terminal enzyme in the
electron transfer chain.
• It reduces oxygen to water
and utilizes the excess
energy to translocate
protons across the
mitochondrial membrane.
• Cytochrome c oxidase is
the enzyme responsible for
over 90% of the oxygen
consumption by living
organisms in the biosphere.

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• The proton gradient across the

mitochondrial membrane is increased
by RED light stimulation.

• Cytochrome c oxidase:
– photoreceptive site
– red light excites electron states that
drive increased ATP production

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Tissue Repair How do various colors (wavelengths)

of light help with Tissue Repair?
Laboratory and clinical studies have proven
Red/Near InfraRed Light Therapy to be effective
for tissue repair related to:
 Skin wounds
 Ulcers
 Ligament tears
 Tendon Ruptures
 Scars
 Burns
 Bone and Dental Tissue

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• Stimulation of the mitochondria within the cell

Therapeutic Effects of Different with RED light will effectively increase ATP
(energy) production from 2 ATP up to 18 ATP.
Wavelengths of Light

• Red visible light (approximately 633nm) This is a 9-fold increase in cell energy !!
will affect the mitochondria
Imagine what YOU could do with 9x more energy!
• Near Infrared Radiation does not affect the
mitochondria, but does affect the cellular
membrane and stimulates cell proliferation

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Cell Injury
• When a cell is injured, the cell • In order to start the repair process
wants to “shut down”.
following a hurricane (or other natural
disaster, etc.)…
• Think of this as a city that has been
devastated with a hurricane…
– The city shuts down
• The city must be re-opened so that
– Curfews are set supplies and rescue workers can come in
– People/workers are not allowed in or and start the clean-up and repair
out….
– Supply lines for food, water, cleaning
supplies are limited

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• In addition…Red and Infrared Light therapy

Following Cell Injury… increases microcirculation (not vasodilation).
This also helps with wound healing.
• In order to speed up healing, it makes
sense to increase the cell permeability. • This is comparable to making new roads or
detours so that supplies and workers can
• Near INFRARED light will increase cell
access damaged areas.
permeability.
• This, in effect, will speed up the
inflammation process.

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Photo- Photobiology of Light Therapy

chemistry of Light (Photons) Applied to Tissue
Light
Therapy
Absorption in the Mitochondria Light Therapy Promotes:
and Cell Membrane by Chromophores
• Inflammation (speeds up the process)
Elevation of ATP synthesis (Ca2+ and the respiratory chain involved); • Fibroplasia (increase in size and
Increases the energy in the cell. number of fibroblasts)
• Neoangiogenesis (formation of new
DNA & RNA synthesis; protein synthesis; blood vessels)
mitosis and cell proliferation
• Collagen Synthesis
Tissue Repair

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Photobiology of Light Therapy

Photobiology
“Laser radiation at 633 “Photoactivation of Enzymes—The light activation of enzymes is one of
nm has been shown to the fastest growing fields of photobiology, and several reviews on this
stimulate collagen subject have appeared. The importance of the light activation of enzymes
synthesis in is that enzymes are catalysts. In principle, one photon can activate one
enzyme molecule, which in turn can process many thousands of
cutaneous wounds by substrate molecules. This provides a huge amplification factor for
enhancing the initiating a biological response with light. This remarkable amplification
synthesis of Type I factor may be the explanation for why low level laser radiation therapy is
effective. If the effect of one photon can be amplified biologically, then one
and Type II
does not need a lot of photons to produce an effect. One just needs to
procollagen mRNA find the proper wavelength of light to stimulate the proper enzyme,
levels.” which in turn will stimulate the beneficial therapeutic effect.”
The Photobiological Basis of Low Level Laser Radiation Therapy—
The Photobiological Basis of Low Level Laser Kendric C. Smith, Department of Radiation Oncology,
Radiation Therapy— Stanford University School of Medicine
Kendric C. Smith, Department of Radiation Oncology,
Stanford University School of Medicine

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The Inflammatory Cycle Phases of Wound Healing

Injury to tissue Leukocytes
Serotonin released

Fibroblasts
Hematoma Action potential decreases –
nerves fire easier and the area is more Inflammation
sensitive Proliferation Maturation

Formation of new Platelets

blood vessels Bradykinin is released Response

Partial pressure of oxygen Prostaglandins are released

increases in tissue Collagen Accumulation

Fibroplasia Wound Contraction

100
Collagen Synthesis
Starts around Day 3 1 3 10 30
Time in Days
Can take up to 100 days for
Tissue remodeling and tissue to mature completely
contraction

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Phases of Wound Healing

Inflammation- Proliferation –cell Injury
Maturation
speeds up and is not as healing occurs sooner
Platelets
severe and is faster
Photobiology of Mast cells
Light Therapy Hematoma
Monocytes
(Blood Clot)
Macrophages
Response
Lymphocytes
(Released factors:
Collagen Accumulation
Fibroblasts Neoangiogenesis Histamine
(formation of PDGF, FGF,
new blood vessels) Leucotrienes, &
Wound Contraction Other growth factors
-occurs sooner

Neurons
Fibroplasia Fibroblasts
1 3 10 30 (Proliferation of fibroblasts)
Time in Days 100
Nerve Tissue Collagen Synthesis
New Collagen Tissue

Remodeling

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LIGHT THERAPY FOR

PAIN RELIEF
Pain Control
Evidence suggests beneficial effects for many pain conditions
including, but not limited to, the following:

 Carpal Tunnel Syndrome

 Neck and Back Pain
 Acute Phase Herpes Zoster [Shingles]
 Post-Herpetic Neuralgia

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• By increasing the Action Potential, the pain fiber

How does Light Therapy Affect Pain?
• Most common theories involve changing the
cell permeability and increasing the action
potential.
nerves are less sensitive and not as easily
stimulated
• We then are less likely to “feel” as much pain

• This results in
– increased endorphin release
– decreased bradykinin
– decreased C fiber activity
– blocking of Prostaglandin E1 and Bradykinin B in
plasma fibrin levels

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There are three main neurotransmitters

involved in generating the action potential:
Compared to “real
➢ Glutamate – associated with acute pain. Appears to be
life”…. Think of the the dominant neurotransmitter when the threshold of
Action Potential as the pain is first crossed.
Media & News reports.
➢ Substance P –peptide that contains 11 amino acids and
is released by C fibers. It is generally associated with
intense, persistent, chronic pain, and used to relay pain
messages leading to the spinal cord and brain.
If we are unaware of the tragedy (or pain),
then we really don’t think about it and are ➢ Glycine – this is involved in suppressing the
unaffected by it in our daily lives. transmission of pain signals in the dorsal root ganglion.

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Light is scattered into tissue

Areas of high and low light differences

produce temperature and pressure
differences across the cell membrane
Bradykinin is reduced

Cell permeability is affected which affects

the mitochondrial membrane

Endorphins are produced

Pain control due to increasing the Action Potential via:

Increased receptor activity on the cell Pain C-fiber activity is decreased
membrane
-increased endorphin release
-decreased bradykinin Sensitivity is decreased because
the Action Potential is increased
-decreased C fiber activity & production of Substance P
-blocking of Prostaglandin E1 and Bradykinin B in plasma fibrin levels

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The Inflammatory Cycle Photobiomodulation

Injury to tissue Leukocytes
Serotonin released
-Term “Photobiomodulation” was added to
Fibroblasts
Hematoma Action potential decreases –
nerves fire easier and the area is more
the MeSH (Medical Subject Heading) in the
Formation of new Platelets
sensitive
National Library of Medicine’s controlled
blood vessels Bradykinin is released vocabulary in 2014
Partial pressure of oxygen Prostaglandins are released • Defined as…. “the therapeutic use of light,
increases in tissue
absorbed by chromophores found in the
Fibroplasia body, to trigger non-thermal, non-harmful
biological reactions that result in beneficial
Collagen Synthesis
Starts around Day 3
therapeutic outcomes.”*
Can take up to 100 days for
Tissue remodeling and tissue to mature completely
*Anders JJ, Lanzafame RJ, Arany PR. Low-level light/laser therapy vs photobiomodulation therapy.
contraction Photomed Laser Sur. 2015;33(4):183-184

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Terms

• Photochemistry
– How light energy is absorbed by the tissue.

• Photobiology
– How light energy is used by tissue.

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Effects of Light Therapy • "This technology may be the answer for problem wounds
that are slow to heal....diabetic skin ulcers and other
Reviewed… wounds in mice healed much faster when exposed to the
special LEDs in the lab. Laboratory research has shown
• Increases cell permeability that the LEDs also grow human muscle and skin cells up
to five times faster than normal...."
• Increases cell energy
• Increases cell division and repair • "Light close to and in the near-infrared range has
documented benefits for promoting wound healing in
• Increases microcirculation
human and animals. "
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pub
med&dopt=Abstract&list_uids=11568632
• Basically… it helps the healing of cells
quicker with less swelling and less • "Near-infrared irradiation potentially enhances the wound
healing process, presumably by its biostimulatory effects."
scarring. The cells heal faster and http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pub
stronger! med&list_uids=11722751

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Basic Terminology

Treatment • Power
Measured in Watts or milliwatts.
MILLIWATT (mW) = one thousandth of a watt.
Power determines length of treatment

Parameters • Wavelength
NANOMETER (nm) = one billionth of a meter.
Wavelength determines two things - depth of penetration & light
absorption

• Energy
Energy is a function of Power and Time
JOULE (J) = Power (W) x Time (s)
Joule / cm² = 1w x 1 sec / 1 cm²
Energy is the preferred unit for reporting doses of treatment

115 116

3 Parameters
for Light Therapy Light
Absorption
Power

1. Power
Depth of
2. Wavelength for Light Absorption Penetration

3. Wavelength for Depth of Penetration

» Wavelength is measured in nanometers (nm) which

Therapeutic Effect
is one billionth of a meter.

117 118

Power
Power

Power
Determines

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

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

• Power determines Treatment Time

119 120

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Laser and Light Therapy

There is an inverse relationship between power

and treatment time. To achieve a specified dose,
Treatment Time decreases as Power increases.
300 sec

270
240
TREATMENT TIME

210
180
(seconds)

150

Seconds
120
90
60
Comparison of
30
Treatment Times
600 mW
0
60 120 180 240 300 360 420 480 540

POWER (mW)

Dynatronics A B C D E

121 122

Effects of Different Types

Light of Light Therapy
Absorption
• Visible RED light (approximately
633nm) will affect the
mitochondria

Wavelength
Determines • Near Infrared Radiation does not
affect the mitochondria, but does
Light Absorption affect the cellular membrane and
stimulates cell proliferation

123 124

Photochemistry of Light Therapy

Electromagnetic Spectrum
“The first law of photochemistry states that light must be
absorbed before photochemistry can occur. An absorption
spectrum is a plot of the probability that light of a given
wavelength will be absorbed by the system under
investigation.”
The Photobiological Basis of Low Level Laser Radiation Therapy
Kendric C. Smith, Department of Radiation Oncology,
Stanford University School of Medicine

125 126

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Laser and Light Therapy

Cluster Probe using Multiple Wavelengths -

660nm & 880nm
Therapeutic Window of Light
880 nm
(590 - 740)

660 nm
(770 - 990)

"Growth factor production and collagen synthesis may be

improved at wavelengths of 660-680 nm and stimulation of
new small blood vessel growth was produced at 880 nm
wavelength. Such studies have been limited by the constraints
of laser technology, but LED’s offer improved power and area of
distribution at longer wavelengths."
- Dr. Norman Salansky

127 128

Wavelength & Depth of Penetration

Depth of
Penetration

Wavelength • The longer the wavelength of the light

source, the deeper the penetration into the
Determines tissue.

Depth of • The shorter the wavelength of the light

source, the lesser the penetration.
Penetration
129 130

WAVELENGTH = Depth of Penetration Depth of Penetration

WAVELENGTH DEPTH OF PENETRATION

Near Infrared Red Near Infrared

880nm 660nm 880nm

Red
660nm

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

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

that radiation at 633 nm does not penetrate through tissues nearly as
well as does radiation at 830 nm".

131 132

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Laser and Light Therapy

Tissue Penetration of Various Wavelengths Depth of Penetration

Wavelength Color Range Depth of
(nm) Penetration • Systemic effects
(mm)
– Direct and Indirect Effects
150-380 Ultraviolet <0.1
390-470 Violet to Deep ~0.3 • Clothing will decrease penetration
Blue • Must press the unit down if contact is necessary
475-545 Blue to Green ~0.3-0.5
– Law of Cosines
545-600 Yellow to ~0.5-1.0
Orange • Treatment depth increases over time
600-650 Red ~1.0-2.0 • Treatment depth dependent upon wavelength
650-1000 Deep Red to 2.0-3.0
Infrared
– 830nm penetrates deeper than 630 nm
1000-1350 Near to Mid- 3.0-5.0 – Some reflection occurs in unit not in contact with skin
Infrared
1350-12000 Infrared <0.1

133 134

“Direct” vs. “Indirect” Effect of Wavelength and Power determine

Penetration Penetration/Absorption

• “Direct” Effect:
– the biological response that occurs from absorption
of energy by the tissues
• “Indirect” Effect:
– A lessened response that occurs deeper in the
tissues.
– The normal metabolic processes in the deeper
tissues are catalyzed from the energy absorption in
the superficial structures to produce the indirect
effect.

135 136

“Optical Window”
Multiple Wavelengths
660nm & 880nm
• Range of wavelengths where there is
minimal absoption from different
substances – such as water, hemoglobin, 880 nm
32 x 30 mW
and melanin. 660 nm
• Visible range (600-800nm) – absorbed 4 x 4 mW

more by hemoglobin and melanin

– Better for superficial areas
Some modalities use multiple wavelengths –
• Near Infrared range (800-1000nm) – better
allowing for multiple cellular effects.
for deeper musculoskeletal conditions

137 138

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Laser and Light Therapy

LASER DIODE PROBES

Is it all about going deep?
905 nm
laser diode
(5)

• The skin is the largest and heaviest organ

Optical
sensor in the body.
“optode” (4)
• 50% - 90% light is absorbed by the skin.
• Important systemic effects can be gained
660 nm by using lower power
laser diode
(4)

139 140

CELL SENSING™ TECHNOLOGY

Each patient has a unique optical profile determined by their:

Now…
▪ Skin color

▪ Subcutaneous fat thickness

▪ Muscle layer thickness How Do We Apply

▪ Bone density
the Light??
▪ Water hydration

▪ Oxygen perfusion

▪ Vascular density

141 142

What is Laser?
Three Options
for • Light
Generating Therapeutic
• Amplification by
Light
• Stimulated
• Emission of
Laser • SLD • LED • Radiation

143 144

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REVIEW…
Basic Properties of Visible Light Properties of Lasers
(400nm -700nm) • Monochromatic –one
color
• Coherent –all the
same wavelength
• Chromatic
• Collimated –in a
– multiple colors
beam due to the lens
• Incoherent • Nothing else like it in
– travels in all directions nature – purification
• Uncollimated of light
– we can try to collimate with use of filters, etc.

145 146

Four Components of Lasers

Ordinary Light vs. 1. Active Medium
-may be solid crystals (ruby), liquid dyes, gases (CO2 or Helium/Neon), or
Laser Light semiconductors (GaAs). Active mediums contain atoms whose electrons may
be excited an energy source.

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

3. High Reflectance Mirror (Feedback Mechanism)

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

4. Partially Transmissive Mirror (Output Coupler)

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

147 148

Classifications of Lasers
• Revised System --part of the revised IEC 60825
standard. From 2007, the revised system is also
incorporated into the US-oriented ANSI Laser Safety
Standard (ANSI Z136.1).
• Accepted by US Food and Drug Administration (FDA)
on laser products imported into the US.
• The classification of a laser: based on accessible
emission limits (AEL) that are defined for each laser
class.
– AEL is usually a maximum power (in W) or energy (in J) that
can be emitted in a specified wavelength range and exposure
time that passes through a specified aperture stop at a
specified distance.

149 150

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Laser and Light Therapy
Types of Lasers
(Old classification – phased out after 2002)
• Class I Laser: < .5 mW power output
– Not used as a therapeutic device
• Class II Laser : <1 mW power output
– Minimally therapeutic
• Class IIIA Laser : < 5 mW power output
– Lower end of power output, but demonstrate certain therapeutic
properties –primarily photochemical effects
• Class IIIB Laser : < 500 mW power output
– Majority of therapeutic devices. Photobiomodulation. No photothermal
effects. Balance power and safety –no harm to skin or clothing,
potential damage to eyes.
• Class IV Laser : > 500 mW power output
– Photothermal effects - Thermally destructive – some surgical in nature.
151
• Class 1
– A Class 1 laser is safe under all conditions of
normal use.
• Class 1M
– A Class 1M laser is safe for all conditions of
use except when passed through magnifying
optics such as microscopes and telescopes.
Class 1M lasers produce large-diameter
beams, or beams that are divergent
153
• Class 3R
– A Class 3R laser is considered safe if handled carefully, with
restricted beam viewing. Visible continuous lasers in Class 3R
are limited to 5 mW. For other wavelengths and for pulsed
lasers, other limits apply.
• Class 3B
– A Class 3B laser is hazardous if the eye is exposed directly. The
AEL for continuous lasers in the wavelength range from 315 nm
to far infrared is 0.5 W. For pulsed lasers between 400 and
700 nm, the limit is 30 mJ. Other limits apply to other
wavelengths and to ultrashort pulsed lasers. Protective eyewear
is typically required where direct viewing of a class 3B laser
beam may occur. Class-3B lasers must be equipped with a key
switch and a safety interlock.
155
© Wendy Varish, DC
Revised Classes of Lasers
• Class 1
• Class 1M
• Class 2
• Class 2M
• Class 3R
• Class 3B
• Class 4
*classification system as specified by the IEC 60825-1 standard
152
• Class 2
– A Class 2 laser is considered to be safe because the blink reflex
will limit the exposure to no more than 0.25 seconds.
– Only applies to visible-light lasers (400–700 nm). Class-2 lasers
are limited to 1 mW continuous wave, or more if the emission
time is less than 0.25 seconds or if the light is not spatially
coherent. Intentional suppression of the blink reflex could lead to
eye injury. Some laser pointers and measuring instruments are
class 2.
• Class 2M
– A Class 2M laser is safe because of the blink reflex if not viewed
through optical instruments. As with class 1M, this applies to
laser beams with a large diameter or large divergence, for which
the amount of light passing through the pupil cannot exceed the
limits for class 2.
154
• Class 4
– Class 4 is the highest and most dangerous class of
laser, including all lasers that exceed the Class 3B
AEL.
– By definition, a class 4 laser can burn the skin, or
cause permanent eye damage as a result of direct,
diffuse or indirect beam viewing.
– These lasers may ignite combustible materials, and
thus may represent a fire risk, even from possible
reflections of the beam (operator must take great care
to control the beam path).
– Class 4 lasers must be equipped with a key switch
and a safety interlock. Most industrial, scientific,
military, and medical lasers are in this category.
156
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157 158

Clinical Use of Lasers

• Low Level Laser Therapy

LLLT
“Soft” Laser
“Cold” Laser

159 160

Types of Lasers
• InGaAlP 630-685 nm
– Indium Gallium Aluminum Phosphate

• GaAs 904 nm Most commonly used in practice

– Gallium Arsenine

• GaAlAs 780-870 nm
– Gallium Aluminum Arsenine

• Ruby 694 nm
• Nd:YAG 1064 nm
• Ho:YAG 2130 nm
• Er:YAG 2940 nm
• Alexanddrite 720-800 nm
• Dye variable nm
• Rhodamine 560-650 nm
• HeNe 633 nm -used for cauterizing in hospitals
• Argon 350-514 nm
• CO2 10600 nm
• Excimer 193-248, 308 nm

161 162

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Pulsing Laser Light Pulsing Laser Light

• May be “super-pulsed” or “chopped”
• May effect the body like pulsing electrical – (also known as “gated”)
current • Often found in the Class IV lasers in order
• Fewer studies on the effects to reduce thermal effects
• Changes the output – Twice the power not twice the depth (5-10%)
• Few studies to determine optimum
frequency of pulses
– At this time no studies indicate advantage of pulsed
vs. continuous light in reducing pain and inflammation
in humans. More evidence is needed.

163 164

Q: Which frequency of pulses

should be used for various Super-pulsed Lasers
conditions?

A: First -- must differentiate between “chopping” and • Greater depth of penetration may be
“super-pulsing”. achieved in some cases
If a continuous laser is pulsed, the average output power
will be lower. With “chopped” lasers, approximately 50% • Depth of penetration is dependent upon
of power is lost (50% duty cycle). – Wavelength
• There is evidence from cell studies that the pulsing can – Whether the laser is super-pulsed
make a difference, but evidence from clinical studies is
almost absent. – Power output
• Must choose a frequency based upon the anecdotal – Absorption by the tissues
evidence for what is best for the condition(s) being
treated.

165 166

Options for Application of Light LED and SLD

Therapy:

• Laser
– Single or multiple diodes • LED – Light Emitting Diodes
• SLD – Usually more superficial conditions
• LED – Initial studies show that lasers may be more
effective, but both are effective
• SLD – Super Luminous Diode
– Ability to produce several specific
wavelengths for greater spectrum of effects.

167 168

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LED and SLD

• LED (light-emitting diode) – special p-n junction
semi-conductor diode that emits visible light
when an electric current passes through it.

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

section of P-type material, with electrodes on each end.
• Electricity is conducted in only one direction.
• When no voltage is applied to the diode, electrons from the
N-type material fill holes from the P-type material along the
junction between the layers, forming a depletion zone.

169 170

The peaks of the LEDs and optimum

wavelengths are not exact, but spread out
about +/- ~10 nm so there is an overlap of
available LEDs and the biologically optimum
wavelengths.

When the negative end of the circuit is hooked up

to the N-type layer and the positive end is hooked
up to P-type layer, electrons and holes start
moving and the depletion zone disappears.

171 172

A broader treatment area and multiple

Therapeutic Window of Light
wavelengths are possible using LED’s vs. Laser

WAVELENGTH SPECTRUM

173 174

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Laser and Light Therapy

The BIG Controversy…

Laser
vs.
LED and SLD
175 176

LED’s vs. Lasers

• LEDs do not deliver enough power to damage
the tissue, but they do deliver enough energy to
stimulate a response from the body to heal itself.
• With a low peak power output but high duty
cycle, the LEDs provide a much gentler delivery
of the same healing wavelengths of light as does
the laser but at a substantially greater energy
output.
• For this reason, LEDs do not have the same risk
of accidental eye damage that lasers do.

177 178

LED’s vs. Lasers

“LIGHT IS LIGHT”
• LEDs are neither coherent nor collimated and
they generate a broader band of wavelengths
than do the single-wavelength laser.
• This allows a broader surface area of treatment. “If wavelength and dosage are identical,
• The multiplicity of wavelengths in the LED, results will be the same”
contrary to the single-wavelength laser, may
enable it to affect a broader range of tissue
types and produce a wider range of Chukuka Enwemeka, PhD, PT

photochemical reactions in the tissue.

179 180

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Laser and Light Therapy
“LIGHT is LIGHT”
"In these cases, the coherent and noncoherent light (i.e., both lasers
and LED’s) with the same wavelength, intensity and dose provides
the same biological response.”
—T.I. Karu; Cellular Mechanisms of Low-Power Laser Therapy
"In this view, laser therapy is really a form of light therapy, and lasers are
important in that they are convenient sources of intense light at
wavelengths that stimulate specific physiological functions.”
—Jeffrey R. Basford, M.D., Department of Physical Medicine
and Rehabilitation, Mayo Clinic, Rochester, Minnesota.
Low-Energy Laser Therapy: Controversies and New Research Findings
181
“ Wavelength determines depth-of-penetration –
the longer the wavelength the deeper the
penetration.
Qualities unique to lasers such as collimation and
coherence do not affect depth-of penetration since
both are lost once light has penetrated the first
millimeter of tissue.”
–D.C. Laycock, Ph.D., MIPEM, MBES, CGLI.,
“Lasers vs. Super Luminescent Light Emitting Diodes”
183
“By light interaction with a biotissue, coherent properties of laser
light are not manifested at the molecular level. The absorption of
low-intensity laser light by biological systems is a purely
noncoherent (i.e., photobiological) nature. On the cellular level,
the biological responses are determined by absorption of light with
photoacceptor molecules. Coherent properties of laser light are
not important when cellular monolayers, thin layers of cell
suspension as well as the layers of tissue surface are irradiated.
In these cases, the coherent and noncoherent light (i.e., both
lasers and LED’s) with the same wavelength, intensity and dose
provide the same biological response.”
Cellular Mechanisms of Low-Power Laser Therapy (Photobiomodulation)—T.I. Karu
185
© Wendy Varish, DC
"...according to all available data, does not depend
on the coherence of radiation."
"Photobiological Principles of Therapeutic Applications
of Laser Radiation“ published by Yu. A. Vladimirov, et al
in Biochemistry (Moscow)
Volume 69, Number 1 / January, 2004
"Lasers are just convenient machines that produce
radiation; It is the radiation that produces the
photobiological and/or photophysical effects and
therapeutic gains, not the machine."
—Kendric C. Smith; The Photobiological Basis of Low Level Laser Radiation Therapy.
Department of Radiation Oncology, Stanford University School of Medicine
182
"An analysis of published clinical results from the point of view of
various types of radiation sources does not lead to the
conclusion that lasers have a higher therapeutic potential than
LEDs.
...The coherent properties of light are not manifested when the
beam interacts with a biotissue on the molecular level
....The conclusion was that under physiological conditions the
absorption of low-intensity light by biological systems is of purely
noncoherent (i.e., photobiological) nature....specially designed
experiments at the cellular level have provided evidence that
coherent and noncoherent light with the same wavelength,
intensity, and irradiation time provide the same biological
effect.
Successful use of LEDs in many areas of clinical practice also
confirms this conclusion."
Professor Tiina Karu (Biomedical Photonics Handbook, 2003).
184
What about the light scattering
effect of
Laser Light vs. LED Light?
186
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Laser and Light Therapy

Tissue scattering degrades coherent effects of lasers:

“At first glance, the polarization and coherency aspects of laser irradiation are attractive
Laser Light Scatters in Tissue
as sources of biological effects, since (poorly defined) resonant effects might be
hypothesized to occur in the interaction of laser radiation and cellular components.
However, this view may not be tenable since 1) stimulative effects are reported following
irradiation with nonlaser light sources and 2) tissue scattering, as well as the fiber optic
delivery systems used in many experiments, rapidly degrade coherency.

Thus, any effects produced by low-energy lasers may be due to the effects of light in
general and not to the unique qualities of lasers. This view is not difficult to accept when
it is remembered that wavelength-dependent photobiochemical reactions occur
throughout nature and are involved in such things as vision, photosynthesis, tanning, and
vitamin D metabolism. In this view, laser therapy is really a form of light therapy, and
lasers are important in that they are convenient sources of intense light at wavelengths
that stimulate specific physiological functions.”

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

Jeffrey R. Basford, M.D., Department of Physical Medicine and Rehabilitation,
Mayo Clinic, Rochester, Minnesota

187 188

LIGHT IS LIGHT
By the time laser-generated light has passed through
SLD vs. Laser
the first millimeter of tissue, the unique qualities of
“Lasers, however, have some inherent characteristics which make their use in a collimation and coherence are primarily lost.
clinical setting problematic, including limitations in wavelength capabilities and
beam width… Light-emitting diodes (LEDs) offer an effective alternative to
lasers.

Due to the nature of light physics and engineering constraints of laser design, the
range of wavelengths attainable is limited. Due to the coherent beam of light
unique to lasers, their ability to easily treat large areas is also limited.
Development of light emitting diodes (LED) offers an alternative source for light
therapy that can be designed to produce many wavelengths and in an array to
emit light at wavelengths proven, in prior studies of laser light, to speed wound
healing.”

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

Harry T. Whelan, M.D., John M. Houle, B.S., Deborah L. Donohoe, A.S., L.A.T.G., Dawn M. Bajic,
B.S., Meic H. Schmidt, M.D., Kenneth W. Reichert, M.D., George T. Weyenberg, R.N.,
David L. Larson, M.D., Glenn A. Meyer, M.D., James A. Caviness, M.D.

189 190

Key Concepts What is Light Therapy /

Photobiomodulation?

What colors/wavelengths
affect the body and how?

How is Light Therapy

delivered to the body?

What conditions are best

treated with Light Therapy?

191 192

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CONTRAINDICATIONS / WARNINGS for

Light Therapy
Do not use Light Therapy:
• Over and around the uterus during pregnancy.
• Where there is active ongoing hemorrhaging / bleeding tendencies.

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

• Over and around the thyroid gland.
• Cancer (tumors or cancerous areas).
• Over open wounds unless covered with a clear sterile protective
barrier. (An open wound may be treated in the non-contact mode without
protective barrier since the probe is never placed on the wound in the non-
contact mode).
• Over the cardiac region and Vagus nerve.
• Where analgesia/ pain relief may mask progressive pathology.
• Over an area that has been treated with a photosensitizing agent.
• In a patient taking medication that may cause sun-sensitivity (some
antibiotics and St. John’s Wort)
• In a patient with Epilepsy (pulsed light therapy)
• Over the growth plates in children
• Direct irradiation of eyes.

193 194

Indications for Light Therapy

WI Chiropractic
• Tension Headache Scope of Practice
• Migraine Headache
•
•
TMJ
Neck-Shoulder Pain • The practice of chiropractic is the application of
• Frozen Shoulder
• Tennis Elbow or Golfer’s Elbow (Lateral and Medial Epicondylitis)
chiropractic science in the adjustment of the
• Osteoarthritis over the thumb (1 st MCP joint) spinal column, skeletal articulations and
• Low Back Strain
• Sciatica adjacent tissue which includes diagnosis and
• Hip or Knee Arthritis or Injury
• Tendinitis – Achilles analysis to determine the existence of spinal
•
•
Ankle Sprain
Plantar Fascitis
subluxations and associated nerve energy
* Be sure to stay within your scope of
• Wound Repair practice! expression and the use of procedures and
• Burns
• Carpal Tunnel Syndrome instruments preparatory and complementary to
• Sinusitis
• Sports Injuries treatment of the spinal column, skeletal
• Trigger Points
• Shingles
articulations and adjacent tissue.

195 196

Clinical Studies of LLLT: Various resources to find

research…
• >130 double-blind positive studies confirming
the clinical effect of LLLT. • www.pubmed.com
• More than 3000 research reports are published • www.medscape.com
with more than 90% of these studies verifying
• www.laser.nu (Swedish Laser Medical Society)
the clinical value of laser therapy.
• About 250 papers are annually published in • http://www.healinglightseminars.com/librar
peer reviewed scientific papers. y.html
• http://www.walt.nu (World Association for Laser Therapy)
• www.naalt.org (North American Association for Laser Therapy)

197 198

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Low Level Laser Therapy (LLLT)

Applications, Case Studies and Low
Level Laser Research

• MUSCULOSKELETAL PAIN
SYNDROMES (CHRONIC AND ACUTE):
– LLLT has been shown to be effective in a
variety of musculoskeletal conditions and
associated pain presentations.

199 200

Acute low back pain with radiculopathy:

– LLLT was applied behind the involved spine
a double-blind, randomized, placebo-
controlled study
• Konstantinovic LM, et al: Photomed Laser Surg.
2010 Aug;28(4):553-60
• RCT, double-blind, placebo-controlled trial was
performed on 546 patients.
– Group A (182 patients) was treated with nimesulide
200 mg/day and additionally with active LLLT
– Group B (182 patients) was treated only with
nimesulide
– Group C (182 patients) was treated with nimesulide
and placebo LLLT.
segment using a stationary skin-contact
method.
• Pts treated 5x/wk, for a total of 15 treatments, with the
following parameters: wavelength 904 nm; frequency 5000
Hz; 100-mW average diode power; power density of 20
mW/cm(2) and dose of 3 J/cm(2); treatment time 150 sec at
whole doses of 12 J/cm(2).
• The outcomes were pain intensity measured with a visual
analog scale (VAS); lumbar movement, with a modified
Schober test; pain disability, with Oswestry disability score;
and quality of life, with a 12-item short-form health survey
questionnaire (SF-12).
• Subjects were evaluated before and after treatment.
Statistical analyses were done with SPSS 11.5.

201 202

LLLT and acute LBP with LLLT for acute neck pain with
Radiculopathy – 2010 study radiculopathy:
• Pain Med. 2010 Aug;11(8):1169-78
• The objective of the study was to investigate
• CONCLUSIONS: The results of this study clinical effects of low-level laser therapy in
show better improvement in acute LBP patients with acute neck pain with radiculopathy.
This was a double-blind, randomized,
treated with LLLT used as additional
placebo-controlled study.
therapy (Group A).
• The study was carried out between January
2005 and September 2007 at the Clinic for
Rehabilitation at the Medical School, University
Konstantinovic LM, et al of Belgrade, Serbia.
Photomed Laser Surg. 2010 Aug;28(4):553-60

203 204

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Laser and Light Therapy

• The primary outcome measure was pain intensity as

60 pts received a course of 15 treatments over 3
measured by a visual analog scale.
weeks with active or an inactivated laser as a
• Secondary outcome measures were neck movement,
placebo procedure. neck disability index, and quality of life.
LLLT was applied to the skin projection at the • Measurements were taken before treatment and at the
anatomical site of the spinal segment involved end of the 3-week treatment period.
with the following parameters: • Statistically significant differences between groups were
• wavelength 905 nm found for intensity of arm pain and for neck extension.
• frequency 5,000 Hz • LLLT gave more effective short-term relief of arm
• power density of 12 mW/cm(2) pain and increased range of neck extension in
patients with acute neck pain with radiculopathy in
• dose of 2 J/cm(2) comparison to the placebo procedure.
• tx time 120 sec at whole doses 12 J/cm(2). • Pain Med. 2010 Aug;11(8):1169-78

205 206

The effect of 300mW, 830NM laser on

Effect of low-level laser (Ga-Al-As 655 nm) chronic neck pain: a double- blind,
on skeletal muscle fatigue induced by randomized, placebo-controlled study
electrical stimulation in rats

“We conclude that LLLT doses of 0.5 and 1.0 -Chow RT et al. Pain. 2006 Jun 23
J/cm2 can prevent development of muscular • 90 patients with chronic neck pain for at least 3
fatigue in rats during repeated tetanic months up to 15 years (mean duration 11 years)
contractions.” were given 14 treatments with laser over 7
weeks.
Rodrigo Álvaro B. Lopes-Martins,1 Rodrigo Labat Marcos,1 Patrícia Sardinha Leonardo,1 Antônio Carlos
Prianti, Jr.,1 Marcelo Nicolas Muscará,1 Flavio Aimbire,2 Lúcio Frigo,3 Vegard V. Iversen,4 and Jan Magnus
Bjordal5
• At 1 month after treatment, 82% of patients in
J Appl Physiol 101: 283-288, 2006. First published April 20, 2006; the active group achieved a positive response
doi:10.1152/japplphysiol.01318.2005
8750-7587/06 vs. only 29% in the placebo group.

207 208

Low level laser therapy before eccentric Effects of Low-Level Laser Therapy (LLLT) in
exercise reduces muscle damage the Development of Exercise-Induced Skeletal
markers in humans Muscle Fatigue and Changes in Biochemical
Baroni BM, Leal Junior EC, De Marchi T, Lopes AL, Salvador M, Vaz MA. Markers Related to Post-Exercise Recovery
Eur J Appl Physiol. 2010 Jul 3. [Epub ahead of print]
• After LLLT or placebo treatment, subjects performed 75 • J Orthop Sports Phys Ther. 2010 Apr 12. [Epub ahead of
print] Leal Junior EC, Lopes-Martins RA, Frigo L, De Marchi T, Rossi RP, de
maximal knee extensors eccentric contractions (five sets Godoi V, Tomazoni SS, da Silva DP, Basso M, Filho PL, de Valls Corsetti F, Iversen
of 15 reps. VV, Bjordal JM.

• Muscle soreness (visual analogue scale-VAS), lactate • CONCLUSION: We conclude that pre-exercise
dehydrogenase (LDH) and creatine kinase (CK) levels irradiation of the biceps with an LLLT dose of 6 J per
were measured prior to exercise, and 24 and 48 h after application location, applied in 2 locations, increased
exercise. endurance for repeated elbow flexion against resistance,
• LLLT treatment before eccentric exercise was effective in and decreased post-exercise levels of blood lactate, CK,
terms of attenuating the increase of muscle proteins in the and CRP.
blood serum and the decrease in muscle force.

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Effects of superpulsed low-level laser

therapy on temporomandibular joint pain. Clinical Evidence and Guidelines for Laser
• Marini I, Gatto MR, Bonetti GA., Clin J Pain. 2010 Sep;26(7):611-6.
Phototherapy
• OBJECTIVES: A randomized double-blind study was in Tendinopathies and Arthritis
conducted to compare the efficacy of superpulsed low-
level laser therapy (SLLLT) with nonsteroidal anti-
inflammatory drugs in the treatment of pain caused by
temporomandibular joint disorders.

DISCUSSION: Mandibular function improved in all NAALT Conference 2011

SLLLT patients proving the effectiveness in the Jan M. Bjordal
treatment of pain, as demonstrated by a significant Professor ,PT, PhD,
Bergen University College & University of Bergen, Norway
improvement in clinical signs and symptoms of Leeds Metropolitan University, Great Britain
temporomandibular joint disc displacement without
reduction and osteoarthritis at the end of treatment and
stability over a period of 1 month.

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LLLT vs. Steroids Conclusions

1. Most musculoskeletal pain treatment guidelines are confounded
Optimal LLLT enhances tissue repair, by authors´ conflict of interests with the drug industry
while steroids inhibit tissue repair 2. Pain treatment guidelines should be developed by authors
without conflicts of interest with any manufacturer of drugs or
pain relief devices
LLLT Steroids
3. Optimal LLLT has greater short-term efficacy than NSAID and
greater long-term efficacy than steroid injections in
tendinopathies
4. In neck pain, there is no evidence in support of NSAID use,
while LLLT efficacy is supported by firm scientific evidence
5. LLLT is at least equally effective as NSAID in low back pain and
osteoarthritis
6. LLLT has superior safety over NSAID and steroid injections in
musculoskeletal pain
14 days after injury
Pessoa et al. 2005 Photomed Laser Surg Pessoa et al. 2005 Photomed Laser Surg

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Use common and

clinical sense
when reviewing
research!

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FDA Approved Uses

Examples of 510(k) Approvals:
• Chiropractors and CTs who have taken an
approved continuing education class are allowed
to use cold laser and light therapy to treat
patients for conditions within their scope of • approval in 2003 for the indication of
practice “but only if those uses have been “adjunctive use in the temporary relief of
approved by the federal Food and Drug hand and wrist pain associated with
Administration.” (FDA) Carpal Tunnel Syndrome.”
• The FDA approves a cold laser or light therapy
device with what is known as a 510(k) form.
• It is important that the device you are utilizing
within your office have a 510(k) approval and
that you know what indications have been
approved.

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Application Considerations…
510(k) Approval
“Dosage”
• Before buying a laser or light therapy device, ask
the vendor for a copy of the FDA 510(k)
approval to be sure that the device has been • Dosage is often measured in Joules per
approved for the indications which you (the unit or in Joules
doctor) intend to treat within the office.
• Time is dependent upon the power of the
modality being used.
• Always treat within your scope of practice –
regardless of what the modality is approved for. • Too much, too little, poor contact, lack of
absorption…. All reasons for poor
outcomes
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Irradiance vs. Time as

Pulse Structure
“dosage”… • Peak Power (W)
• Irradiance (W/cm2) • Pulse freq (Hz)
Often called Intensity, or Power Density and • Pulse Width (s)
is calculated as • Duty cycle (%)
Irradiance = Power (W)/Area (cm2)
If the beam is pulsed, then the Power should
More accurate representation of dosage than be the Average Power and calculated as
just “time” follows:
Average Power (W) = Peak Power (W) ×
pulse width (s) × pulse
frequency (Hz)
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Arndt-Schultz
Principle

• There is an optimal amount of energy absorption per

unit of time that is beneficial.

• Too much, or too little, loses therapeutic benefits.

• Too little stimuli will not produce effects, whereas

too much stimuli may actually have harmful effects.

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Q: What happens if too Cosine Law

high of a dose is applied?

• A: May have a non-optimal

effect, or worse, a
biosuppressive effect . Radiant energy is more easily transmitted to
deeper tissues if the source of radiation is at
a right angle to the area being radiated.
• For example: The healing of a
wound may take longer time than
normally expected.
• Very high doses on healthy tissues
will not damage them.

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Law of Cosines Conventional Treatment Protocols

• Treatment parameters are designed to get the
required amount of photons to the target tissue
• Given the same amount of J/cm2, a higher dose
over a shorter period of time is preferred.
• Typically treatment will be directed at the injured
area. Apply Laser or Light:
– Over the damaged tissue
– Over the affected nerve roots
– Over the muscle insertion
– Over trigger points or tender points
– Over acupuncture points related to the condition

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Conventional Treatment
Protocols
• When treating points, push down with the laser
or probe to move the blood out of the way to get
better/deeper penetration. (Be careful if using a
high-powered laser that may cause heat!!)

• When treating edema – treat the proximal part

first in order to promote drainage before treating
the distal part.

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Conventional Treatment
Protocols
• In order to get the desired amount of therapy • Treat proximal areas
into a target tissue, the probe or cluster needs to before distal regions
be stationary.
• If the probe/therapy head is moving, then the
treatment time needs to be changed
accordingly.
• In other words, treat multiple points instead of
moving the probe.

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CHALLENGES WITH LLLT

Conventional Treatment Protocols Factors affecting LLLT Efficacy
• Each patient’s tissue characteristics is unique
• Frequency of Treatment: Light therapy • Can change over time as tissue conditions change as a
has been shown to have a cumulative result of treatment
• Therefore, optical profile is affected
effect – every other day to 3x/wk for the
first 2 wks is recommended.
• Chronic conditions may be aggravated in
the first few treatments
• Acute conditions usually respond quicker
than chronic.

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Dosage Recommendations Factors Affecting Absorption

• Refer to user’s manual if backed by research • Skin Color
• Per World Association for Laser Therapy: – Use shorter wavelengths (eg. 980 vs. 810nm)
– For LLLT of 904nm for darker skin
http://www.walt.nu/images/stories/files/Dose_table_90
4nm_for_Low_Level_Laser_Therapy_WALT-2010.pdf
• Patient Size
– For LLLT of 780-860 nm: – Larger dose required for larger patients
http://www.walt.nu/images/stories/files/Dose_table_78
0-860nm_for_Low_Level_Laser_Therapy_WALT-
2010.pdf • Non-contact Mode
– Significant amount of light lost to reflection

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CELL SENSING™ TECHNOLOGY A TECHNOLOGY SOLUTION – WHAT IF?

• TLC 2000 laser system is the new next-generation What if?

patented technology • What if we can increase the power on the probes that will
▪ Delivers an exact dose of energy to a targeted tissue location reduce treatment times?
and structure
▪ Takes into account physical characteristics such as skin
• What if we can increase the overall peak power on the probes
pigmentation, fat and muscle content
that will increase depth of treatment to tissue?
▪ Devised to remember the clinical protocols performed by
practitioners based on a patients physical and, hence, optical
tissue characteristics • What if we can increase the number of probes available for a
practitioner while utilizing a single controller system?

This technology was designed

and patented by:
The University health Network,
Princess Margaret Cancer
Centre, and
Theralase Technologies Inc.
• What if we can develop a device that possesses the ability to
precisely target injured tissue with clinically optimal doses of
energy that is specific for each patient, at the time of each
treatment?

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Applications
Reminder!
• Refer to your User Manual

• The State of Wisconsin restricts the use of • Be sure to check the 510(k) FDA approval
a Light Therapy device to the purpose
specified on the FDA 510(k) statement.
• Class Examples:
• You should have a written copy of the
510(k) statement from the manufacturer.
• The state will not accept “ignorance” as an
excuse.

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Specific Examples: Specific Examples:

• Neck / Shoulder Pain • Lateral Epicondylitis (Tennis Elbow)

• Lateral Epicondylitis – Using Light Cluster Probe or Laser
• Soft Tissue Inflammation – Treatment Areas:
• Insertion site – extensor muscles at the lateral
• Cervical Radiculopathy epicondyle
• Other conditions: TMJ, sinus pressure, – Dosage:
migraine/headaches, plantar fasciitis, tight • 1-3 J/cm2 per point
muscles, etc. • 1-2x/wk for 3-6 wks.
• Consider treatment of cervical region if slow
progress

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Specific Examples:
• Soft Tissue Inflammation (including bursitis,
tendonitis, etc.)
• Review of modalities used for
– Treatment areas:
• Points along inflammed areas – treat proximal
demonstration in this class:
before distal
– Dosage:
• 4-8 J/cm2 per point – select dosage based upon
depth of the target tissue (deeper needs higher
dosage)
• 2-3x/wk

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COMPONENT DESCRIPTION

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Neck / Shoulder Pain Lower Back/ Hip Pain

Lower Back/ Hip Pain

Neck / Shoulder Pain
– Direct skin contact
– Direct skin contact
– Treatment Areas:
– Treatment Areas: • Paravertebrally from T12-S1
• Paravertebrally from C5-T2 • Sacroiliac joint regions
– Dosage:
• 3-4 J/cm2 per point – Dosage:
• 1-2x/wk for 3-4 wks • 5-15 J/cm2 per point
– Also consider treatment over trigger points especially • 1-2x/wk for 3-4 wks – depends upon chronicity
in the trapezius muscle, rhomboids & levator – Also consider treatment over trigger points especially
scapulae in the Q/L, multifidi, glutes and piriformis muscles as
– Chiropractic adjustments as clinically indicated. well as the TFL, ITB and trochanteric bursa
– Chiropractic adjustments as clinically indicated.

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Lateral Epicondylitis Soft Tissue Inflammation

Lateral Epicondylitis (Tennis Elbow)
– Using Light Cluster Probe
– Treatment Areas:
• Insertion site – extensor muscles at the lateral epicondyle and
then distal through the extensor muscle
• Cervical and cervicothoracic muscles, trigger points, etc.
– Dosage:
• 3-4 J/cm2 per point
• 1-2x/wk for 3-6 wks.
• Consider further treatment of cervical region if slow progress
– Include chiropractic adjustment to subluxations at
elbow, wrist and cervicothoracic regions as clinically
indicated, ice massage & extensor
stretches/exercises.
Soft Tissue Inflammation
(including bursitis, tendonitis, etc.)
– Treatment areas:
• Points along inflamed areas – treat proximal before distal
• Include trigger points if indicated
– Dosage:
• 4-8 J/cm2 per point – select dosage based upon depth of the
target tissue (deeper needs higher dosage)
• 2-3x/wk
– Chiropractic adjustments as clinically indicated.

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Sprain / Strain Cervical Radiculitis

Cervicobrachial Radicular Pain

Sprain/ Strain – Direct skin contact
Treatment areas: – Treatment Areas:
• Disc level (4-8 j/cm2)
• Points along injured tissue areas – treat proximal before distal
• Paravertebrally from C5-T4-5 bilaterally if indicated
• Include trigger points if indicated
• At trigger points, tight points– include scalenes, traps,
– Dosage: rhomboids, levator scap
• 4-8 J/cm2 per point – select dosage based upon depth of the • Along dermatome
target tissue (deeper needs higher dosage) – Dosage:
• 3-5x/wk for acute and decrease to 1-3x/wk • 3-4 J/cm2 per point
– Chiropractic adjustments as clinically indicated. • 3x/wk for 3-4 wks
– Chiropractic adjustments & treatment as clinically
indicated.

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TMJ

Temporomandibular Joint Disorder

– Direct skin contact
– Treatment Areas:
• Suboccipital and C2 levels (3-5 j/cm2)
• Directly over the TM joint capsule (multiple spots) 5-8 j/cm2
• At trigger points, tight points– include scalenes, traps,
rhomboids, levator scap
– Dosage:
• 3-5 J/cm2 per point at CS and 5-8 j/cm2 over TMJ
• 3x/wk for 3-4 wks
– Chiropractic adjustments & treatment as clinically
indicated.

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“The sun with all those planets revolving

around it and dependent on it, can still ripen
a bunch of grapes as if it had nothing else in
the universe to do.”
Galileo Galilei (1564-1652)

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