Laser therapy (physiotherapy)

Laser therapy physiotherapy

1. Laser therapy Physiotherapy

2. What is Laser Therapy? L ight A mplification by the S timulated E mission of R adiation Compressed light of a wavelength from the cold, red part of the spectrum of electromagnetic radiation Monochromatic - single wavelength, single color Coherent - travels in straight line Polarized - concentrates its beam in a defined location/spot

3. Electromagnetic Spectrum

4. History Albert Einstein – 1 st described this theory that was transformed in to laser therapy By the end of the 60’s, Endre Mester (Hungary) - was reporting on wound healing through laser therapy In early 1960’s, the 1 st low level laser was developed. In Feb. 2002, the MicroLight 830 (ML830) received FDA approval for Carpal Tunnel Syndrome Treatment (research treatment) Laser therapy – has been studied in Europe for past 25-30 years; US 15-20 years

5. LASER Regulation LASERs - classified by the FDA’s Center for Devices & Radiological Health based on the Accessible Emission Limit (AEL). Class Levels 1-4 1 = incapable of producing damaging radiation levels (laser printers & CD players) 2 = low-power visible lasers (400-700 nm wavelength, 1 mW ) 3 = medium-power lasers - needs eye protection 3a – up to 5 mW 3b** – 5 mw-500 mW 4 = high-power lasers – presents fire hazard (exceeds 500 mW )

6. Types of Lasers Low Medical Lasers Soft Lasers Subthermal Energy – 1-500 mW Therapeutic (Cold) lasers produce maximum output of 90 mW or less 600-1000 nm light High Surgical Lasers Hard Lasers Thermal Energy – 3000-10000 mW

7. Types of Lasers Four categories of lasers Crystal & Glass ( solid - rod) Synthetic ruby & others (synthetic ensures purity) Gas ( chamber ) – 1961 HeNe , argon, CO 2 , & others ( HeNe under investigation) Semiconductor ( diode - channel) - 1962 Gallium Arsenide (GaAs under investigation) Liquid (Dye) - Organic dyes as lasing medium Chemical – extremely high powered, frequently used for military purposes

8. Laser Generators Components of a generator: Power supply – electrical power supply that can deliver up to 10,000 volts & 100’s amps Lasing medium – gas, solid, liquid Pumping device – high voltage, photoflash lamps, radio-frequency oscillators or other lasers (pumping is used to describe the process of elevating an orbiting electron to a higher, excited energy level) Optical resonant cavity – contains lasing medium

9. Low level laser therapy Laser Therapy Acronym is Light Amplification by Stimulated Emission of Radiation Therapy. Low-level laser therapy (LLLT) is a pain-free, non-invasive, affordable tool used by physical therapists throughout the healing process that is becoming more prevalent in PT practices nationwide . Laser Therapy works on the principle of inducing a biological response through energy transfer, in that the photonic energy delivered in to the tissue by the laser modulate the biological processes within the tissue. So it is called PHOTOBIOMODULATION.

10. Low level laser therapy continue…… The photobiomodulation can have both: Photobiostimulative effect Photobioinhibitive effect The L a ser Therapy e f fectiven e ss based o n t h e p r i nci p le o f ‖ T he Ar n d t - Schultz law‖ of biomodulation. The Arndt-Schultz law of Biomodulation infers that low dosage of photonic energy will stimulate the biological process in the tissue the higher dosage of photonic energy will inhibit the biological process in the tissue.

11. Low level laser therapy continue…… Laser Generators Lasers require the following components to be operational. 1- Power supply: Lasers use an electrical power supply that can potentially deliver up to 10,000 V and hundreds of amperes. 2- Lasing medium (material): This is the material that generates the laser light. It can include any type of matter: gas, solid, or liquid 3- Pumping device (excitation mechanism or energy source): "Pumping" is the term used to describe the process of elevating an orbiting electron to a higher, "excited" energy level Fig. (68) . This creates the population inversion that is essential for laser operation. The pumping device may be high voltage, photoflash lamps, radio-frequency oscillators, or other lasers . 4- Optical resonant cavity: This contains the reflecting mirrors (full or partial reflecting

12. Low level laser therapy continue…… Properties of laser Monochromaticity: Laser light is concentrated in a narrow range of wavelength (same wavelength and same color). Coherence: All photons emitted in one phase (same time and distance) . Collimation ( directionality): In one direction and non-spread ( Focusing the beam of light on certain point).

13. Lamb light Vs Laser light Many wavelengths Multidirectional Incoherent Mon o ch r oma t ic Directional Coherent

14. Classification of laser According to nature of the material placed between two reflecting surfaces. According to intensity. According to hazards.

15. Classification of laser continue… 1. According to nature of the material placed between two reflecting surfaces. a ) Crystal lasers (solid state lasers) include Ruby crystal (aluminum oxide and chromium) Neodymium crystal is embedded in yttrium- aluminium garnet ( Nd:YAG ) lasers. Gas lasers include Helium neon ( HeNe ) Argon Carbon dioxide (CO2) Semiconductor or diode laser Gallium arsenide (GaAs) Liquid laser Polyphenyle - Oxazine Chemical laser Laser with high intensity not used therapeutically but used in industrial production

16. Classification of laser continue… 2. According to intensity. High power: known as "hot" lasers because of the thermal responses they generate. These are used in the medical realms in numerous areas, including surgical cutting and coagulation, ophthalmologic, dermatologic, oncologic, and vascular specialties. Low power: known as "low power laser therapy" or "low level laser therapy". It used for wound healing and pain management. These lasers produce a maximal output of less than 1 milliwatt (1 mW = 1/1000 W) causing photochemical, rather than thermal effects. No tissue warming occurs.

17. Classification of laser continue… 3. According to hazards. a) Class 1 (less than 0.5 mW) Visible and non-visible No eye or skin danger Laser printers, car entry, CD players No heating/no healing Safe in all uses unless focused through magnifier a) Class 2 (less than 1 mW) Visible Safe for short periods on eyes and extended on skin Safe because blink reflex limits retina exposure No healing/no heating.

18. Classification of laser continue… a) Class 3 (1mW to 500 mW) Visible and invisible. Helium neon (HeNe). Galium Arsenide (GaAs)—infrared. GaAluminumAs (GaAlAs)—infrared. MPE can be exceeded with limited effects (skin). Protective eye ware if direct viewing of beam . a) Class 4 (more than 500 mW) Increases tissue temperature--can burn Dehydrates tissue Coagulates protein Thermolysis CO2, Argon, YAG laser Eye danger can result from indirect or reflected beam

19. Classification of laser continue… Most Commonly Used Lasers Helium neon ( HeNe ) Gallium arsenide (GaA s) .

20. Classification of laser continue… 1- Helium neon (HeNe) The HeNe gas laser uses a gas mixture of primarily helium with neon in a pressurized tube. This creates a laser in the red portion of the electromagnetic spectrum with a wavelength of 632.8 nm. The power output of the HeNe can vary, but typically runs from 1.0 to 10.0 mW, depending on the gas density used.

21. Classification of laser continue… 2- Gallium arsenide (GaAs) The GaAs lasers utilize a diode to produce an infrared (invisible) laser at a wavelength of 904 nm. Diode lasers are composed of semiconductor silicone materials that are precisely cut and layered. An electrical source is applied to each side, and lasing action is produced at the junction of the two materials. The cleaved surfaces function as partially reflecting surfaces that will ultimately produce coherent light. The 904-nm laser is delivered in a pulsed mode because of the heat produced at the junction of the diode chips. N.B: Diode laser can single beam or multisource cluster beam

22. Physiological effects 1- Reducing Pain There is an increase in serotonin ( 5-HT) levels (inhibit pain transmission to brain and from nociceptors). There are also increases in Beta Endorphins, which decrease pain sensation. Decrease bradykinins ( is an inflammatory mediator. It is a peptide that causes blood vessels to dilate (enlarge )) which can be prevalent in injured tissue, induce pain sensation by stimulating nociceptive afferents. Increase release of Acetylcholine: Acetylcholine helps normalize nerve signal transmission in the autonomic and somatic pathways.

23. Physiological effects continue… 2- Reducing Inflammation Enhancement of ATP by stimulation of mitochondria. Stabilization of the Cellular Membrane. Acceleration of Leukocytic Activity Increased Angiogenesis ( is the physiological process through which new blood vessels form by vascular endothelial cells in proliferation (growth of new tissue)).

24. Physiological effects continue… 3- Promoting Tissue Healing Increased macrophage activity. Increased fibroblast proliferation. Keratinocyte proliferation. ( Keratinocyte: the outermost layer of the skin The p r i m ary func t ion of ker a tino c yte s i s t h e fo r m ation o f a bar r i e r against en v iron m en t a l damage by pathogenic bacteria, fungi, parasites, and viruses, heat, UV radiation ) Early epithelialization. Growth factors increase ( Growth factors: act on stimulating cellular growth, proliferation and healing. Examples are fibroblast growth factors and vascular endothelial growth factors stimulate blood vessel differentiation (angiogenesis).

25. Physiological effects continue… 4- Recovery from nerve injury Accelerate nerve regeneration ( by stimulation of Nerve growth factor ) Increase frequency of action potential. Increase rate of nerve conduction. 5- Increase bone and cartilage formation ( by stimulation of bone morphogenetic proteins that stimulate bone cell differentiation)

26. Indications of laser therapy 1. Dermatological disorders Wounds Ulcers 2 . Pain and inflammation in orthopedic and sport cases. Ankle sprain Chronic Low back pain Tennis Elbow Plantar fasciitis Frozen shoulder 3. Neurogenic pain Trigeminal neuralgia

27. Treatment procedures 1) Preparation of the patient: • a) The skin in the area of electrode placement should be cleaned by saline water, soap or Vaseline to lower skin resistance. • b) Special gels, sprays or water is applied to the skin as a condition medium for better stimulation. • c) Electrodes should be fixed in position, using mending tapes to maintain good contact throughout the treatment period

28. Clinical application of laser Calculation of laser dose . Penetration of laser. Techniques of laser.

29. Clinical application of laser Calculation of laser dose dependent on : The output power of the laser in mw. The time of exposure in seconds. The beam surface area of the laser in cm2 (area of irradiation). Equations: Energy or total energy (Joule) = Watts X Seconds \ Time of exposure (seconds) = Joules/Watts.

30. Clinical application of laser Depth of Penetration HeNe laser energy Absorbed rapidly in the superficial structures, especially within the first 2-5 mm of soft tissue. The response that occurs from absorption is termed the "direct effect." HeNe laser has an indirect effect on tissues up to 8-10 mm. The GaAs, which has a longer wavelength, is directly absorbed in tissues at depths of 1-2 cm and has an indirect effect up to 5 cm.

31. 3 ) Laser treatment techniques There are two main techniques 1. Contact technique: GaAs only for trigger points or around wound . Non-contact technique: for HeNe and GaAs for superficial wounds or stimulation of wound bed Clinical application of laser

32. Basford, J.  Low intensity laser therapy: Still not an established tool.  Lasers in Surgery and Medicine . 1995;16:331–342. Basford , JR, Sheffield, CG, Harmsen , WS.  Laser therapy: A randomized, controlled trial of the effects of low-intensity Nd:YAG laser irradiation on musculoskeletal back pain.  Archives of Physical Medicine and Rehabilitation . 1999;80:647–652. Basford , JR, Sheffield, CG, Mair , SD, Ilstrup , DM.  Low-energy helium neon laser treatment of thumb osteoarthritis.  Archives of Physical Medicine and Rehabilitation . 1987;68:794–797. Bertolucci , LE, Grey, T.  Clinical analysis of midlaser versus placebo treatment of arthralgic TMJ degenerative joints.  Journal of Craniomandibular Practice . 1995;13:26–29. Bradley P, Groth E and Rajab A (1998): Low intensity laser therapy for hard tissue problems of the oro -facial region. Proceedings of the 6th International Congress on Lasers in Dentistry. London, pp. 103–105 .. Brosseau , L, Welch, V, Wells, G, deBie , R, Gam, A, Harman, K, Morin, M, Shea , B, Tugwell , P.  Low level laser therapy (classes I, II and III) for the treatment of osteoarthritis. The Cochrane Library, Issue 2 . Update Software, Oxford; 2000. Reference