Laser Therapy

The term laser is an acronym for Light Amplification by Stimulated Emission of R

adiation. It refers to the production of a beam of radiation, which differs from
ordinary light in the following ways: Monochromaticity: Lasers are of a single
specific wavelength and hence of a defined frequency. In the case of visible las
ers a single pure colour is produced, e.g. ruby lasers give a red light at 694.3
nm. Single wavelength laser radiation is also referred to as monochromatic in t
he infrared and ultraviolet regions, despite being invisible. Coherence: Laser r
adiation is not only of the same wavelength but also in phase, i.e., the peaks a
nd troughs of the electric and magnetic fields all occur at the same time. This
is called temporal coherence. The laser radiation travel in the same direction;
this is called spatial coherence. The distance over which the wavelengths stay i
n phase is called the coherence length. It varies from less than a millimeter to
hundreds of metres. Collimation: As a consequence of spatial coherence lasers r
emain in a parallel beam. Because the radiations do not diverge the energy is pr
opagated over very long distances. When laser radiations interact with matter th
e effects are the same as any other equivalent electromagnetic radiation reflect
ion, refraction, absorption and hence scattering. In this way collimation and co
herence are diminished or lost. The extent to which this happens depend on the n
ature and density of matter present so that laser radiations will pass unaffecte
d through space and be only slightly altered in air but be markedly altered on e
ntering a more dense material such as the tissues. Lasers can be both pulsed or
focused. They can therefore be used to deliver large amounts of energy to a smal
l region over a very short time. When the tissues absorb laser radiation it will
cause heating if it is of sufficient intensity, but it is also considered to ha
ve specific biological effects due to the special nature of laser radiation. Pri
nciples of Lasers: Electrons of an individual atom exist as a cloud of negative
charges circling the positively charged nucleus. According to quantum theory; el
ectrons can only occupy certain energy levels or shells around the nucleus. The
electrons in the outermost orbit or shell are most easily affected by outside fo
rces.
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If the atom is given additional energy, by heating, these outer electrons can be
made to occupy higher levels and, if enough energy is added to the atom, an out
er electron may gain sufficient energy to free itself from the pull of the nucle
us. The atom then becomes a positively charged ion and the electron a free negat
ive charge. When the outer electrons are in one of the higher energy states, the
y will tend to return to a lower energy state, sometimes to the most stable or g
round state. An electron may do this either by cascading down from one energy le
vel to the next or it may jump directly to the ground state. In both cases the a
dditional energy must be given up and this is done by giving off a photon (quant
um) of radiation. Each step from one energy level to the next is known as a tran
sition and the wavelength (and thus the frequency) of the emitted photon depends
on the energy difference between the two energy levels; the more the energy dif
ference, the shorter the wavelength and higher the frequency. While an electron
is in a higher energy state the atom is said to be excited and this state will l
ast a very short time, characteristically about 10-8 seconds, before the electro
n falls to a lower energy level emitting a photon. There are some excitation lev
els in all atoms from which electrons cannot easily leave spontaneously but need
to give up their energy on collision with other atoms. Such electrons remain in
their higher energy state for much longer average time, e.g. 0.0001 seconds (10
-3 seconds) and are referred to as being metastable states. Energy can be introd
uced into matter in various ways. Heat, for example, leads to molecular collisio
ns, which alter the complex energy levels sustained by molecular interaction cau
sing excitation. Electrons falling back to their stable states emit photons at n
umerous different wavelengths giving a continuous spectrum in the infrared and v
isible spectrum. An electric charge applied to a gas of a single element may cau
se certain permitted transitions only. Thus only photons of a few characteristic
wavelengths are emitted, hence a line spectrum. Photons themselves, if absorbed
, can give energy to an atom; this causes excitation. For absorption of a photon
to occur its wavelength must correspond exactly to the difference in energy bet
ween the existing state of the electron and a possible higher energy level. Simi
larly if the electron is already in a higher energy state and can move to a lowe
r level with a difference that corresponds to the energy of the stimulating phot
on it may do so by giving out a photon of its own identical to that of the colli
ding photon. This process is called stimulated emission.
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A large number of atoms with electrons in the excited state can lead to amplific
ation since one photon releases a second and these two release two more and so o
n a kind of cascade or avalanche effect. Such a system can only emit photons if
there are more electrons at a higher energy level than in the ground state. If t
his does not occur all the photons released from electrons falling from highener
gy states are absorbed in the molecules, raising the energy of electrons in the
low-energy (ground) state. Having more atoms in the upper energy state than the
lower is called population inversion, simply because it is the reverse of the us
ual situation in which there are more electrons in the ground state and at lower
energy levels. Such a population inversion can be achieved by forcing the elect
rons of many atoms into their metastable state. As electrons remain in this stat
e for a relatively long time it is possible, with an intense energy input, to ha
ve more electrons entering the metastable state than leaving it. Hence a tempora
ry population inversion is achieved. Types of Lasers: Ruby Laser: The ruby laser
consists of a small synthetic ruby rod made of aluminium oxide. A helical xenon
flash tube, wound around it, gives an intense flash of white light. Both ends o
f the rode are made flat and silvered, one end being totally reflecting and the
other partially transparent so that some radiation can be emitted. This brief li
ght pulse (0.5 ms) excites the ruby molecules and raises many electrons to highe
r levels which they occupy for very short average times before falling to the me
tastable level where they remain for much longer average times. Thus, for a time
, there are more electrons in the metastable level than the ground level and so
population inversion has occurred. When the transition from metastable to ground
state does occur a photon with a wavelength of 694.3 nm is emitted. This photon
would have exactly the right energy to raise a ground state electron to the met
astable level and be reabsorbed but as there are relatively few ground-state ele
ctrons the photon is much more likely to interact with other metastable electron
s, causing them to return to the ground state and so emitting an identical photo
n. The process rapidly accelerates as more and more photons are released; i.e.,
stimulated emission of radiation occurs.
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The photons, having a wavelength of 694.3 nm, which is of course red light, are
reflected up and down the short ruby rod, rapidly increasing the effect. Thus al
l the energy stored in the ruby molecules is released in a very brief time, as a
pulse of red light of identical photons and so of a single wavelength of cohere
nt radiation, which emerges from the rod at the partially transparent end. Heliu
m Neon Lasers: Helium neon lasers consist of a long tube containing helium and n
eon, natural gases, at low pressure surrounded by a flashgun tube. Excitation of
these atoms leads to different energy levels between them and the transfer of e
nergy, giving off a photon of wavelength equivalent to the energy gap. The photo
ns are reflected to and fro along the tube giving rise to further photon emissio
n and emerging as a narrow beam of about 1 mm diameter from the partially transp
arent end. Helium neon lasers give radiation in the red visible region at 632.8
nm. The output is usually applied to the tissues via an optical guide, which is
a fibreoptic cable, the end of which is held in contact with the tissues. There
are, of course, some energy losses in the glass fiber of the cable and the laser
beam may diverge somewhat as it emerges at the end of the optical fiber. Diode
Lasers: These are specialized light-emitting diodes, based on semiconductor pn ju
nctions. They are of various kinds, involving gallium aluminium arsenide (GaAlAs
). In these, electrons can flow more readily in one direction than in the other.
The electrons are excited by the application of a suitable electrical potential
and their occupation of holes in the crystal lattice arrangement may lead to th
e emission of a photon which may then stimulate identical photons. The photons a
re reflected to and fro and emitted as a laser beam from one partially transpare
nt end. These are conveniently small, relatively cheap, and robust devices. By v
arying the ratio of gallium to aluminium such devices can be built to emit speci
fic wavelengths. Semiconductor laser diodes can give either a continuous or a pu
lsed output. Continuous wave diode lasers are usually of relatively low power. A
lternatively they can be pulsed electronically. On some machines the pulse frequ
ency can be varied.
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Superluminous Diodes: Making diode lasers fully coherent is difficult. It is che
aper to produce superluminous diodes (SLDs), which are fully monochromatic and c
ollimated but non-coherent. It is argued that coherence is therapeutically super
fluous and in any case is rapidly lost as radiations enter the tissues. While su
perluminous diodes (SLDs) are not strictly lasers, they are widely used in thera
py. Due to their small size semiconductor lasers can be applied directly to the
tissues in a hand-held applicator. Sometimes several laser diodes of assorted wa
velengths are mounted together to form an emitter, which can be used to treat a
larger area. These are known as cluster probes. They may also contain superlumin
ous diodes. For all these forms of low-power laser a suitable electronic circuit
is provided to generate appropriate currents to power the diodes. Pulsing and t
iming are also controlled electronically. Classification of Lasers:
Class
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Power
Low
Effect
None on eye or skin Safe on skin Eye protected by aversion responses Direct intr
abeam viewing with optical aids may be hazardous Direct intrabeam viewing may be
hazardous Hazardous to skin and eye
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Usage
Blackboard pointer Supermarket barcode reader -----
2
Low CW 1mW
3A
Lowmedium (mid) CW 5 mW
Therapeutic Physiotherapy models
3B
Medium (mid) CW 500 mW High CW 500 mW plus
-----
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Destructive Surgical models
Measurement of Laser Energy: The amount of energy falling on a surface is expres
sed in joules per square meter (J/m2) or joules per square centimeter (J/cm2). I
t is often called energy density. The rate at which energy is produced or absorb
ed is measured in joules per second, i.e., in watts and called power. Most laser
s used in physiotherapy have output powers of milliwatts. The average power per
unit area can be expressed as irradiance or power density in W/cm2. The laser be
am is not perfectly collimated and the divergence may be expressed in terms of a
n angle. Therapeutic Uses of Lasers: The terms Low-reactive Level Laser Therapy
(LLLT) and Low-Intensity Laser Therapy (LILT) are sometimes used to distinguish
the low-energy applications used in physiotherapy, from the high-energy applicat
ions used therapeutically for tissue destruction. There are two major areas for
which laser therapy is used: Tissue Healing Pain Control Within these two broad
categories, laser therapy is widely used in the treatment of all kinds of soft t
issue injuries, such as muscle tears, haematomas, and tendinitis. Laser acupunct
ure is also applied and the laser treatment of some arthropathies has been repor
ted. Tissue Healing: The use of radiations of all kinds to accelerate wound heal
ing, especially red part of the visible spectrum has been found to be effective.
Wavelength:
Laser radiations of 660 nm, 820 nm, and 870 nm wavelengths encourage macrophages
to release factors that stimulate fibroblast proliferation but 880 nm wavelengt
h has inhibitory effect. Only the 820 nm wavelength is coherent and polarized, w
hich shows that at certain wavelengths coherence and polarization are not essent
ial. In general, it seems that responses to visible radiations occur at both cel
lular and organismal levels; that laser stimulation is of a photobiological natu
re and that effects are due to both coherent and noncoherent radiation.
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Pulse Frequency:
There is a suggestion that 16 Hz is an effective pulse frequency for tissue heal
ing. Additional factors involved in the acceleration of wound healing by laser m
ay include a marked increase in collagen formation, vasodilatation, and DNA synt
hesis, and an increase in RNA production. Laser treatment is recommended for the
treatment of indolent wounds and trophic ulcers to promote more rapid healing a
nd it is considered that lowintensity visible radiation has an effect in acceler
ating or stimulating cell proliferation. In such wounds cell proliferation may b
e inhibited by low oxygen concentration, abnormal pH or other abnormality such a
s deficiency of nutrients. In these circumstances light may act as a signal to i
ncrease proliferation. Pain Control:
Musculoskeletal Pain:
Laser therapy is used for the relief of pain in many conditions, both acute and
long-term like rheumatoid arthritis, osteoarthritis, bursitis, back pain (nerve
inflammation and muscle spasm), tennis elbow, golfer's elbow, supraspinatus tendin
itis, etc. It is also found to be effective in fracture consolidation and accele
ration & post-traumatic nerve degeneration.
Neurogenic Pain:
Trigger / Acupuncture Points:
Neurogenic pain like trigeminal neuralgia, postherpetic neuralgia, etc have been
found to be relieved by laser therapy which is thought to be due to the laser a
ffecting serotonin metabolism. Pain is also often treated by application of lase
r on trigger or acupuncture points, which have low skin resistance than normal.
Resolution of condition is associated with a return to normal skin resistance.
Contraindications: Active or suspected carcinoma (except in hospice care) Direct
irradiation of the eyes Cognitive difficulties or unreliable patients Increased
sensitivity to light Irradiation over the pregnant uterus Hemorrhage and infect
ed tissue
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Precautions: Avoid irradiation of the gonads. Avoid irradiation of patients with
a history of epilepsy. Avoid irradiation of areas of altered skin sensitivity.
Ensure that the patient understands the nature of the treatment and related dang
ers. Avoid active epiphyseal regions in children. Use laser devices only in spec
ially designated areas. Avoiding reflecting the laser beam from shiny surfaces.
Only switching the laser on when the applicator is in contact with the skin. Usi
ng appropriate protective goggles.
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