LASER THERAPY

Sagar Naik, PT

Laser Therapy (Notes)

Sagar Naik,

PT

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The term laser is an acronym for Light Amplification by Stimulated Emission of Radiation. 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 lasers 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 the infrared and ultraviolet regions, despite being invisible. Coherence: Laser radiation is not only of the same wavelength but also in phase, i.e., the peaks and 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 in 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 remain in a parallel beam. Because the radiations do not diverge the energy is propagated over very long distances. When laser radiations interact with matter the effects are the same as any other equivalent electromagnetic radiation reflection, refraction, absorption and hence scattering. In this way collimation and coherence are diminished or lost. The extent to which this happens depend on the nature and density of matter present so that laser radiations will pass unaffected through space and be only slightly altered in air but be markedly altered on entering 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 small 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 have specific biological effects due to the special nature of laser radiation.

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LASER THERAPY

Sagar Naik, PT

Principles of Lasers: Electrons of an individual atom exist as a cloud of negative charges circling the positively charged nucleus. According to quantum theory; electrons 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 forces. 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 outer electron may gain sufficient energy to free itself from the pull of the nucleus. The atom then becomes a positively charged ion and the electron a free negative charge. When the outer electrons are in one of the higher energy states, they will tend to return to a lower energy state, sometimes to the most stable or ground state. An electron may do this either by cascading down from one energy level to the next or it may jump directly to the ground state. In both cases the additional energy must be given up and this is done by giving off a photon (quantum) of radiation. Each step from one energy level to the next is known as a transition 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 difference, 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 last a very short time, characteristically about 10-8 seconds, before the electron falls to a lower energy level emitting a photon. There are some excitation levels 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 introduced into matter in various ways. Heat, for example, leads to molecular collisions, which alter the complex energy levels sustained by molecular interaction causing excitation. Electrons falling back to their stable states emit photons at numerous different wavelengths giving a continuous spectrum in the infrared and visible spectrum. An electric charge applied to a gas of a single element may cause certain permitted transitions only. Thus only photons of a few characteristic wavelengths are emitted, hence a line spectrum.

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LASER THERAPY

Sagar Naik, PT

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Types of Lasers:
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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 between the existing state of the electron and a possible higher energy level. Similarly if the electron is already in a higher energy state and can move to a lower level with a difference that corresponds to the energy of the stimulating photon it may do so by giving out a photon of its own identical to that of the colliding photon. This process is called stimulated emission. A large number of atoms with electrons in the excited state can lead to amplification since one photon releases a second and these two release two more and so on 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 this does not occur all the photons released from electrons falling from highenergy 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 usual 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 electrons of many atoms into their metastable state. As electrons remain in this state for a relatively long time it is possible, with an intense energy input, to have more electrons entering the metastable state than leaving it. Hence a temporary population inversion is achieved.

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 of 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 light pulse (0.5 ms) excites the ruby molecules and raises many electrons to higher levels which they occupy for very short average times

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LASER THERAPY

Sagar Naik, PT

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Helium Neon Lasers: Helium neon lasers consist of a long tube containing helium and neon, 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 energy, giving off a photon of wavelength equivalent to the energy gap. The photons are reflected to and fro along the tube giving rise to further photon emission and emerging as a narrow beam of about 1 mm diameter from the partially transparent 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 junctions. They are of various kinds, involving gallium aluminium arsenide (GaAlAs).
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before falling to the metastable 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 metastable level and be reabsorbed but as there are relatively few ground-state electrons the photon is much more likely to interact with other metastable electrons, causing them to return to the ground state and so emitting an identical photon. The process rapidly accelerates as more and more photons are released; i.e., stimulated emission of radiation occurs. 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 all 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 coherent radiation, which emerges from the rod at the partially transparent end.

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LASER THERAPY

Sagar Naik, PT

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Class
1

Superluminous Diodes: Making diode lasers fully coherent is difficult. It is cheaper to produce superluminous diodes (SLDs), which are fully monochromatic and collimated but non-coherent. It is argued that coherence is therapeutically superfluous and in any case is rapidly lost as radiations enter the tissues. While superluminous diodes (SLDs) are not strictly lasers, they are widely used in therapy. 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 wavelengths 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 superluminous 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 timing are also controlled electronically.

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Classification of Lasers:

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Power
Low

Low

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Effect
None on eye or skin Safe on skin Eye protected
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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 the emission of a photon which may then stimulate identical photons. The photons are reflected to and fro and emitted as a laser beam from one partially transparent end. These are conveniently small, relatively cheap, and robust devices. By varying the ratio of gallium to aluminium such devices can be built to emit specific wavelengths. Semiconductor laser diodes can give either a continuous or a pulsed output. Continuous wave diode lasers are usually of relatively low power. Alternatively they can be pulsed electronically. On some machines the pulse frequency can be varied.

Usage
Blackboard pointer Supermarket barcode reader

LASER THERAPY

Sagar Naik, PT

CW 1mW

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Medium (mid) CW 500 mW

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Measurement of Laser Energy: The amount of energy falling on a surface is expressed in joules per square meter (J/m2) or joules per square centimeter (J/cm2). It is often called energy density. The rate at which energy is produced or absorbed is measured in joules per second, i.e., in watts and called power. Most lasers 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 beam is not perfectly collimated and the divergence may be expressed in terms of an 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 applications 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 tissue injuries, such as muscle tears, haematomas, and tendinitis.

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High CW 500 mW plus

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----Hazardous to skin and eye Destructive Surgical models

3A

Lowmedium (mid) CW 5 mW

by aversion responses Direct intrabeam viewing with optical aids may be hazardous Direct intrabeam viewing may be hazardous

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Therapeutic Physiotherapy models

LASER THERAPY

Sagar Naik, PT

Laser acupuncture is also applied and the laser treatment of some arthropathies has been reported. Tissue Healing: The use of radiations of all kinds to accelerate wound healing, especially red part of the visible spectrum has been found to be effective.

Wavelength:

Pulse Frequency:

There is a suggestion that 16 Hz is an effective pulse frequency for tissue healing. Additional factors involved in the acceleration of wound healing by laser may include a marked increase in collagen formation, vasodilatation, and DNA synthesis, and an increase in RNA production. Laser treatment is recommended for the treatment of indolent wounds and trophic ulcers to promote more rapid healing and it is considered that lowintensity visible radiation has an effect in accelerating or stimulating cell proliferation. In such wounds cell proliferation may be inhibited by low oxygen concentration, abnormal pH or other abnormality such as deficiency of nutrients. In these circumstances light may act as a signal to increase proliferation.

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Pain Control:

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Musculoskeletal Pain:
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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, golfers elbow, supraspinatus tendinitis, etc. It is also found to be effective in fracture consolidation and acceleration & post-traumatic nerve degeneration.

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Laser radiations of 660 nm, 820 nm, and 870 nm wavelengths encourage macrophages to release factors that stimulate fibroblast proliferation but 880 nm wavelength has inhibitory effect. Only the 820 nm wavelength is coherent and polarized, which shows that at certain wavelengths coherence and polarization are not essential. In general, it seems that responses to visible radiations occur at both cellular and organismal levels; that laser stimulation is of a photobiological nature and that effects are due to both coherent and noncoherent radiation.

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LASER THERAPY

Sagar Naik, PT

Neurogenic Pain:
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 affecting serotonin metabolism. Pain is also often treated by application of laser 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 infected 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 dangers. Avoid active epiphyseal regions in children. Use laser devices only in specially designated areas. Avoiding reflecting the laser beam from shiny surfaces. Only switching the laser on when the applicator is in contact with the skin. Using appropriate protective goggles.

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Trigger / Acupuncture Points: