Laser Therapy

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:
y 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.
y 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.
y 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.

Ö 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.

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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
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.
 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.
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  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 high-
energy 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.

Ö Types of Lasers:
D 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
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.
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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 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.
D 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.
D Diode Lasers:
 These are specialized light-emitting diodes, based on semiconductor p–n
junctions. 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
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.

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 D 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.

Ö Classification of Lasers:

Class Power Effect Usage

Blackboard pointer
None on eye
1 Low Supermarket
or skin
barcode reader
Safe on skin
Low Eye protected
2 -----
CW – 1mW by aversion
responses
Direct
intrabeam
Low–medium Therapeutic
viewing with
3A (mid) Physiotherapy
optical aids
CW – 5 mW models
may be
hazardous
Direct
Medium (mid) intrabeam
3B -----
CW – 500 mW viewing may
be hazardous
High
Hazardous to Destructive
4 CW – 500 mW
skin and eye Surgical models
plus
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Ö 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.

Ö 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:
y Tissue Healing
y 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.
 Laser acupuncture is also applied and the laser treatment of some arthropathies
has been reported.
D 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:
 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 non-
coherent radiation.

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 ™ 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 low-
intensity 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.
D 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 tendinitis, etc.
 It is also found to be effective in fracture consolidation and acceleration
& post-traumatic nerve degeneration.
™ 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.
™ Trigger / Acupuncture Points:
 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.

Ö 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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Ö 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.