The following studies are regarding the use of Laser Therapy for various conditions. Treatment of repetitive use carpal tunnel syndrome Smith CF, Vangsness CT, Anderson T & Good W (1995)
Proceedings SPIE (1995) 2395; 658-661.
In 1990, a randomized, double-blind study was initiated to evaluate the use of an eight-point conservative treatment program in carpal tunnel syndrome. A total of 160 patients were delineated with symptoms of carpal tunnel syndrome. These patients were then divided into two groups. Both groups were subjected to an ergonomically correct eight-point work modification program. A counterfeit LLLT unit was used in Group A, while an actual LLLT unit was used in Group B. Groups A and B were statistically significantly different in terms of return to work, conduction study improvement, and certain range of motion and strength studies.
Noninvasive laser neurolysis in carpal tunnel syndrome Weintraub MI, MD, FACP
Muscle Nerve (1997) 20:1029-1031.
The peripheral nervous system is photosensitive providing the scientific rationale for this study, which determines the efficacy and safety to laser light exposure in 30 cases with CTS. Nine joules of energy over 5 points (7-15 treatments) reversed CTS in 77% of cases with three-fold normalization of CMAP. A photobiologic response was seen in 80% of nerves. This unique and novel approach is cost-effective and will play a role in future management of CTS.
Comparison between low level laser therapy, transcutaneous electro-neural stimulation, visible incoherent polarised light and placebo in the treatment of lateral epicondylitis: A pilot clinical study on 120 patients Simunovic Z and Trobonjaca T
Lasers in Surgery and Medicine (2002) Supplement 14, Atlanta, Georgia
The aim of this pilot study was to compare the efficacy of Low Level Laser therapy (LLLT), Transcutaneous Electro-Neural Stimulation (TENS), visible incoherent polarized (VIP) light and placebo in the treatment of lateral epicondylitis-tennis elbow. The patient population (n=120) was randomly allocated into four groups according to treatment applied. The therapy lasted three weeks per each treatment modality, where total number of treatments per patient was twelve (5+4+3 per three weeks). LLLT was applied as trigger points technique in all patients, using an infrared diode laser in a dosage of 4 J/point. TENS was applied using gummy plates in the same sizes and by exactly measuring the amount of mA, mV and Hertz in all patients. VIP light was applied in a dosage of 4/J.cm2 . Placebo was applied by using a laser device with no active laser emission. All patients suffered from chronic form of lateral epicondylitis, with x-ray proved no changes on the cervical spine. The outcome measurement was focused on the level of pain relief, estimated according to the Visual Analogue Scale (VAS). The results have demonstrated that the highest percentage of pain relief was achieved in patients treated with LLLT (over 45% of lased patients reported 90-100% pain relief). The second best pain relief was reported in the group of patients treated with TENS. None of the patients treated with VIP light reported 90-100% pain relief. The worst results were reported in placebo group (<20% of average pain relief). This pilot study indicates epicondylitis compared to other treatments modalities and placebo. Carefully conducted multicenter, randomized, placebo controlled clinical studies are recommended for assessing the efficacy of LLLT, TENS and VIP light in the treatment of chronic form of lateral epicondylitis.
Efficacy of low power laser therapy in fibromyalgia: a single-blind, placebo-controlled trial Gur A, Karakoc M, Nas K, Cevik R, Sarac J, Demir E.
Lasers in Medical Science (2002) 17(1):57-61.
Low energy lasers are widely used to treat a variety of musculoskeletal conditions including fibromyalgia, despite the lack of scientific evidence to support its efficacy. A randomized, single-blind, placebo-controlled study was conducted to evaluate the efficacy of low-energy laser therapy in 40 female patients with fibromyalgia. Patients with fibromyalgia were randomly allocated to active (GaAs) laser or placebo laser treatment daily for two weeks except weekends. Both the laser and placebo laser groups were evaluated for the improvement in pain, number of tender points, skinfold tenderness, stiffness, sleep disturbance, fatigue, and muscular spasm. In both groups, significant improvements were achieved in all parameters (p<0.05) except sleep disturbance, fatigue and skinfold tenderness in the placebo laser group (p>0.05). It was found that there was no significant difference between the two groups with respect to all parameters before therapy whereas a significant difference was observed in parameters as pain, muscle spasm morning stiffness and tender point numbers in favour of laser group after therapy (p<0.05). None of the participants reported any side effects. Our study suggests that laser therapy is effective on pain, muscle spasm, morning stiffness, and total tender point number in fibromyalgia and suggests that this therapy method is a safe and effective way of treatment in the cases with fibromyalgia.
The clinical efficacy of low-power laser therapy on pain and function in cervical osteoarthritis. Oezdemir F, Birtane M, Kokino S
Clinical Rheumatology (2001) 20(3): 181-184
Pain is a major symptom in cervical osteoarthritis (COA). Low-power laser (LPL) therapy has been claimed to reduce pain in musculoskeletal pathologies, but there have been concerns about this point. The aim of this study was to evaluate the analgesic efficacy of LPL therapy and related functional changes in COA. Sixty patients between 20 and 65 years of age were clinically and radiologically diagnosed COA were included in the study. They were randomized into two equal groups according to the therapies applied, either with LPL or placebo laser. Patients in each group were investigated blindly in terms of pain and pain-related physical finds, such as increased paravertebral muscle spasm, loss of lordosis and range of neck motion restriction before and after therapy. Functional improvements were also evaluated. Pain, paravertebral muscle spasm, lordosis angle, the range of neck motion and function were observed to improve significantly in the LPL group, but no improvement was found in the placebo group. LPL seems to be successful in relieving pain and improving function in osteoarthritic diseases.
Low level laser therapy for tendinopathy. Evidence of a dose-response pattern Bjordal J M, Couppe´ C, Ljunggren E
Physical Therapy Reviews (2001) 6: 91-99
To investigate whether low-level laser therapy can reduce pain from tendinopathy, the authors performed a review of randomized placebo-controlled trials with laser therapy for tendinopathy. Validity assessment of each trail was done according to predefined criteria for location-specific dosage and irradiation of the skin directly overlying the affected tendon. The literature search identified 78 randomised control trials of which 20 included tendinopathy. Seven trials were excluded for not meeting the validity criteria on treatment procedure and trial design. 12 of the remaining 13 trials investigated the effect of laser therapy for patients with subacute and chronic tendinopathy and provided a pooled mean effect of 21%. If results from only the nine trials adhering to assumed optimal treatment parameters wereincluded, the mean effect over placebo increased to 32%. Laser therapy can reduce pain in subacute and chronic tendinopathy if a valid treatment procedure and location-specific dose is used.
Clinical evaluation of the low intensity laser antialgic action of GaAIAs (wavelength=785 nm) in the treatment of the temporomandibular disorders Sanseverino NTM, Sanseverino CAM, Ribeiro MS et al.
Lasers in Medicine and Surgery (2002) Supplement 14, Atlanta, Georgia.
The improved outcome of laser therapy, if higher doses are given, is documented in the study by Sanseverino 10 patients with pain and limitation of movements of the jaw were treated by 785 nm GaAIAs laser, dose 45 J/cm2. The joint and tender points in the masticatory and otherwise involved muscles was applied three times per week during three weeks. A control group of 10 patients was given sham laser therapy. The evaluation was performed through subjective pain assessment and measurement of the movements of the jaw. There was a significant improvement in the laser group only.
Treatment of medial and lateral epicondylitis - tennis and golfer's elbow - with LLLT: a multicenter double blind, placebo-controlled clinical study on 324 patients. Simunovic Z, Trobonjaca T, Trobonjaca Z
Journal of Clinical Laser Medicine and Surgery (Jun 1998) 16(3):145-151.
Among the other treatment modalities of medial and lateral epicondylitis, LLLT has been promoted as a highly successful method. The aim of this clinical study was to assess the efficacy of LLLT using trigger points (TPs) and scanner application techniques under placebo-controlled conditions. The current clinical study was completed at two Laser Centers (Locarno, Switzerland and Opatija, Croatia) as a double-blind, placebo controlled, crossover clinical study. The patient population (n=324), with either medical epicondylitis (Golfer's elbow; n=50) or lateral epicondylitis (Tennis elbow; n=274), was recruited. Unilateral cases of either type of epicondylitis (n=283) were randomly allocated to one of three treatment groups according to the LLLT technique applied: (1) Trigger points; (2) Scanner; (3) Combination Treatment (i.e., TPs and scanner technique). Bilateral cases of either type of epicondylitis (n=41) were subject to crossover, placebo-controlled conditions. Laser devices used to perform these treatments were infrared (IR) diode laser (GaAIAs) 830 nm continuous wave for treatment of TPs and He-Ne 632.8 nm combined with IR diode laser 904 nm, pulsed wave for scanner technique. Energy doses were equally controlled and measured in Joules/cm2 either during TPs or scanner technique sessions in all groups of patients. The treatment outcome (pain relief and functional ability) was observed and measured according to the following methods: (1) short form of McGill's Pain Questionnaire (SF-MPQ); (2) visual analogue scales (VAS); (3) verbal rating scales (VRS); (4) patient's pain diary; and (5) hand dynamometer. Total relief of the pain with consequently improved functional ability was achieve in 82% of acute and 66% of chronic cases, all of which were treated by combination of TPs and scanner technique. The best results were obtained using combination treatment (i.e., TPs and scanner technique). Good results are obtained from adequate treatment technique correctly applied, individual energy doses, adequate medical education, clinical experience, and correct approach of laser therapist. Under-and over irradiation dosage can result in the absence of positive therapy effects or even opposite, negative (e.g., inhibitory) effects. The data gave further evidence of the efficacy of LLLT in the management of lateral and medial epicondylitis.
Wound healing of animal and human body sport and traffic accident injuries using low-level therapy treatment; a randomized clinical study of seventy-four patients with control group. Simunovic Z, Ivankovich AD, Depolo A.
Journal of Clinical Laser Medicine and Surgery (2000) Apr;18(2):67-73
Background and Objective: The main objective of current animal and clinical studies was to assess the efficacy of low level laser therapy (LLLT) on wound healing in rabbits and humans. Study Design/Materials and Methods: In the initial part of our research we conducted a randomized controlled animal study, where we evaluated the effects of laser irradiation on the healing of surgical wounds on rabbits. The manner of the application of LLLT on the human body are analogous to those of similar physiologic structure in animal tissue, therefore, this study was continued on humans. Clinical study was performed on 74 patients with injuries to the following anatomic locations: ankle and knee, bilaterally, Achilles tendon; epicondylitis; shoulder; wrist; interphalangeal joints of hands, unilaterally. All patients had had surgical procedure prior to LLLT. Two types of laser devices were used: infrared diode laser (GaAIAs) 830 nm continuous wave for treatment of trigger points (TPs) and HeNe 632.8 nm combined with diode laser 904 nm pulsed wave for scanning procedure. Both were applied as monotherapy during current clinical study. The results were observed and measured according to the following clinical parameters: redness, heat, pain, swelling and loss of function, and finally submitted to statistical analysis via chi2 test. Results: After comparing the healing process between two groups of patients, we obtained the following results: wound healing was significantly accelerated (25%-35%) in the group of patients treated with LLLT. Pain relief and functional recovery of patients treated with LLLT were significantly improved comparing to untreated patients. Conclusion: In addition to accelerated wound healing, the main advantages of LLLT for postoperative sport-and traffic-related injuries include prevention of side effects of drugs, significantly accelerated functional recovery, earlier return to work, training and sport competition compared to the control group of patients, and cost benefit.
LLLT with trigger points technique: a clinical study on 243 patients Simunovic Z
Journal of Clinical Laser Medicine and Surgery (Aug. 1996) 14(4):163-167.
Among the various methods of application techniques in LLLT (He-Ne 632.8 nm visible red or infrared 820-830 nm continuous wave and 904 nm pulsed emission) there are very promising "trigger points" (TPs), i.e., myofascial zones of particular sensibility and of highest projection of focal pain points, due to ischemic conditions. The effect of LLT and the results obtained after clinical treatment of >200 patients (headaches and facial pain, skeletomuscular ailments, myogenic neck pain, shoulder and arm pain, epicondylitis, tenosynovitis, low back and radicular pain, Achilles tendonitis) to whom the "trigger points" were applied were better than we had ever expected.. According to clinical parameters, it has been observed that the rigidity decreases, the mobility is restored (functional recovery), and the spontaneous or induced pain decreases or even disappears, by movement, too. LLLT improves local microcirculation and it can also improve oxygen supply to hypoxic cells in the TP areas and at the same time, it can remove the collected waste products. The normalization of the microcirculation, obtained due to laser applications, interrupts the "circulus vitiosus" of the origin of the pain and its development (Melzak: muscular tension->pain->increased tension->increased pain, etc.). Results measured according to VAS/VRS/PTM: in acute pain, diminished >70%; in chronic pain >60%. Clinical effectiveness (success or failure) depends on the correctly applied energy dose - over/under dosage produces opposite, negative effects on cellular metabolism. We noted no negative effects and the use of analgesic drugs could be reduced or completely excluded. LLLT can be used as monotherapy or as a supplementary treatment to other therapeutic procedures for pain treatment.
Laser-Accelerated
INFLAMMATION/PAIN
REDUCTION AND HEALING
by Richard Martin, BS, CLT Injured cells and tissues have greater affinity for LLLT than healthy cells and tissues. Effect of laser amplifies more easily in damaged cells and tissue because the particular emitted enzymes encourage receipt of LLLT treatment. LLLT in the treatment of inflammation, pain and healing is a highly integrated process, but the author separates those processes categorically for identification. Acute Inflammation Reduction (flowchart provided in the original article) - After the injury, tissues initiate a series of biological responses and cellular membrane reactions which manifest in a combination of edema, inflammation, pain and functional debility. LLLT mediates the situation by: (1) Stabilization of cellular membrane; (2) Enhancement of molecule ATP production and synthesis; (3) Stimulated vasodilation via increased Histamine, Nitric Oxide and Serotonin; (4) Beneficial acceleration of leukocytic activity; (5) Increased Prostaglandin synthesis; (6) Reduction in Interleukin-1; (7) Enhanced lymphocyte response; (8) Increased angiogenesis; (9) Temperature modulation; (10) Enhanced superoxide dismutase levels; and (11) Decreased C-reactive protein and neopterin levels. Pain Reduction (flowchart provided in the original article) - A body of medical evidence justifies a conclusion that LLLT reduces pain by combination of processes: (1) Increase in b-Endorphins; (2) Blocked depolarization of C-fiber afferent nerves; (3) Increased nitric oxide production; (4) Increased nerve cell action potential; (5) Axonal sprouting and nerve cell regeneration; (6) Decreased Bradykinin levels; (7) Increased release of acetylcholine; and (8) Ion channel normalization. Tissue Healing - LLLT enhances wound healing through a series of processes: (1) Enhanced leukocyte infiltration; (2) Increased macrophage activity; (3) Increased neovascularization; (4) Increased fibroblast proliferation; (5) Keratinocyte proliferation; (6) Early epithelialization; (7) Growth factor increases; (8) Enhanced cell proliferation and differentiation, and (9) Greater healed wound tensile strength.
Thermographic study of Low Level Laser Therapy for Acute-Phase Injury
Yoshimi Asagai, M.D.1, Atsuhiro Imakiire, M.D.2, Toshio Ohshiro, M.D.3, 1. Shinano Handicapped Children`s Hospital Shimosuwa, Nagano, Japan 2. Department of Orthopaedic Surgery, Tokyo Medical University Shinjuku, Tokyo, Japan 3. Japan Medical Laser Laboratory, Shinanomachi, Tokyo, Japan
Acute-phase injury is generally treated by localized cooling of the region, and rarely by the active use of low level laser therapy (LLLT) in Japan. Thermographic studies of acute-phase injury revealed that circulatory disturbances at the site of trauma occurred due to swelling and edema on the day following the injury, and that skin temperature was high at the site of the trauma and low at the periphery. Following LLLT, circulatory disturbances rapidly improved, while temperature in the high temperature zone around the site of trauma fell by 3 degrees on the average, but at the periphery the low temperature rose by 3 degrees on the average to nearly normal skin temperature. Clinically, swelling and edema improved. LLLT was also useful in treating necrosis of the skin in the wound area and in accelerating healing of surgical wounds of paralytic feet, which are prone to delayed, wound healing and also wounds due to spoke injury. LLLT is useful in treating swelling and edema in acute-phase injury and in accelerating healing of surgical wounds.
The Biological Effects of Laser Therapy and Other physical Modalities on Connective Tissue Repair Processes
Chukuka S. Enwemeka, P.T., Ph.D., FACSM, G. Kesava Reddy, Ph.D., Department of Physical Therapy and Rehabilitation Sciences, University of Kansas Medical Center, Kansas City, KS 66160-7601, USA
Connective tissue injuries, such as tendon rupture and ligamentous strains, are common. Unlike most soft tissues that require 7-10 days to heal, primary healing of tendons and other dense connective tissues take as much as 6 - 8 weeks during which they are inevitably protected in immobilization casts to avoid re-injury. Such long periods of immobilization impair functional rehabilitation and predispose a multitude of complications that could be minimized if healing is quickened and the duration of cast immobilization reduced. In separate studies, we tested the hypothesis that early function, ultrasound, 632.8 nm He-Ne laser, and 904 nm Ga-As laser, when used singly or in combination, promote healing of experimentally severed and repaired rabbit Achilles tendons as evidenced by biochemical, biomechanical, and morphological indices of healing. Our results demonstrate that: (1) appropriate doses of each modality, i.e., early functional activities, ultrasound, He-Ne and Ga-As laser therapy augment collagen synthesis, modulate maturation of newly synthesized collagen, and overall, enhance the biomechanical characteristics of the repaired tendons. (2) Combinations of either of the two lasers with early function and either ultrasound or electrical stimulation further promote collagen synthesis when compared to functional activities alone. However, the biomechanical effects measured in tendons receiving the multi-therapy were similar, i.e., not better than the earlier single modality trials. Although tissue repair processes in humans may differ from that of rabbits, these findings suggest that human cases of connective tissue injuries, e.g., Achilles tendon rupture, may benefit from appropriate doses of He-Ne laser, Ga-As laser, and other therapeutic modalities, when used singly or in combination. Our recent metaanalysis of the laser therapy literature further corroborate these findings.
Effects of visible NIR low intensity laser on implant osseointegration in vivo. Laser Med Surg Abstract issue, 2002: 11.
Blay A, Blay C C, Groth E B et al.
The effects of 680 and 830 nm lasers on osseointegration was studied by Blay. 30 adult rats were divided into three groups; two laser groups and one control. The rats in the two laser groups had pure titanium Frialit-2 implants implanted into each proximal metaphysis of their respective tibias, inserted with a 40 Ncm torque. The initial stability was monitored by means of a resonance frequency analyzer. Ten irradiations were performed, 48 hours apart, 4 J/cm2 on two points, starting immediately after surgery. Resonance frequency analysis indicated a significant difference between frequency values at 3 and 6 weeks, as compared to control. At 6 weeks the removal torque in the laser groups was much higher than in the control group.
Low-energy laser irradiation promotes the survival and cell cycle entry of skeletal muscle satellite cells. J Cell Science. 2002; 115: 1461-1469.
Shefer G, Partridge T A, Heslop L et al.
Shefer has demonstrated that HeNe laser can stimulate cell cycle entry and the accumulation of satellite cells around isolated single fibers, grown under serum-free conditions. It is demonstrated that laser therapy promotes the survival of muscle fibers and their adjacent cells, as well as cultured myogenic cells, under serum-free conditions that normally lead to apoptosis.
The Japanese Experience in Sumo Wrestling
Toshio Ohshiro (1), Katsumi Sasaki (2), Shouhei Yasuda (2), Shunji Fujii (3), Takafumi Ohshiro (3), Takeo Touno (4), Shigeru Matsumoto (4) 1) Japan Medical Laser Laboratory , 2) Oshiro Clinic, 3) Keio University Dept. of Plast. and Reconst. Surgery, 4) Nihon Sport Science University.
Sumo Wrestling is the only national endorsed sport in Japan. Professional Sumo Wrestlers belong to the Nihon Sumo Kyokai (Japan Sumo Wrestling Association). Sumo Wrestling meets bimonthly, 6 times a year. Each Sumo sessions has 15 days where the Wrestlers must wrestle for 15 consecutive days against 15 different opponents. This national sport is popular and there are many Sumo Wrestling Teams for all ages. The strongest person from these teams are recruited to the Nihon Sumo Kyokai and become professional. Most Sumo Wrestlers have some symptoms such a pain due to prior injuries and their hard training. We recently had the opportunity to perform Laser Therapy on 6 Sumo Wrestlers who were complaining of various symptoms. We would like to explain about the removal of those symptoms by LLLT, and how Laser therapy affected their performance. All 6 performed better both subjectively and objectively while their symptoms were alleviated by Laser and their winning rate increased following treatment. We will discuss major and common injuries associated with Sumo Wrestling and the treatment thereof. We would like to comment on treatment methodology and statistical analysis.
Laser and Sports Medicine in Plastic and Reconstructive Surgery.
Junichiro Kubota M.D. Department of Plastic and Reconstructive Surgery, Kyorin University School of Medicine, Tokyo, Japan.
Flap survival with diode laser therapy: Skin flap or graft surgery are major procedures in Plastic and Reconstructive Surgery. Skin flap necrosis has been a problem for us. The author reported on the enhanced blood flow following the low reactive laser therapy in skin flaps. The 830 nm diode laser (20 - 60 mw) irradiated flaps showed a greater perfusion, a greater number of blood vessels, and a higher rate of survival areas than the control flaps in the rat models and clinical cases. Improvement of wound healing with diode laser therapy: The diode laser therapy was indicated for traumatic skin ulcers received from sport activities and traffic accidents which had proved resistant to conservative treatment. The diode laser system has a wavelength of 830 nm. and output power of 150or 1000mw in continuous wave. The diode laser was applied with the non-contact method to the area on the wound for one minute once a day every day during the treatment period. The diode laser was used successfully for the rapid enhanced healing of traumatic skin ulcers in clinical cases
Discussion: The majority of patients hope to avoid undergoing a surgical operation, trying instead with conservative treatments for injuries. The diode laser therapy improved the flap circulation and wound healing of severe skin ulcers. And this therapy has been applied for temporomandibular joint pain and we have obtained favorable results. The diode laser therapy has proved to be particularly effective for pain attenuation. The diode laser therapy may well offer an additional convenient, safe and side-effect free method. On the other hand, the Q-switched Nd:YAG laser system applied to the traumatic tattoos, achieving consistently good results concomitant with easy and safe operation, successfully achieving excellent lightening of the target lesions.
BIOMODULATORY EFFECTS OF LLLT ON BONE REGENERATION
Antonio L.B. Pinheiro1, Marilia G. Oliveira2, Pedro Paulo M. Martins3, Luciana Maria Pedreira Ramalho4, Marcos A. Matos de Oliveira5, Aurelício Novaes Júnior and Renata Amadei Nicolau 1 School of Dentistry, Department of Diagnostic and Therapeutics, Universidade Federal da Bahia, Salvador, BA, 40110-150,Brazil; 2 School of Dentistry, Post-Graduate Program on Oral and Maxillofacial Surgery, Pontifícia Universidade Católica do Rio Grande do Sul, Porto Alegre, RS, Brazil;
3School of Dentistry, University of Pernambuco, Camaragibe, 50000-000,Brazil; 4School of Dentistry, Laser Center, Universidade Federal da Bahia, Salvador, BA, 40110-150,Brazil; 5Lecture, Institute of Research and Development (IP&D) Universidade Vale do Paraíba (UNIVAP) - São José dos Campos,SP, 12244-000, Brazil
Tissue healing is a complex process that involves local and systemic responses. The use of Low Level Laser Therapy (LLLT) for wound healing has been shown to be effective in modulating both local and systemic response. Usually the healing process of bone is slower than that of soft tissues. The effects of LLLT on bone are still controversial as previous reports show different results. This paper reports recent observations on the effect of LLLT on bone healing. The amount of newly formed bone after 830nm laser irradiation of surgical wounds created in the femur of rats was evaluated morphometricaly. Forty Wistar rats were divided into four groups: group A (12 sessions, 4.8J/cm2 per session, 28 days); group C (three sessions, 4.8J/cm2 per session, seven days). Groups B and D acted as non-irradiated controls. Forty-eight hours after the surgery, the defects of the laser groups were irradiated transcutaneously with a CW 40mW 830nm diode laser, (f~1mm) with a total dose of 4.8J/cm2. Irradiation was performed three times a week. Computerized morphometry showed a statistically significant difference between the areas of mineralized bone in groups C and D (p=0.017). There was no significant difference between groups A and B (28 days) (p=0.383). In a second investigation, we determined the effects of LLLT on bone healing after the insertion of implants. It is known that dental implants need four and six months period for fixation on the maxillae and on the mandible before receiving loading. Ten male and female dogs were divided into two groups of five animals that received the implant. Two animals of each group acted as controls. The animals were sacrificed 45 and 60 days after surgery. The animals were irradiated three times a week for two weeks in a contact mode with a CW 40mW 830nm diode laser, (f ~1mm) with a total dose per session of 4.8J/cm2 and a dose per point of 1.2J/cm2. The results of the SEM study showed better bone healing after irradiation with the 830nm diode laser. These findings suggest that, under the experimental conditions of the investigation, the use of LLLT at 830nm significantly improves bone healing at early stages. It is concluded that LLLT may increase bone repair at early stages of healing.
ADVANCES IN LASER THERAPY FOR BONE REPAIR
A. Barber 1, JE. Luger 1, A. Karpf 1 , Kh. Salame 2 , B. Shlomi 3, G. Kogan 3, M. Nissan 4, M. Alon 5, and S. Rochkind 2,6.
1Foot & Ankle Unit, Departments of Orthopedic Surgery "B", Departments of 2Neurosurgery, 3Oral and Maxillofacial Surgery, and 5Rehabilitation, 6Division of Peripheral Nerve Reconstruction, Tel Aviv Sourasky Medical Center, Tel Aviv University; 4Ben Gurion University, Israel. During the last decade, it was discovered that low-power laser irradiation has stimulatory effects on bone cell proliferation and gene expression. The purposes of this review are to analyze the effects of low- power laser irradiation on bone cells and bone fracture repair, to examine what has been done so far, and to explore the additional works needed in this area. The studies reviewed show how laser therapy can be used to enhance bone repair at cell and tissue levels. As noted by researchers, laser properties, the combinations of wavelength and energy dose need to be carefully chosen so as to yield bone stimulation.
A comparative study of the effects of low laser radiation on mast cells in inflammatory fibrous hyperplasia colored or not colored by the toluidine blue. Laser Surg Med. Abstract issue 2002, abstract 301 Sawazaki I, Ribeiro M S, Mizuno L T et al. A
The effect of toluidine blue and laser in combination has been studied by Sawazaki. Eight patients with inflammatory fibrous
hyperplasias caused by ill-fitting dentures were selected for the study. Each hyperplasia was randomly divided into three areas. One was surgically removed without any treatment; one was treated by a 670 nm laser, 15 mW, 8 J/cm2 and then removed. The third part was dyed with TBO, and laser treated in the same way as part two. Mast cell degranulation in the control specimens was average 49´%, in the laser specimens 87% and in the combined TBO/laser specimens 88%. With these parameters the TBO did not have any additional effect.
Low level laser therapy for tendinopathy. Evidence of a dose-response pattern. Physical Therapy Reviews. 2001; 6: 91-99. Bjordal J M, Couppé C, Ljunggren E.
To investigate whether low-level laser therapy can reduce pain from tendinopathy, the authors performed a review of randomized placebo-controlled trials with laser therapy for tendinopathy. Validity assessment of each trial was done acc. to predefined criteria for location-specific dosage and irradiation of the skin directly overlying the affected tendon. The literature search identified 78 randomized control trials of which 20 included tendinopathy. Seven trails were excluded for not meeting the validity criteria on treatment procedure and trial design. 12 of the remaining 13 trials investigated the effect of laser therapy for patients with subacute and chronic tendinopathy and provided a pooled mean effect of 21%. If results from only the nine trials adhering to assumed optimal treatment parameters were included, the mean effect over placebo increased to 32%. Laser therapy can reduce pain in subacute and chronic tendinopathy if a valid treatment procedure and location-specific dose is used.
TREATMENT OF MEDIAL AND LATERAL EPICONDYLITIS - TENNIS AND GOLFER¨S ELBOW - WITH LOW
LEVEL LASER THERAPY: A MILTICENTER, DOUBLE - BLIND, PLACEBO - CONTROLLED CLINICAL STUDY ON 324 PATIENTS. Zlatko Simunovic, M.D. F.M.H. (1), Tatjana Trobonjaca, M.D. (2), Zlatko Trobonjaca, M.D. (3). (1) Pain Clinic, Laser Center, Locarno, Switzerland; (2) Laser Center, Opatija, Croatia; (3) Department of Physiology and Immunology, Faculty of Medicine, University of Rijeka, Croatia.
Among the other treatment modalities of medial and lateral epicondylitis, Low Level Laser Therapy (LLLT) has been promoted as highly successful method. The aim of this clinical study was to determine the efficacy of LLLT on medial and lateral epicondylitis using Trigger Points (TPs) and scanning application technique under placebo - controlled conditions in two independent Laser Centers located at Locarno, Switzerland and Opatija, Croatia. Unilateral cases of either type of epicondylitis (n=283) were randomly allocated to one of three treatment groups according to the LLLT technique applied: (1) TPs; (2) scanning; (3) combination of TPs and scanning. Bilateral cases of either type of epicondylitis (n=41) were subject to crossover, placebo-controlled conditions. Laser devices used in all groups of patients were infrared diode laser (GaAlAs) 830 nm continuous wave for treatment of TPs and HeNe 632,8 nm combined with infrared diode laser 904 nm. Pulsed wave for scanning technique. Treatment outcome was observed and measured according to the following methods: (1) short form McGill's Pain Questionnaire; (2) Visual Analogue Scales; (3) Verbal Rating Scales; (4) Patient's pain diary; and (5) hand dynamometer. The result have demonstrated that total relief of pain with consequently improved functional ability was achieved in 82% of chronic cases all of which were treated by combination of TPs and scanning technique. The current clinical study provides further evidence of the efficacy of LLLT in the management of lateral and medial epicondylitis.
LOW LEVEL LASER THERAPY OF SOFT TISSUE INJURIES UPON SPORT ACTIVITIES AND TRAFFIC
ACCIDENTS: A MULTICENTER, DOUBLE-BLIND, PLACEBO-CONTROLLED CLINICAL STUDY ON 132 PATIENTS.
Zlatko Simunovic, M.D., F.M.H. (1), Tatjana Trobonjaca, M.D. (2) (1) Pain Clinic-Laser Center, Locarno, Switzerland; (2) 2 Laser Center, Opatija, Croatia. (3)
The aim of current multicenter clinical study was to assess to efficacy of Low Level Laser Therapy (LLLT) in the treatment of sport- and traffic-related soft tissue injuries compared to the placebo and classical physiotherapeutic procedures. This study was conducted in two centers located in Locarno, Switzerland (n=94) and Opatija, Croatia (n=38). Two types of irradiation techniques were used: (1) direct, skin contact technique for treatment of Trigger Points (TPs) where infrared diode laser (GaAIAs) 830 nm continuous wave was applied; and (2) scanning technique for irradiation of larger surface area with use of Helium Neon (HeNe) laser 632.8 nm combined with infrared diode laser 904 nm pulsed wave. Control group of patients was treated with classical physiotherapeutic procedures. Results were evaluated according to the clinical parameters like: hematoma, edema, heat, pain and loss of function. All findings were scored and statistically analyzed according to the chi-square test. The results have demonstrated that the recovery process was accelerated (35-50%) in 85% of patients treated with LLLT compared to the control group of patients, what is especially important by professional athletes. The advantages of LLLT observed in this study appear to be efficient withdrawal of all clinical symptoms, functional recovery, no risks or side effects, painlessness, good toleration by any age and sex, cost benefit, etc. The results and advantages obtained proved once again the efficacy of LLLT as new as successful way in the treatment of soft tissue injuries.
Biostimulation of human chondrocytes with Ga-Al-As diode laser: 'In vitro' research. Artificial Cells, Blood Substitutes, and Immobilization Biotechnology. 2000; 28(2):193-201. Morrone G, Guzzardella G A, Tigani D et al.
The aim of the study was to verify the effects of lllt performed with GaAlAs (780 nm, 2500 mW) on human cartilage cells in vitro. The cartilage sample used for the biostimulation treatment was taken from the right knee of a 19-year-old patient. After the chondrocytes were isolated and suspended for cultivation, the cultures were incubated for 10 days. The cultures were divided into four groups. Groups I, II, III were subject to biostimulation with the following laser parameters: 300J, 1W, 100Hz,10 min. exposure, pulsating emission; 300J, 1W, 300Hz, 10 min. exposure, pulsating emission; and 300J, 1W, 500Hz, 10 min. exposure, pulsating emission, respectively. Group IV did not receive any treatment. The laser biostimulation was conducted for five consecutive days. The data showed good results in terms of cell viability and levels of Ca and Alkaline Phosphate in the groups treated with laser compared to the untreated group. The results obtained confirm our previous positive in vitro results that the GaAlAs Laser provides biostimulation without cell damage.
LOW LEVEL LASER THERAPY IN TENDON INJURIES? - A REVIEW OF IN VITRO AND IN VIVO TRIALS
J.M. Bjordal, C. Couppe University of Bergen, Dept. Physiotherapy Science, Bergen, Norway
Purpose: To investigate the effect of different laser treatment parameters on fibroblast inflammation and production of collagen fibers.
Material : Controlled in vitro or in vivo trials with low level laser therapy (LLLT) Method : Literature search for trials published after 1980 using LLLT on Medline, Embase, Cochrane Library and handsearch of physiotherapy journals in English and Scandinavian languages. Optimal treatment parameters regarding timing, treatment frequency, dose and power density at target tissue were synthesized.
Results : The literature search identified 31 controlled trials with LLLT on collagen tissue. Three in vitro trials were performed on stretch-induced and inflammation in fibroblast cultures and five in vitro trials were performed on collagen production. Optimal dose and power density for inhibition of prostaglandin PGE2 and interleukin 1- beta production was found to be 3.2-6.3 J/cm2 and 5.3 mW/cm2 measured at the target fibroblast cells after 5 days of irradiation. Data on upper range limits for anti-inflammatory treatment were inconclusive. Optimal dose and power density for collagen production was found to be in the range 0.2-2.0 J/cm2 and 2 .20 mW/cm2 measured at the target fibroblast cells. Daily treatment for 2 weeks with optimal parameters yielded a maximum increase in collagen production of 37%. The results from three in vivo trials showed similar increase in collagen production. Doses in excess of 4.5 J/cm2 and power densities higher than 30 mW/cm2 inhibited fibroblast metabolism and decreased collagen production.
Conclusion : There is evidence of a dose-response pattern for LLLT in the treatment of tendon injuries during the proliferative phase of regeneration.
LOW LEVEL LASER THERAPY CAN BE EFFECTIVE FOR TENDINITIS: A META-ANALYSIS
J.M. Bjordal, C. Couppe University of Bergen, Dept. Physiotherapy Science, Bergen, Norway
Purpose: To investigate if low level laser therapy (LLLT) with previously defined optimal treatment parameters can be effective for tendinitis. Material : Randomized controlled trials with LLLT for tendinitis. Method : Literature search for trials published after 1980 using LLLT on Medline, Embase, Cochrane Library and handsearch of physiotherapy journals in English and Scandinavian languages. Only trials that compared laser exposure of the skin directly over the injured tendon with optimal treatment parameters with identical placebo treatment were included.
Results: The literature search identified 77 randomized controlled trials with LLLT, of which 18 included tendinitis. Three trials were excluded for lack of placebo control, of which one trial was comparative; another lacked patients with tendinitis in the treatment group, while the last unwittingly gave the placebo group active treatment. Four trials used too high power density or dose, and three trials did not expose the skin directly overlying the injured tendon. The remaining eight trials were included in a statistical pooling, where the mean effect of LLLT over placebo in tendinitis was calculated to 32% [25.0-39.0, 95% CI].
Conclusion: Low level laser therapy with optimal treatment procedure/parameters can be effective in the treatment of tendinitis.
THE USE OF LASER THERAPY AND ADDITIONAL THERAPEUTIC MODALITIES AFTER ARTHROSCOPY OF THE KNEE AT ALPINE SKI TEAM Lilic Alen, physiotherapist; 2Kozlevcar _ivec Maja, dr. med. spec.fiz.reh.med.; 3Marcan Radoslav, dr.med., spec.ortop 1FIZIO, Ilirska Bistrica, Slovenija, 2Iskra Medical, Ljubljana, Slovenija, 3Ortopedska bolni_nica Valdoltra, Slovenija In the present article we will review different kind of injuries in the alpine ski sport and we will concentrate on the injuries of the ligamentar part of the knees and meniscs in slovenian ski team. After the description of the injuries follows detailed presentation of the rehabilitational procedures from the first day of the injury till the return in to the competition arena. We will try to explain the modalities of the rehabilitational procedures and their influence in the tissues, their main and side effects. Our main attention will be focused to the use of the biostimulative laser of higher power - 1,2 W and wave length of 830 nm and it's influence on the velocity of recovery in the patients and their success in following competitions.
WOUND HEALING IN ANIMALS AND HUMANS WITH USE OF LOW LEVEL LASER THERAPY-TREATMENT OF OPERATED SPORT AND TRAFFIC ACCIDENT INJURIES:
A Randomized Clinical Study. 1Zlatko Simunovic, M.D., F.M.H., 2Anthony D. Ivankovich, M.D., 3Arsen Depolo, M.D., Ph.D
1Department of Anesthesiology and Intensive Care Unit, La Caritá Medical Center, Laser Center, Locarno, Switzerland 2Department of Anesthesiology, Rush Presbyterian St. Luke's Medical Center, Chicago, Illinois, USA 3Department of Surgery, Medical School, University of Rijeka, Rijeka, Croatia
Background and Objective: The main objective of current animal and clinical studies was to assess the efficacy of Low Level Laser Therapy (LLLT) on wound healing in rabbits and humans.
Study Design/Materials and Methods: A randomized controlled study in rabbits initially evaluated the effects of laser irradiation on the healing of surgical wounds. The application of LLLT to human tissues is comparable to animal tissues of similar physiological structure, so a clinical evaluation was subsequently conducted. After surgical therapy for injuries involving the ankle and knee bilaterally, Achilles tendon, epicondylus, shoulder, wrist, or interphalangeal joints of hands unilaterally, LLLT was used in 74 patients for 18 days. Infrared diode laser (GaAlAs) 830 nm continuos wave was used for treatment of Trigger Point (TP) and HeNe 632.8 nm combined with diode laser 904 nm pulsed wave laser for scanning procedures, both applied as monotherapy during the current clinical study. The presence of redness, heat, pain, swelling and loss of function were assessed.
Results: Wound healing was significantly accelerated (25-35%) in the group of patients treated with LLLT. Pain relief and functional recovery of patients treated with LLLT were significantly improved comparing to untreated patients.
Conclusion: In addition to accelerated wound healing, main advantages of LLLT of postoperative sport- and traffic- related injuries are reduced exposure to side effects of drugs, significantly accelerated functional recovery, earlier return to work, training and sport competition, with cost benefit compared to control patients.
Asagai reports on the use of GaAlAs (100 mW) laser treatment in a group of 1000 patients with cerebral palsy.
The laser reduces muscle spasm and increases the mobility of the muscles. Although the duration of the LLLT effect was limited to one to several hours, it can be applied in conjunction with conventional functional therapies, thereby enhancing the effects of the latter. Asagai Y et al. Application of low reactive-level laser therapy (LLLT) in the functional training of cerebral palsy patients. Proc. 2nd Congress World Assn for Laser Therapy, Kansas City, September 1998; p. 99-100.
Bjordal J M. Low level laser therapy can be effective for tendinitis: a meta-analysis.
A literature search identified 77 randomized clinical trials with LLLT, of which 18 included tendinitis. Three trials were excluded for lack of placebo control, of which one was comparative, another lacked patients with tendinitis in the treatment group, while the last unwittingly gave the placebo group active treatment. Four trials used too high power density or dose, and three did not expose the skin directly overlying the injured tendon. The remaining eight trials were included in a statistical pooling, where the mean effect of LLLT over placebo in tendinitis was calculated to 29.5% (19.5-39.0). LLLT with optimal treatment procedure/parameters can be effective in the treatment of tendinitis.
Laser's effect on bone and cartilage change induced by joint immobilization: an experiment with animal model. Akai M, Usuba M, Maeshima T, Shirasaki Y, Yasuoka S. Lasers Surg Med. 1997. 21(5): 480-4.
The influence of low-level (810 nm)) laser on bone and cartilage during joint immobilization was examined with rats' knee model. The hind limbs of 42 young Wistar rats were operated on in order to immobilize the knee joint. They were assigned to three groups 1 wk after operation; irradiance 3.9 W/cm2, 5.8 W/cm2, and sham treatment. After 6 times of treatment for another 2 wk both hind legs were prepared for 1) indentation of the articular surface of the knee (stiffness and loss tangent), and for 2) dual energy X-ray absorptiometry (bone mineral density) of the focused regions. The indentation test revealed preservation of articular cartilage stiffness with 3.9 and 5.8 W/cm2 therapy. Soft laser treatment may possibly prevent biomechanical changes by immobilization.
LLLT is as well documented as NSAIDs and steroid injections for shoulder tendinitis/bursitis and epicondylaglia.
The Norwegian physiotherapist Jan M Bjordal published his thesis .Low level laser therapy in shoulder tendinitis/bursitis, epicondylalgia and ankle sprain. in 1997, at the Division of Physiotherapy Science, University of Bergen. It has also been published in Physical Therapy Reviews. 1998; 3: 121-132.
Here is the Conclusion of the thesis: .A systematic review has been performed on the effect of LLLT for three diagnoses. LLLT was evaluated on similar criteria for methodological assessments of trials as previously established for medical interventions. No evidence was found to indicate that randomized controlled trials on LLLT for tendinitis/bursitis of the shoulder, lateral epicondylalgia and ankle sprains were methodologically inferior to RCTs on medical interventions. The clinical effects of LLLT were found to be supported by scientific evidence regarding short (0-4 weeks) and medium term (<3 months) efficacy for subacute or chronic lateral epicondylitis, and short term efficacy (>3 months) for subacute or chronic lateral epicondylitis, and short term efficacy (> 3 months) for subacute or chronic shoulder tendinitis/bursitis. The evidence of effect from LLLT for acute ankle sprain in inconclusive, although there seems to be a slight tendency in favor of LLLT. Adverse effects of LLLT are rarely seen and only in minor forms (nausea, headache) compared to medication, where more serious gastrointestinal discomfort or ulcers are not uncommon. It has also been shown that trials in favor of active treatment had more treatments per week than the trials showing no difference in effect. In short one could say that LLLT should be used much in the same way as NSAID are used for short periods of time. Most trials showing significant effects used an IR 904 nm laser, but some results in favor of IR lasers with wavelengths of 780, 820 and 830 nm were also observed. Clinical effects of LLLT were best in subacute conditions. In chronic conditions a higher dosage and more treatments seem to be needed. The results of the high quality LLLT trials were all in favor of treatment with confidence intervals not including zero, and the trials came from several different research groups. Evidence was found to be at the highest or the second highest level depending on what level of clinical significance is decided according to the classification of Oxman (1994) and McQuay (1997). The review found little support for the alleged large placebo effects of LLLT. In chronic cases the placebo effect is probably less that 10%, after the natural history of the complaints is taken into account..
In the .Summary of discussion on clinical effect estimates for LLLT. the author writes:
.The majority of the included LLLT-trials found significant clinical effect from LLLT. Seven of the eleven LLLT-trials with acceptable methods included calculations of 95% confidence limits above zero, and one LLLT-trial on ankle sprain included zero (Axelsen & Bjerno 1993). The clinical effect estimates from LLLT-trials for shoulder tendinitis/bursitis are similar or higher than for NSAID or steroid injections. For lateral epicondylalgia estimates for short term clinical effects are similar or lower for LLLT than for steroid injections, but medium clinical effect estimates are similar or higher for LLLT. Recurrence of symptoms in lateral epicondylalgia is less likely after LLLT than after steroid injections. Evidence of clinical effects from ankle sprain is inconclusive. Adverse effects from LLLT are seldom seen and they appear less serious than for patients treated with NSAID and steroid injections..
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In a rapidly developing technological workplace, the human body has a hard time keeping pace with the demands of modern machines and repetitive motions. The cumulative daily effect of fast, forceful and seemingly harmless movements of one's shoulders, elbows, wrists and hands while operating computers, cutting meat, assembling automobiles, or handling packages, adversely affects workers and industries worldwide.