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What is low level laser therapy ?

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Low low level laser therapy (low level laser therapy) sometimes known as Low Level Light Therapy or Photobiomodulation (PBM) is a low intensity light therapy. The effect is photochemical not thermal. The light triggers biochemical changes within cells and can be compared to the process of photosynthesis in plants, where the photons are absorbed by cellular photoreceptors and triggers chemical changes.

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What is History of low level laser therapy?

In 1903, Dr. Nils Finsen was awarded a Nobel Prize for his contribution to the treatment of diseases, especially lupus vulgaris, with concentrated light radiation . In 1960, Professor Maiman TH built the first working red ruby laser , but it was not until 1967 when Mester E et al. was able to demonstrate the phenomenon of “laser bio stimulation” . In 1999, Whelan H et al. presented his work on the medical applications of light emitting diodes (LED) for use on the NASA space station . Subsequently over 400 Phase III randomized, double-blind, placebo-controlled trials have been published, with over 4000 laboratory studies of low level laser therapy. (Pubmed.gov)

A laser is a device that generates light through a process of optical amplification based on the stimulated emission of electromagnetic radiation. There are four main classes of lasers as defined by the International Engineering Consortium (IEC standard 60825.) These classes indicate potential danger the radiation is to the eye.

Class 1/1M – CD player
Class 2/2M – laser pointer
Class 3R/3B – low level laser therapy and CD and DVD writers
Class 4 – Surgical laser

low level laser therapy is the application of light (usually a low powered laser or LED typically power range of (10mW–500mW). Light with a wavelength in the red to near infrared region of the spectrum (660nm–905nm), is generally employed because these wavelengths have the ability to penetrate skin, and soft/hard tissues (Figure 2) and are proven in clinical trials to have a good effect on pain, inflammation and tissue repair. The power density (irradiance) is usually between 5W/cm2 and is applied to an injury or to a painful site for 30–60 seconds a few times a week for several weeks. The result is a reduction of inflammation, pain relief and accelerated tissue regeneration. In most cases the lasers/LEDs used for low level laser therapy emit a divergent beam (not focused or collimated) because collimation is lost in tissue, but as a consequence ocular risks are also diminished over distance.

How low level laser therapy work?

For low-power visible or near-infrared light to have an effect on a biologic system, the photon must be absorbed by electronic absorption bands belonging to a photon acceptor or chromophore (first law of photobiology) . A chromophore is a molecule (or portion of a molecule) which imparts a color to a compound (e.g. chlorophyll, hemoglobin, myoglobin, cytochrome c oxidase, other cytochromes, flavin, flavoproteins or porphyrins) . The “optical window” in a tissue describes a range of wavelengths where the penetration of light into tissue is maximized by employing red and near-infrared wavelengths . The optimum wavelength has been estimated to be around 810 nm. Mitochondria are “the cellular power plants” in our cells and as such they convert food molecules and oxygen into energy (ATP) by oxidative phosphorylation. It has been proposed that cytochrome c oxidase (COX) is the primary photo-acceptor for the red-NIR wavelength range in mammalian cells . Nitric oxide (NO) produced in mitochondria can inhibit respiration by binding to COX and displace oxygen especially in injured or hypoxic cells . It is proposed that low level laser therapy can photo-dissociate NO from COX and reverse the mitochondrial inhibition of respiration due to excessive NO binding . The process of light mediated vasodilation was first described by RF Furchgott in 1968, and his research on the biological properties of nitric oxide eventually led to the award of a Nobel Prize in 1998 . low level laser therapy is able to produce a shift in the overall cell redox potential in the direction of greater oxidation by increasing reactive oxygen species (ROS) and decreasing reactive nitrogen species (RNS). The long-term effects of low level laser therapy are thought to be due to the activation of various transcription factors by the immediate chemical signaling molecules produce from mitochondrial stimulation by low level laser therapy. The most important of these signaling molecules are thought to be ATP, cyclic-AMP, NO and ROS .

low level laser therapy at low doses has been shown to enhance cell proliferation of fibroblasts , keratinocytes, endothelial cells and lymphocytes . The mechanism of proliferation is thought to result from photo-stimulation of the mitochondria leading to activation of signaling pathways and up regulation of transcription factors eventually giving rise to increases in growth factors . low level laser therapy can enhance neovascularization, promote angiogenesis and increase collagen synthesis to aid in the healing of acute and chronic wounds . It has been observed in many studies, that low level laser therapy exhibits a biphasic dose response curve, where by lower doses of light are more effective than much higher doses. These low doses of light have demonstrated the ability to heal skin, nerves, tendons, cartilage and bones.

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How to choose low level laser therapy device?

Many massage therapists, acupuncturists, chiropractors, physical therapists, and other health care professionals use low level laser therapy in their healing practices, and it may be easiest to find them in your area by asking your physician for a referral or searching online. The World Association for Laser Therapy sponsors Find a Laser Therapist to help you find a laser therapist in your area; however, know that the current therapist list is short.

Many companies now manufacture and sell low-level lasers to the general public; however, quality lasers can be quite pricey, ranging up to $25,000 or more, and there are many complex options to choose from. To provide an alternative to purchasing a laser for home use, some therapists rent their lasers to clients.

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How Calculating low level laser therapy Dosage?-Calculating low level laser therapy Dosage
There has been a lot of discussion about the best method to quantify low level laser therapy dosage.
However, it is my opinion that:

There is no agreed method of defining beam area
Dosage expressed as J/cm² is inadequate

No agreed method for measuring low level laser therapy dosage

So beam area is hard to define and there is no agreement in our industry for defining it. [I propose 1/e2 – will explain this soon].
Dosage expressed as J/cm² is inadequate

“Dosage” is usually calculated as Power / Beam Area x Time = J/cm². However, to consider that dosage should equal J/cm² is, in my opinion, inadequate.

Let me explain:

Assume there is a well-defined beam area and thus a quantifiable dosage.

A 500mW laser with a beam area of 0.25Cm2 used for 20 seconds
delivers 40 J/cm²
A 200mW laser with a beam area of 0.1Cm2 used for 20 seconds
delivers 40 J/cm²
A 30mW laser with a beam area of 0.015Cm2 used for 20 seconds
also delivers 40 J/cm²

Each of these probes apparently apply the same “dosage”. However, the total energy delivered is clearly different [10 Joules, 4 Joules and 0.6 Joules respectively]. While dosage appears consistent using J/cm², I suggest that the clinical results would be quite diverse. So I say that J/cm² is an inadequate method of expressing dosage.
low level laser therapy dosage 1 low level laser therapy dosage 2
Calculating the area of an laser beam should be simple:

But laser beams are rarely round:
Area of a circle = r²

Area of a circle = r1r2

low level laser therapy dosage 3 low level laser therapy dosage 4
And laser beams are rarely of uniform density:

Some diode laser beams appear
very distorted

Where is the edge of the beam? What is the beam area?

How to Report Low-low level laser therapy (low level laser therapy) / Photomedicine Dose and Beam Parameters in Clinical and Laboratory Studies

Jenkins PA, Carroll JD

BACKGROUND: Dose and beam parameters are critical for successful laser, LED, and other light therapy treatments, however, in our experience, researchers frequently make critical errors and omissions when submitting papers for publication. Journals frequently publish studies with missing data, mathematical errors, and no reported verification of beam parameters. This makes reproducibility impossible, and further confounds an already complex subject.

OBJECTIVE: This article is intended to be a reference document for non-physicist researchers conducting low-low level laser therapy (low level laser therapy) laboratory studies and clinical trials to help them design and report the beam and dose aspects of their trials.

RECOMMENDATIONS: It provides a checklist to help low level laser therapy researchers understand and report all the necessary parameters for a repeatable scientific study. It includes the eight most important beam parameters to report, which are: wavelength, power, irradiation time, beam area at the skin or culture surface (this is not necessarily the same as the aperture size), pulse parameters, anatomical location, number of treatments, and interval between treatments. The three commonly used dose parameters are time, energy, and energy density. In addition, more thorough reporting would include coherence, application technique (contact, projection, scanning, pressure), beam profile, and spectral width, as these may also be considered important. Beam power often decreases as the device warms up and as the device ages; therefore, this should be checked routinely during an experiment/trial. Measurements of beam area and beam power require special instruments and trained technicians to operate them. Power measurements should be taken before, after, and at frequent intervals during research trials.

CONCLUSION: Reviewers should insist that the minimum eight most important beam parameters are included and authors should take care to measure and record these accurately before during and after an experiment or clinical trial.

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