Science is based upon trials and errors. Yes, even errors give serendipitous results; the discovery of penicillin is just one of them. Science starts with ideas, but has to be confirmed. Too often ideas are commercialized before there is any documentation.

One good idea seems to be Interferential laser therapy. This means that two probes are used simultaneously, for instance one in the front and one in the back of a shoulder. Sounds like a good idea: more energy into the area and arriving from two sites. Well, it still may be a good idea, but the first controlled trial failed to find any additional effect of the 2nd probe! Here is the paper in abstract:

Montes-Molina R, Prieto-Baquero A, Martínez-Rodríguez ME, Romojaro-Rodríguez AB, Gallego-Méndez V, Martínez-Ruiz F. Interferential laser therapy in the treatment of shoulder pain and disability from musculoskeletal pathologies: a randomised comparative study. Physiotherapy. 2012; 98(2):143-50.

BACKGROUND: Interference is an important feature of the waves. When two or more in phase light waves meet, a new and reinforced wave is generated. Shoulder pain is a common clinical problem and laser is one of the treatments frequently used to relieve it.

OBJECTIVE: To test the safety of interferential laser therapy generated by two independent low level lasers and compare its effectiveness with conventional single laser therapy in the reduction of shoulder musculoskeletal pain and associated disability.

DESIGN: Randomised and single-blind controlled clinical trial.

PARTICIPANTS: 200 patients with shoulder musculoskeletal pain were randomly assigned in two groups, 100 people each.

INTERVENTIONS: Group I, experimental (n=100) received interferential laser, placing two probes opposite each other over the shoulder joint. Group II, control (n=100) received conventional laser therapy, using a single probe along with a second inactive dummy probe. Lasers used were GaAlAs diode (810 nm, 100 mW), in continuous emission. Laser was applied in contact mode through ten sessions, on 5 shoulder points (7 Joules/point) per session.

MAIN OUTCOME MEASURES: visual analogue scale (VAS) score and shoulder pain disability index (SPADI), recorded before and after laser treatment.

RESULTS: There were no differences between both groups in the reduction of pain, either assessed by VAS scale (median difference=0, 95% CI of the difference = -.6 to .5, p = 0.81) or SPADI index (median difference = .4, 95% CI of the difference = -2.9 to 3.8, p = 0.80), using the Mann-Whitney U-test. Comparison between the scores recorded before and after the treatment, within each group, showed significant differences for VAS during movement (median difference=3, 95% CI of the difference = 2.07 to 4, p < 0.001) and SPADI index (median difference=3.5, 95% CI of the difference = 2.67 to 3.85, Wilcoxon test, p < 0.001), for both groups.

CONCLUSIONS: In this study, the application of two low level lasers in order to generate interference inside the irradiated tissue showed to be a safe therapy. Both interferential and conventional laser therapy reduced shoulder pain and disability. Nevertheless, differences between them were not detected. Future research in this field could include applying this technique with other laser parameters or application forms.

[NB. If one wishes to play with words, laser therapy could, in and of itself, be called ‘interferential’, in that the random interference of coherent light waves in the tissue results in the creation of a speckle field. However, attempting to ‘enhance’ this effect – as in the previously discussed study – by introducing additional light sources to irradiate the same volume of tissue, may decrease efficacy by reducing the contrast of the original speckle field, as hypothesised by Hode T et al (2009, 2011).]

Other ideas are commercialized upon wishful thinking or lack of knowledge. One such example is the combination of continuous wave 808 nm and pulsed 904 nm into one single probe. At first glance this looks like a good idea, but there are complications: Pulsed 904 nm is known to require lower energies than CW 808 nm, so the treatment of e.g. open wounds may become problematic, and overdosing may be a potential risk in some cases. And it is not obvious that two wavelengths always make 1 + 1 = 2. Still, it is an interesting idea, albeit not new.

The dark side of the commercialization of this type of probe is the claims made by the manufacturer. Read this:

“Continuous Laser emissions act fast on inflammation, stimulating blood and lymphatic circulation and inducing fast re-absorption of fluid build-ups; however, they only have a secondary effect on pain, which is diminished after reducing the inflammatory process.”

“Pulsed Laser emissions, on the other hand, have a practically immediate effect on pain, since they are able to induce analgesia, interfering with the very transmission of the pain impulse to the higher brain centers, but they are less effective at treating inflammation and oedema, only achieving results after a long period of application.”

Sadly, there is no scientific documentation behind these claims; actually, the weight of evidence would seem to support opposite argument: CW lasers have an excellent and immediate effect on pain (see Chow R et al 2009, 2011a, 2011b), inducing analgesia directly by interrupting the transmission of pain signals to the brain; and pulsed 904 nm lasers are fine for reducing oedema (see Lievens P 1989, Carati CJ et al 2003) and inflammation and, secondarily, relieving pain. In short, one could swap the words ‘Continuous’ and ‘Pulsed’ in the two sentences above and, arguably, produce a more accurately representative summary of the current evidence base. These are just a few examples disproving the extravagant claims of this manufacturer.

In war, truth is the first victim, they say. Why, then, in the marketing of therapeutic lasers, when the truth is good enough?

By Jan Tunér

The application of laser instead of needles has a long history. The very low powered HeNe laser was used in the beginning of the 80ies and from that period different lasers have been widely used to replace needles. But does that really work? Possibly, but the first question should really be: Does acupuncture work?

The first thorough scientific evaluation of acupuncture was performed by the World Health Organization in 1979. The report was positive about a great number of medical indications. In 2003 the WHO published a less positive report, ”Acupuncture: Review and analysis of reports on controlled trials. 293 studies”. Later on, the Cochrane collaboration performed an analysis of the available literature, and came to a less optimistic conclusion. There was some evidence for a few indications, notably certain types of pain, nausea and vomiting, throat problems and nocturnal uresis. The number of scientifically accepted indications for acupuncture was shrinking.

Laser acupuncture was not mentioned in these reports, in spite of being performed in parallel with needling during 20 years. Using a laser instead of a needle appeared attractive; there was no pain involved and no risk of infection. The drawback was that the use of multiple points was not possible.

Critics pointed out the problems to understand and accept laser acupuncture. All wavelengths seemed to work and any power density and energy too. And when needling is used, it is important to pinpoint a very small acupuncture point and get the ”qi” reaction. When a laser is used, a very large area is illuminated and there is no qi. The problem is very obvious in auricular acupuncture. Using an infrared laser on 3-4 points in the ear means that the entire ear has been illuminated! It just does not make sense. Still, studies using fMRI [1,2] showed that the reactions in the brain were similar when using a needle and a laser. So obviously it workes, but how?

We may now have an explanation at hand! In 2009 Burnstock [3] proposed that mechanical deformation of the skin by needles and application of heat or electrical current leads to release of large amounts of ATP from keratinocytes, fibroblasts and other cells in skin; the ATP then occupies specific receptor subtypes expressed on sensory nerve endings in the skin and tongue; the sensory nerves send impulses through ganglia to the spinal cord, the brain stem, hypothalamus and higher centres; the brain stem and hypothalamus contain neurons that control autonomic functions, including cardiovascular, gastrointestinal, respiratory, urinogenital and musculo-skeletal activity. Impulses generated in sensory fibres in the skin connect with interneurons to modulate (either inhibition or facilitation) the activities of the motoneurons in the brain stem and hypothalamus to change autonomic functions; specifically activated sensory nerves, via interneurons, also inhibit the neural pathways to the pain centres in the cortex.

In 2012 Goldman [4] found that adenosine, a neuromodulator with anti-nociceptive properties, was released during acupuncture in mice and that its anti-nociceptive actions required adenosine A1 receptor expression. Direct injection of an adenosine A1 receptor agonist replicated the analgesic effect of acupuncture. Inhibition of enzymes involved in adenosine degradation potentiated the acupuncture-elicited increase in adenosine, as well as its anti-nociceptive effect. These observations indicate that adenosine mediates the effects of acupuncture and that interfering with adenosine metabolism may prolong the clinical benefit of acupuncture.

What implication does this has for laser acupuncture? Well, is has been known for more than  30 years that laser irradiation at certain energy levels triggers increased mitochondrial production of ATP [5-9]! And ADP is a precursor to ATP. This possible explanation has been put forward by Karu [10]. So if the stimulation of ADP/ATP is the basic mechanism of needling and laser acupuncture, then the confusion may be over.

The laser acupuncture technique has been refined by the introduction of ”laser needles”. These are very thin fibres which stick to the area over the acupuncture point by an adhesive ring.  Several points can be irradiated at the same time and different wavelengths can be selected.  The thin fibres can introduce the photons over small areas and the use of e.g. green light can reduce the scattering of the light, thus making auricular therapy more feasible.

Photo: Weber Medical

A few recent clinical studies [11-13] are included in the list of references below.

References

[1] Siedentopf C M, Golaszewski S M, Mottaghy F M, Ruff C C, Felber S, Schlager A. Functional magnetic resonance imaging detects activation of the visual association cortex during laser acupuncture of the foot in humans. Neurosci Lett. 2002; 327 (1): 53-56.

[2] Litscher G, Rachbauer D, Ropele S, Wang L, Schikora D, Fazekas F, Ebner F. Acupuncture using laser needles modulates brain function: first evidence from functional transcranial Doppler sonography and functional magnetic resonance imaging. Lasers Med Sci. 2004; 19 (1): 6-11.

[3] Burnstock G. Acupuncture: a novel hypothesis for the involvement of purinergic signalling. Med Hypotheses. 2009; 73 (4): 470-472.

[4] Goldman N, Chen M, Fujita T, Xu Q, Peng W, Liu W, Jensen TK, Pei Y, Wang F, HanX, Chen JF, Schnermann J, Takano T, Bekar L, Tieu K, Nedergaard M. Adenosine A1 receptors mediate local anti-nociceptive effects of acupuncture. Nat Neurosci. 2010; 13 (7): 883-888.

[5] Salet C, Moreno G, Vinzens F. A study of beating frequency of a single myocardial cell. III. Laser microirradiation of mitochondria in the presence of KCN or ATP. Exp. Cell Res. 1979; 120: 25.

[6] Passarella S et al. Increase in the ADP/ATP exchange in rat liver mitochondria irradiated in vitro by helium-neon laser. Biochem Biophys Res Commun. 1988; 156 (2): 978-986.

[7] Pastore D et al. Stimulation of ATP synthesis via oxidative phosphorylation in weak mitochondria irradiated with helium-neon laser. Biochem Mol Biol Int. 1996; 39 (1): 149-157.

[8] Karu T, Pyatibrat L, Kalendo G. Irradiation with He-Ne laser increases ATP level in cells cultivated in vitro. J Photochem Photobiol B. 1995; 27 (3): 219-223.

[9] Houreld NN, Masha RT, Abrahamse H. Low-intensity laser irradiation at 660 nm stimulates cytochrome c oxidase in stressed fibroblast cells. Lasers Surg Med. 2012; 44 (5): 429-434.

[10] Karu T I. Mitochondrial Mechanisms of Photobiomodulation in Context of New Data About Multiple Roles of ATP. Photomed Laser Surg. 2010; 28 (2): 159-160.

[11] Chow R, Yan W, Armati P. Electrophysiological effects of single point transcutaneous 650 and 808 nm laser irradiation of rat sciatic nerve: a study of relevance for low-level laser therapy and laser acupuncture. Photomed Laser Surg. 2012; 30 (9): 530-535.

[12] Shin YI, Kim NG, Park KJ, Kim DW, Hong GY, Shin BC.Skin adhesive low-level light therapy for dysmenorrhoea: a randomized, double-blind, placebo-controlled, pilot trial. Arch Gynecol Obstet. 2012; 286 (4): 947-952.

[13] Cunha RG, Rodrigues KC, Salvador M, Zangaro RA. Effectiveness of Laser treatment at acupuncture sites compared to traditional acupuncture in the treatment of peripheral artery disease. Conf Proc IEEE Eng Med Biol Soc. 2010; 1262-1265. doi: 10.1109/IEMBS.2010.5626418.

By Jan Tunér

In early (and, sadly even in recent) publications, several incorrect contraindications of LLLT have been proposed. Most of them have been more or less disposed of, such as pacemakers. It is just stunning to believe that an electrical gadget can be influenced by a ray of light, such as the TV remote control.

Another alleged contraindication is patients with diabetes. So far it has not been claimed that LLLT can cure diabetes, but most certainly LLLT is a very useful tool to treat the side effects of diabetes, such as poor circulation, pain and consequent chronic wounds. Animal studies suggest that diabetic wounds treated with LLLT heal at a level of a non-treated wound in a healthy object [1].

The thyroid gland is another frequently seen contraindication. But never substantiated. Of course, hyperthyroidism could possibly be influenced in a negative way, but then again, LLLT is more of a normalizer than a stimulator. So where is the evidence? And hypothyroidism, then? Well, read this:

Höfling DB, Chavantes MC, Juliano AG, Cerri GG, Knobel M, Yoshimura EM, Chammas MC. Low-level laser in the treatment of patients with hypothyroidism induced by chronic autoimmune thyroiditis: a randomized, placebo-controlled clinical trial. Lasers Med Sci. 2012 Jun 21. [Epub ahead of print]

Chronic autoimmune thyroiditis (CAT) is the most common cause of acquired hypothyroidism, which requires lifelong levothyroxine replacement therapy. Currently, no effective therapy is available for CAT. Thus, the objective of this study was to evaluate the efficacy of low-level laser therapy (LLLT) in patients with CAT-induced hypothyroidism by testing thyroid function, thyroid peroxidase antibodies (TPOAb), thyroglobulin antibodies (TgAb), and ultrasonographic echogenicity. A randomized, placebo-controlled trial with a 9-month follow-up was conducted from 2006 to 2009. Forty-three patients with a history of levothyroxine therapy for CAT-induced hypothyroidism were randomly assigned to receive either 10 sessions of LLLT (830 nm, output power of 50 mW, and fluence of 707 J/cm²; L group, n = 23) or 10 sessions of a placebo treatment (P group, n = 20). The levothyroxine was suspended 30 days after the LLLT or placebo procedures. Thyroid function was estimated by the levothyroxine dose required to achieve normal concentrations of T(3), T(4), free-T(4) (fT(4)), and thyrotropin after 9 months of postlevothyroxine withdrawal. Autoimmunity was assessed by measuring the TPOAb and TgAb levels. A quantitative computerized echogenicity analysis was performed pre- and 30 days postintervention. The results showed a significant difference in the mean levothyroxine dose required to treat the hypothyroidism between the L group (38.59 ± 20.22 μg/day) and the P group (106.88 ± 22.90 μg/day, P < 0.001).  Lower TPOAb (P = 0.043) and greater echogenicity (P < 0.001) were also noted in the L group. No TgAb difference was observed. These findings suggest that LLLT was effective at improving thyroid function, promoting reduced TPOAb-mediated autoimmunity and increasing thyroid echogenicity in patients with CAT hypothyroidism.

So how about LPT contraindications? Basically, LPT has no serious side effects but it is of course a matter of dosage. One indication that remains to be investigated further is the irradiation over healthy growth plates. The first report came from Cheetham [2] who irradiated the healthy growth plates in young rats. One knee joint of each animal in the experimental group was irradiated three times a week at an energy density of 5 J/cm². The animals were examined histologically after 6 and 12 applications. There was no difference between the irradiated knee joints, the untreated contralateral knee joint or those in the sham-irradiated control group.

The above seems to be confirmed by de Andreade [3], who writes: The longitudinal growth of long bones is attributed to epiphyseal growth. However, the effect of LPT in such structures has still not been studied extensively in the literature. Therefore, the aim of this study was to evaluate the use of LLLT, 30 mW, 670 nm, at three different doses on the epiphyseal growth of the right tibia of rats. Twenty-one Wistar rats, aged four weeks, were subjected to the application of LLLT, with dosage according to the group (G4: were submitted to the application of 4 J/cm²; G8: were submitted to the application of 8 J/cm²; G16: were submitted to the application of 16 J/cm²). After completion of protocol (ten consecutive days) they were kept until they were 14 weeks of age and then submitted to a radiological examination (evaluation of limb length) and euthanised. The histological analysis of the growth plates (total thickness and hypertrophic and proliferative zones) was then performed. Comparisons were made with the untreated left tibia. No differences were observed in any of the reviews (radiological and histological), when comparing the right sides (treated) to the left (untreated). It was concluded that the treatment with LLLT within the parameters used caused changes neither in areas of the epiphyseal cartilage nor in the final length of limbs.

But energy and number of sessions play a role, of course. In the following experiment, the rats were irradiated daily for 21 days, and it is no surprise that things do happen, for good and for worse, depending on parameters: To determine the influence of LPT on femoral growth plate in rats, Oliveira [4] used 30 rats, aged 40 days, and divided them into two groups, G1 and G2. In G1 the area of the distal growth plate of the right femur was irradiated at one point using 830 nm, 40 mW, energy density 10 J/cm². The irradiation was performed daily for a maximum of 21 days. The same procedure was done in G2, but the probe was turned off. Five animals in each group were euthanized on days 7, 14 and 21 and submitted to histomorphometric analysis. In both groups the growth plate was radio graphically visible at all moments from both craniocaudal and mediolateral views. On the 21st day percentage of femoral longitudinal length was higher in G2 than G1 compared to basal value while hypertrophic zone chondrocyte numbers were higher in G1 than G2. Calcified cartilage zone was greater in G1 than in G2 at all evaluation moments. Angiogenesis was higher in G1 than in G2 at 14th and 21st days.

The effects of LPT on rheological factors need to be considered with caution. Laser irradiation increases microcirculation [5] but in fact of this, observations indicate that LPT reduce bleeding after tooth extractions. This appears to be contradictory. The safety of irradiating the blood itself seems to be high, since the method of intravascular blood irradiations has been used in Russia and other countries for decades. One advantage, beside the global stimulation, seems to be increased uptake of pharmaceuticals in the targeted area, leading to lower dosage of pharmaceuticals and reduced risks for side effects from these. So what about LPT for patients on warfarin? Experience indicates that this is a minimal risk and may even be useful for reduction of bleeding. But certainly not a clear recommendation at this stage of knowledge. And patients with haemophilia? Still needing a warning sign due to lack of knowledge.

Summing up: Most of the classical “contraindications” for LPT can be discarded, but those remaining are often depending on the diagnoses and laser parameters used. These are rather caveats than contraindications. One “contraindication” after the other has been dismantled, but this does not automatically mean that there are none. In a forthcoming edition of the Annals we will discuss another suggested contraindication – light sensitivity.

References:

[1] Al-Watban F A. Laser Therapy Converts Diabetic Wound Healing to Normal Healing. Photomed Laser Surg. 2009; 27 (1): 127-135.

[2] Cheetham M J, Young R S, Dyson M.  Histological effects of 820 nm laser irradiation on the healthy growth plate of the rat. Laser Therapy 1992; 4 (2): 59-64.

[3] de Andrade A R, Meireles A, Artifon E L, Costa Brancalhão R M, Ferreira J R L, Flor Bertolini G R. The Effects of Low-Level Laser Therapy, 670 nm, on Epiphyseal Growth in Rats. ScientificWorldJournal. 2012 : 231723. PMCID: PMC3361141

[4] Oliveira S P, Rahal S C, Pereira E J, Bersano P R, Vieira Fde A, Padovani C R. Low-level laser on femoral growth plate in rats. Acta Cir Bras. 2012; 27 (2): 117-122.

[5] Schaffer M, Bonel H, Sroka R et al. Effects of 780 nm diode laser irradiation on blood microcirculation: Preliminary findings on time-dependent T1-weighted contrast-enhanced magnetic resonance imaging (MRI). J Photochemistry and Photobiology B: Biology. 2000; 54 (1): 55-60.

Bisphosphonates have been introduced to treat osteoporosis. These sub­stances can be administered orally or intravenously. The bisphosphonates have a high affinity to hydroxyapatite and are accumulated in bony struc­tures. During bone remodeling, osteoclasts are exposed to large concentra­tions of bisphosphonates with consequent apoptosis of the osteoclasts. An uncommon but problematic side effect of bisphosphonates is local necrosis of the bone, particularly in the mandible. This is called Bisphosphonate Related Osteonecrosis of the Jaw (BRONJ). However, other substances such as denosumab can cause bone necrosis and a more appropriate term would therefore be Osteonecrosis of the Jaw (ONJ) [1].  Patients affected by BRONJ may present wide areas of exposed necrotic bone, particularly after surgical oral procedures. The main symptom is pain that is poorly controlled by common analgesic drugs.   Different lasers have been used to treat ONJ and seem to have a poten­tial for this condition. The following is a number of recent studies using different lasers and therapeutic approaches to treat ONJ.

The aim of a study by Martins [2] was to compare retrospectively the effect of three different treatments on the healing outcome of BRONJ in cancer patients. Twenty-two cancer patients were treated for BRONJ with one of the following protocols: clinical (pharmacological therapy), surgical (pharmacological plus surgical therapy), or PRP plus LPT (pharmacological plus surgical plus platelet rich plasma (PRP) plus LPT. The laser treatment was applied with a continuous 660 nm laser, using punctual and contact mode, 40 mW, spot size 0.042 cm², 6 J/cm², 6 s and total energy of 0.24 J per point. The irradiations were performed on the exposed bone and surrounding soft tissue. The analysis of demographic data and risk factors was performed by gathering the following information: age, gender, primary tumor, bisphosphonate (BP) used, duration of BP intake, history of chemotherapy, use of steroids, and medical history of diabetes. Most BRONJ lesions occurred in the mandible (77%) after tooth extraction (55%) and in women (72%). A significantly higher percentage of patients reached the current state of BRONJ without bone exposure (86%) in the PPR plus LPT group than in the pharmacological (0%) and surgical (40%) groups after 1-month follow-up assessment. These results suggest that the association of pharmacological therapy and surgical therapy with PRP plus LPT significantly improves BRONJ healing in oncologic patients.

Kan [3] presents the successful management of two dental patients who had high potentials for BRONJ development as a result of chemo and radiotherapy combined with IV zoledronic acid application. Multiple consecutive teeth extractions followed with primary wound closure and LLLT applications were performed under high doses of antibiotics prophylaxis. Satisfactory wound healing in both the surrounding soft and hard tissues was achieved. LLLT application combined with atraumatic surgical interventions under antibiotics prophylaxis is a preferable approach in patients with a risk of BRONJ development, according to the authors. Adjunctive effect of LLLT in addition to careful infection control on preventing BRONJ was reported and concluded.

Twelve patients affected by BRONJ were monitored in a study by Romeo [4]. Among these patients, only seven had pain in necrotic areas and were recruited for LLLT. Laser applications were performed with double diode laser simultaneously emitting at two different wavelengths (650 nm and 904-910 nm, spot size 8 mm). All of the patients were irradiated with a fluence of 0.053 J/cm² for 15 min five times over a period of 2 weeks, in a non-contact mode, ∼1 mm from the pathologic area. The patient’s maximum and minimum pain was recorded using a numeric rating scale (NRS) evaluation before and after the treatment. Six patients showed significant pain reduction, and only one patient indicated a worsening of the symptoms, which was probably related to a reinfection of the BRONJ site, which occurred during the study. A statistically significant difference was found between the NRS rates before and after the protocol.

One hundred ninety patients affected by BRONJ were observed by Vescovi [5] between January 2004 and November 2011 and 166 treated sites were subdivided in five groups on the basis of the therapeutical approach (medical or surgical, traditional or laser-assisted approach, with or without LPT. Clinical success has been defined for each treatment performed as clinical improvement or complete mucosal healing. Combination of antibiotic therapy, conservative surgery performed with Er:YAG laser and LLLT applications showed best results for cancer and noncancer patients. Nonsurgical approach performed on 69 sites induced an improvement in 35 sites (50.7%) and the complete healing in 19 sites (27.5%), while surgical approach on 97 sites induced an improvement in 84 sites (86.6%) and the complete healing in 78 sites (80.41%). Improvement and healing were recorded in 31 (81.5%) and 27 (71.5%) out of the 38 BRONJ sites treated in noncancer patients and in 88 (68.75%) and in 69 (53.9%).

The aim of a retrospective study by Atalay [6] was to compare the effects of laser surgery with biostimulation to conventional surgery in the treatment of BSP-induced avascular bone necrosis on 20 patients who have been treated in our clinic. BRONJ was evaluated in patients with lung, prostate, and breast cancer under intravenous BSP treatment. Twenty patients in this study developed mandibular or maxillary avascular necrosis after a minor tooth extraction surgery or spontaneously. Bone turnover rates were evaluated by serum terminal C-telopeptide levels (CTX) using the electrochemiluminescence immunoassay technique and patients were treated with laser or conventional surgical treatments and medical therapy. Ten patients were treated with laser surgery and biostimulation. An Er:YAG laser, very long pulse (VLP) mode (200 mJ, 20 Hz) using a fiber tip 1.3 mm in diameter and 12 mm in length was used to remove the necrotic and granulation tissues from the area of avascular necrosis. Biostimulation was applied postoperatively using an Nd:YAG laser. Low-level laser therapy (LLLT) was applied to the tissues for 1 min from 4 cm distance using an Nd:YAG laser with a R24 950-µm fiber handpiece long-pulse (LP) mode, 0.25-W, 10 Hz power/cm² from the mentioned distance the spot size was 0.4 cm², and power output was 2.5 J. Energy density from the mentioned distance was calculated to be 6.25 J/cm². The other ten patients were treated with conventional surgery. Treatment outcomes were noted as either complete healing or incomplete healing. There were no statistically significant differences between laser surgery and conventional surgery. CTX values also did not affect the prognosis of the patients. Treatment outcomes were significantly better in patients with stage II osteonecrosis than in patients with stage I osteonecrosis. These findings suggest that dental evaluation of the patients prior to medication is an important factor in the prevention of BRONJ. Laser surgery is a beneficial alternative in the treatment of patients with this situation.

The purpose of a study by Bayram [7] was to investigate the effects of LLLT on cell proliferation and alkaline phosphatase (ALP) activity of human osteoblast-like cells (Saos-2) treated with different doses of zoledronate, the most potent bisphosphonate. Saos-2 cells were treated with different concentrations of zoledronate and were irradiated with diode laser (808 nm, 10 s, 0.25 or  0.50 W). Cell numbers and ALP activity of the cells were determined. LLLT mildly increased the proliferation rate or ALP activity, while zoledronate reduced both. When applied together, LLLT lessened the detrimental effects of zoledronate and improved cell function and/or proliferation. Based on the results of this study, it was concluded that LLLT has biostimulative effects on Saos-2 cells, even after treatment with zoledronate. LLLT may serve as a useful supportive method for BRONJ treatment through enhancement of healing by osteoblasts.

One hundred and twenty-eight patients (33 males, 95 females; 52 with diagnosis of multiple myeloma, 53 with diagnosis of bone metastasis, and 23 with diagnosis of osteoporosis) affected by BRONJ were evaluated by Vescovi [8] between January 2004 and July 2009. Overall number of BRONJ sites was 151, and number of treated sites was 101. In order to assess the efficacy of different treatments, sites were subclassified as follows: Group 1 (G1): 12 sites treated with medical therapy; Group 2 (G2): 27 sites treated with medical therapy associated with low level laser therapy (LLLT); Group 3 (G3): 17 sites treated with a combination of medical and surgical therapy; Group 4 (G4): 45 sites treated with a combination of medical therapy, surgical (including laser-assisted) therapy, and LLLT. Outcome of treatment was assessed using the staging system proposed by Ruggiero et al. Transition from a higher stage to a lower one for at least 6 months was considered as clinical improvement and suggestive of a successful treatment. Clinical improvement was achieved in 3 out of 12 (25%) BRONJ sites in G1. Sites if G2 with an improvement were 18 out of 27 (66%). Nine out 17 BRONJ sites (53%) in G3 had a transition to a lower stage after treatment. For sites in G4, a clinical improvement was recorded in 40 out of 45 cases (89%). In the experience of the research group, the percentage of success obtained with a combined approach based on medical therapy, surgical (including laser-assisted) therapy, and LLLT (G4) is significantly higher than the percentage of improvement obtained in G1, G2, and G3.

Further literature: [9-11]

1. Lerner U H, Mellström D. Behandlingsprinciper för olika läkemedel vid osteoporos. Tandläkartidningen. 2012.
2. Martins MA, Martins MD, Lascala CA, Curi MM, Migliorati CA, Tenis CA, Marques MM. Association of laser phototherapy with PRP improves healing of bisphosphonate-related osteonecrosis of the jaws in cancer patients: a preliminary study. Oral Oncol. 2012; 48 (1): 79-84.
3.  Kan B, Altay MA, Taşar F, Akova M. Low-level laser therapy supported teeth extractions of two patients receiving IV zolendronate. Lasers Med Sci. 2011; 26 (5): 569-575.
4. Romeo U, Galanakis A, Marias C, Vecchio AD, Tenore G, Palaia G, Vescovi P, Polimeni A. Observation of pain control in patients with bisphosphonate-induced osteonecrosis using low level laser therapy: preliminary results. Photomed Laser Surg. 2011; 29 (7): 447-452.
5. Vescovi P, Merigo E, Meleti M, Manfredi M, Fornaini C, Nammour S. Surgical Approach and Laser Applications in BRONJ Osteoporotic and Cancer Patients. J Osteoporos. 2012; 2012: 585434.
6. Atalay B, Yalcin S, Emes Y, Aktas I, Aybar B, Issever H, Mandel NM, Cetin O, Oncu B. Bisphosphonate-related osteonecrosis: laser-assisted surgical treatment or conventional surgery? Lasers Med Sci. 2011; 26 (6): 815-823.
7. Bayram H, Kenar H, Taşar F, Hasırcı V. Effect of low level laser therapy and zoledronate on the viability and ALP activity of Saos-2 cells. Int J Oral Maxillofac Surg. 2013; 42 (1): 140-146.
8. Vescovi P, Manfredi M, Merigo E, Guidotti R, Meleti M, Pedrazzi G, Fornaini C, Bonanini M, Ferri T, Nammour S. Early surgical laser-assisted management of bisphosphonate-related osteonecrosis  of the jaws (BRONJ): a retrospective analysis of 101 treated sites with long-term follow-up. Photomed Laser Surg. 2012; 30 (1): 5-13.
9. Rugani P, Acham S, Truschnegg A, Obermayer-Pietsch B, Jakse N. Bisphosphonate-associated osteonecrosis of the jaws: surgical treatment with ErCrYSGG-laser. Case report. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2010;110(6):e1-6.
10. Vescovi P, Merigo E, Meleti M, Manfredi M, Guidotti R, Nammour S.Bisphosphonates-related osteonecrosis of the jaws: a concise review of the literature and a report of a single-centre experience with 151 patients. J Oral Pathol Med. 2012; 41 (3): 214-221.

The word “alternative” has to be used with some caution when LPT is discussed. LPT is indeed an excellent alternative to many of the traditional medical procedures, but it is not “alternative medicine”. Using the word “alternative” may lead to a semantic misunderstanding, so I try to avoid it. A method which reports 194 RCT:s on the PEDRO physiotherapy site is not an “alternative” method! So what is “alternative medicine”? Let´s see what Wikipedia has to say:

Alternative medicine is any of a wide range of health care practices, products and therapies, using methods of medical diagnosis and treatments which, at least up to the end of the twentieth century, were typically not included in the degree courses of established medical schools teaching western medicine in the tradition of the Flexner Report or similar.^[1][2] Examples include homeopathy, Ayurveda, chiropractic and acupuncture.

Complementary medicine is alternative medicine used together with conventional medical treatment, in a belief, not proven by using scientific methods, that it increases the effectiveness, or “complements”, the treatment.^[3][4][5][6] CAM is the abbreviation for Complementary and alternative medicine.^[7][8] Integrative medicine (or integrative health) is the combination of the practices and methods of alternative medicine with evidence-based medicine.^[9]

It is true that many practitioners in the “alternative” field of medicine are using LPT. This doesn’t mean that the therapy itself is anything “alternative”, but I often sense a “guilt-by-association”.

OK, now that we have sorted out the meaning of “alternative” in medicine, let us see if LPT can be a valuable ALTERNATIVE in traditional medicine!

Would it be a good alternative to NSAIDs? Bjordal [1, 2] summarises that nonsteroidal anti-inflammatory drugs (NSAIDs), including cyclo-oxygenase-2 inhibitors (coxibs), reduce short-term pain associated with knee osteoarthritis only slightly better than placebo, and long-term use of these agents should be avoided. Up for analysis were 23 placebo-controlled trials involving 10,845 patients, 7767 of whom received NSAID therapy and 3078 placebo therapy. 21 of the NSAID-studies were funded by the pharmaceutical industry, and the results of 13 of these studies were inflated by patient selection bias as previous NSAID-users were excluded if they had not previously responded favourably to NSAID. Such an exclusion criterion for non-responders has never been seen in any controlled trial of laser therapy or other non-pharmacological therapies of osteoarthritis. In the remaining 10 unbiased NSAID-trials, the difference from placebo was only 5.9 mm on a 100 mm pain scale. This is far less than established data on differences that are considered minimally perceptible (9 mm) or clinically relevant (12 mm) for knee osteoarthritis patients. In addition, none of the trials found any effects beyond 13 weeks.

From the above, it seems that NSAIDs have only a short term effect in knee osteoarthritis, and it is not a daring guess to believe that the same goes for other joints too. Tens of thousands of persons die annually rather from taking NSAIDs over long periods than being helped by them. But they keep taking them because their doctors have no other alternative. At least that is what they believe. But watch this [3]:

OBJECTIVES: To estimate the effects of low level laser therapy in combination with a programme of exercises on pain, functionality, range of motion, muscular strength and quality of life in patients with osteoarthritis of the knee. DESIGN: A randomized double-blind placebo-controlled trial with sequential allocation of patients to different treatment groups. SETTING: Special Rehabilitation Services. SUBJECTS: Forty participants with knee osteoarthritis, 2-4 osteoarthritis degree, aged between 50 and 75 years and both genders. INTERVENTION: Participants were randomized into one of two groups: the laser group (low level laser therapy dose of 3 J and exercises) or placebo group (placebo laser and exercises). MAIN MEASURES: Pain was assessed using a visual analogue scale (VAS), functionality using the Lequesne questionnaire, range of motion with a universal goniometer, muscular strength using a dynamometer, and activity using the Western Ontario and McMaster Universities Osteoarthritis (WOMAC) questionnaire at three time points: (T1) baseline, (T2) after the end of laser therapy (three weeks) and (T3) the end of the exercises (11 weeks). RESULTS: When comparing groups, significant differences in the activity were also found (P = 0.03). No other significant differences (P > 0.05) were observed in other variables. In intragroup analysis, participants in the laser group had significant improvement, relative to baseline, on pain (P = 0.001), range of motion (P = 0.01), functionality (P = 0.001) and activity (P < 0.001). No significant improvement was seen in the placebo group. CONCLUSION: Our findings suggest that low level laser therapy when associated with exercises is effective in yielding pain relief, function and activity on patients with osteoarthritis of the knees.

LPT has no serious side effects. Many of these patients have chronic problems, but after being properly diagnosed and treated by a professional, home laser units are available. So: long time effect (lifelong), no side effects, cost effective. Seems to be a fair alternative to NSAIDs.

Here is my second example. The following paper [4] is long, but worth reading:

In the UK, chronic wounds represent a significant burden to patients and the NHS. Some 200,000 patients in the UK have a chronic wound. The impact on their quality of life is well documented (Franks and Morgan, 2003). Common symptoms of ulceration include pain, exudate and odour, and these symptoms are frequently associated with poor sleep, loss of mobility and social isolation. The cost to the NHS of caring for patients with a chronic wound is conservatively estimated at 2.3bn–3.1bn per year (at 2005–2006 costs), around 3% of the total estimated out-turn expenditure on health (89.4bn) for the same period (Posnett and Franks, 2007). With proper diagnosis and treatment, much of this burden should be avoidable.

Venous leg ulcers

Leg ulceration is most commonly caused by venous hypertension resulting from valvular incompetence in the superficial, deep or perforating veins. Sustained venous hypertension causes swelling, restricted blood flow and damage to the skin and other tissues.

Population prevalence rates generally fall in the range of 1.2–3.2 per 1,000 people (Graham et al, 2003), which means there are 70,000–190,000 individuals in the UK with a venous leg ulcer at any time. Prevalence increases markedly with age. A UK study examined the prevalence of venous ulceration in a local population (Moffatt et al, 2004). Crude prevalence was 0.3/1,000 in men and 0.5/1,000 in women. In those aged over 85, rates were 8.29/1,000 (men) and 8.06/1,000 (women). In this study, 55% of patients had had their ulcer for longer than a year.

The cost to the NHS of treating patients with venous ulceration, mostly in primary care and through community nursing services, is at least 168–198m per year.

Pressure ulcers

A pressure ulcer is an area of damage to the skin and underlying tissue that is caused by unrelieved pressure, friction and/or shear forces.

A severe ulcer is susceptible to infection and may be life-threatening.

It is estimated that one in five hospital inpatients has a pressure ulcer (Clark et al, 2004) – this represents at least 20,000 hospital patients in the UK at any time. Many more individuals with an ulcer are cared for at home or in residential and nursing homes but the prevalence of ulceration in these settings is not well-documented in the UK (Bennett et al, 2004). In the UK, around 400,000 individuals develop a new pressure ulcer annually. The cost to the NHS is high, primarily because prolonged hospital treatment is needed in serious cases and those at risk must be protected. The annual cost is in the range of 1.8–2.6bn).

Foot ulcers

Foot ulceration is a common complication of diabetes. Gradual loss of sensation renders the foot susceptible to even minor trauma. Susceptibility to infection and peripheral vascular disease inhibit healing once injury has occurred and may lead to gangrene and amputation. The age-adjusted rate of lower-limb amputation is estimated to be 15 times higher in individuals with diabetes than in the general population (Armstrong et al, 1997). In the UK it is conservatively estimated that there are around 64,000 individuals with active foot ulceration at any time and 2,600 amputations annually in patients with a foot ulcer (Gordois et al, 2003). The cost to the NHS is around 300m per year.

Future trends

Trends in the structure of the UK population over the next 20 years are likely to lead to a significant increase in the number of patients with chronic wounds. The population of the UK is forecast to increase between 2005 and 2025 by 3.4 million (5.6%) from 60.4 million to 63.8 million. In the same period, the UK population aged 65 and older is forecast to increase by 3.5 million (36%) from 9.5 million to 13.0 million (US Census Bureau).

The prevalence of chronic ulceration is higher in the population aged over 65. In one UK prevalence study, 68% of patients with a leg ulcer were aged 65 or more (Gottrup et al, 2001). In a similar study in Australia, 90% of patients with a venous leg ulcer were aged over 60 and the median age of these patients was 75 years (Kumar et al, 1994). In the US, 72% of hospital stays in which pressure ulcers were noted occurred in patients aged 65 or above (Russo and Elixhauser, 2003).

The prevalence of type two diabetes is also strongly correlated with age. One estimate claims the number of individuals in the UK with type two diabetes will increase between 2000 and 2010 by more than one million (55%) (Amos et al, 1997). The expected increase in the number of people with diabetes alone could increase the number of new cases of foot ulceration by 25,000 a year.

Reducing the chronic-wound burden

A wound audit was carried out in a population of around 590,000 in the UK in mid-2005, covering both acute and community health services (Drew et al, 2007). It highlighted some of the practical issues of chronic wound care in the NHS.

One audit feature was the fairly high incidence of non-healing wounds. One in three chronic wounds had been unhealed for at least six months and one in five for a year or more. Almost 42% of leg/foot ulcers had not healed in the previous six months and 28% had been unhealed for a year or longer. In an audit at the Mid-Western Health Board in Ireland, the median duration of ulceration was eight months and 27% of patients had had continuous ulceration for two years or more (O’Brien et al, 2002). In a similar Canadian audit (Lorimer et al, 2003), the median duration of leg ulceration was six months (mean duration was 15 months). One-third (33%) of patients had had an ulcer for over a year and 19% had had one for over two years.

The problem of delayed healing highlights the importance of effective diagnosis and appropriate treatment. Drew et al’s (2007) UK audit showed that 26% of wounds classified as leg or foot ulcers had no definite diagnosis. Of the 432 leg ulcers classified as venous, 24% had not had a Doppler assessment, and 46% of patients with a venous leg ulcer did not receive multilayer high compression. This is not unique to the UK: a review of wound treatment in a primary-care setting in Copenhagen found that only 51% of patients with a chronic wound had had a significant diagnostic examination; 40% of patients with suspected venous leg ulcers had not been treated with compression and 34% of those with a foot ulcer were not investigated for diabetes (Gottrup et al, 2001). In the Irish audit (O’Brien et al, 2002), only one-half of patients with a leg ulcer had had its cause properly investigated.

Nurse time is an important component of cost. The estimate in the UK audit suggests nurse time accounts for 33–41% of the total cost (Drew et al, 2007). This is probably too low as it does not account for the time nurses spend assessing and monitoring wounds or repositioning patients at risk of pressure damage. On the basis of the UK audit, dressing changes alone might have required the equivalent of 88.5 full-time nursing staff annually across acute and community sectors.

Conclusion

UK cost estimates are subject to a wide margin of error, but are sufficiently accurate to indicate that wound care has a significant impact on NHS resources. Results from local audits of wound-care practice in the UK and elsewhere highlight that a relatively high proportion of chronic wounds remain unhealed for long periods – almost certainly longer than necessary. Likely reasons for this include just treating the ulcer itself, rather than diagnosing and treating its underlying cause.

One gets the impression that non-healing wounds is a real problem and quite costly. Any savings around the corner? Read this link and find out: http://www.laserannals.com/2013/01/22/the-wound-healing-contradiction

Here is yet another field where LPT would be a good alternative. Some statistics:

Diabetes increase in the USA:

Data from the 2011 National Diabetes Fact Sheet (released Jan. 26, 2011)

Total prevalence of diabetes

Total: 25.8 million children and adults in the United States—8.3% of the population—have diabetes.

Diagnosed: 18.8 million people

Undiagnosed: 7.0 million people

Prediabetes: 79 million people*

New Cases: 1.9 million new cases of diabetes are diagnosed in people aged 20 years and older in 2010.

The above are just a few examples of areas where LPT can be a valuable alternative and/or complimentary therapy.

On top of this, here are some mortality statistics on premature death due to lack of effect of antibiotics: 100 000 US per year, 8 000 Chinese, 25 000 Europeans. LPT does not kill these drug resistant bacteria but effective use of LPT will contribute to situations where mortal bacterial infections will not appear.

Laser phototherapy: Safe, cost effective but sparsely used. Any medical decision maker around interested in cutting costs?

References

[1] Bjordal JM, Klovning A, Ljunggren AE, Slørdal L. Short-term efficacy of pharmacotherapeutic interventions in osteoarthritic knee pain: A meta-analysis of randomised placebo-controlled trials. Eur J Pain. 2007;11(2):125-138.

[2] Bjordal JM, Ljunggren AE, Klovning A, Slørdal L. NSAIDs, including coxibs, probably do more harm than good, and paracetamol is ineffective for hip OA. Ann Rheum Dis. 2005;64(4):655-656.

[3] Alfredo PP, Bjordal JM, Dreyer SH, Meneses SR, Zaguetti G, Ovanessian V, Fukuda TY, Junior WS, Lopes Martins RÁ, Casarotto RA, Marques AP. Efficacy of low level laser therapy associated with exercises in knee osteoarthritis: a randomized double-blind study. Clin Rehabil. 2012;26(6):523-533.

[4] Posnett, J., Franks, P.J. The burden of chronic wounds in the UK. Nursing Times. 2008; 104: 3, 44–45.

By Jan Tunér

Improved wound healing was one of the first discoveries when low level laser was tested in medicine. Since then, a multitude of cell studies and animal studies have been carried out and published. The overall result is that dosages within the “therapeutic window” have an impressing effect on wound healing, and in particular for the healing of chronic wounds. Nevertheless, its use in traditional medicine is more of an exception than a rule. And why? Probably because the clinical studies are so few. This is rather surprising. With the vast number of cell and animal studies as support, one could presume that there would be an interest in clinical studies. But these are few and small. Is it because other methods are working well? No! In Sweden alone, with a population of 9 million inhabitants, more than 40 000 persons are suffering from chronic wounds. The average cost per patient and year is estimated to be around 3 000 euro. That adds up to 120 million euro! Are new method needed? Are big national savings around the corner?

Clinicians using LLLT for wound healing know very well that it has an impressing effect, if applied within the therapeutic window. What is typical of a chronic wound is exactly that it is chronic. But with LLLT these wounds start to heal. Typically, the pain disappears after a few sessions. Often, what looks like a worsening of the situation appears, but this is just the phase when the chronic wound turns into an acute wound. And different from the chronic wound – the acute wound has an ability to start a healing process.

Let us look at just one single case. The lady on the two photos below had been suffering from her leg ulcer for about 10 year and “everything” had been tried. The “discovery” in the dental situation was just a coincidence, and I offered her LLLT. One session was performed with 100 mW 660 nm, and then the patient had a home laser unit on loan (Treatlite, Sweden, 70 mW, 808 nm). After a few sessions, the pain was gone and within four months the wound caused no problems for the patient. She now only has a pigment change in the area.

 Treatlite home care laser unit

Diabetes is increasing rapidly and the poor wound healing ability of diabetic patients leads to chronic wounds and many amputations. Below is an impressing case of wound healing in a diabetic patient. Could any other therapy do this?

So here is the contradiction: (1) Chronic wounds are chronic in their nature, and the number of chronic wounds is steadily increasing. From a strict economic point of view, Health Care authorities and insurance companies could save a lot of money by introducing new and better methods (not forgetting the individual suffering).  (2) Cell and animal studies are strongly pointing at the value of introducing LLLT. But to finally convince the medical authorities, more and better clinical studies are needed. But no one seems to be interested. Catch 22!

Examples from the literature:

1)    History

Abergel P, Lyons R, Castel J, Dwyer R, Uitto J. Biostimulation of wound healing by laser: Experimental approaches in animal models and in fibroblast cultures. J.Dermatol. Surg. Oncol. 1987; 13: 127-133.

Bihari I, Mester A. The biostimulative effect of low level laser therapy of long-standing crural ulcer using Helium Neon laser, Helium Neon plus infrared lasers and noncoherent light: Preliminary report of a randomized double blind comparative study. Laser Therapy. 1989; 1 (2): 97-102.

Mester E et al. Effect of laser-rays on wound healing. Am J Surg. 1971; 122 (4): 532-535.

2)    Cells

Hawkins D, Abrahamse H. The role of laser fluence in cell viability, proliferation, and membrane integrity of wounded human skin fibroblasts following helium-neon laser irradiation. Lasers Surg Med. 2006; 38 (1): 74-83.

Hawkins D, Abrahamse H. Biological effects of helium-neon laser irradiation on normal and wounded human skin fibroblasts. Photomed Laser Surg. 2005; 23 (3): 251-259.

Houreld N, Abrahamse H. Effectiveness of Helium-Neon Laser Irradiation on Viability and Cytotoxicity of Diabetic-Wounded Fibroblast Cells. Photomed Laser Surg. 2007; 25 (6): 474-481.

3)    Diabetic wounds, animals

Reddy K, Stehno-Bittel L, Enwemeka C. Laser photostimulation accelerates wound healing in diabetic rats. Wound Repair and Regeneration. 2001, 9 (3): 248-255.

Byrnes K R, Barna L, Chenault V M et al. Photobiomodulation improves cutaneous wound healing in an animal model of type II diabetes. Photomed Laser Surg. 2004; 22 (4): 281-290.

Maiya G A, Kumar P, Rao L. Effect of low intensity helium-neon (He-Ne) laser irradiation on diabetic wound healing dynamics. Photomed Laser Surg. 2005; 23 (2): 187-190.

Bicalho Rabelo S, Balbin Villaverde A , Amadei Nicolau  R, Castillo Salgado M A et al. Comparison between Wound Healing in Induced Diabetic and Nondiabetic Rats after Low-Level Laser Therapy. Photomed Laser Surg. 2006; 24 (4):  474-479.

Al-Watban F, Zhang X Y, Andres B L. Low-Level Laser Therapy Enhances Wound Healing in Diabetic Rats: A Comparison of Different Lasers. Photomed Laser Surg. 2007, 25 (2): 72-77.

Al-Watban F A. Laser Therapy Converts Diabetic Wound Healing to Normal Healing. Photomed Laser Surg. 2009; 27 (1): 127-135.

Al-Watban F A, Zhang X Y, Andres B L, Al-Anize A. Visible lasers were better than invisible lasers in accelerating burn healing on diabetic rats. Photomed Laser Surg. 2009; 27 (2): 269-272.

4)    Literature reviews

Woodruff L D, Bounkeo J M, Brannon W M, Dawes Jr K S et al. The efficacy of laser therapy in wound repair: a meta-analysis of the literature. Photomed Laser Surg. 2004; 22 (3): 241-248.

Enwemeka C S, Parker J C, Dowdy D S et al. The efficacy of low-power laser in tissue repair and pain control. A meta-analysis study. Photomed Laser Surg. 2004; 22 (4): 323-329.

Bjordal J M, Bensadoun R J, Lopes–Martins R A, Tunér J, Pinheiro A, Ljunggren A E. A systematic review of low level laser therapy (LLLT) in cancer therapy-induced oral mucositis. Support Care Cancer. 2011; 19 (8): 1069-1077.

5)    Clinical studies

Hopkins J T, McLoda T A, Seegmiller J G, Baxter G D. Low-Level Laser Therapy Facilitates Superficial Wound Healing in Humans: A Triple-Blind, Sham-Controlled Study. J Athl Train. 2004; 39 (3): 223-229.

By Jan Tunér

If you do not think that laser light can penetrate deep into human tissue, just have a look at the photo below. What you see is a 660 nm, 60 mW laser shining through a finger.

Not bad! Strong penetration! And below is the wavelength indicator of the Coherent LaserCheck and the measured output: 660 nm, 60.6 mW.

However, how much is really getting through the finger? Well, not as much as your eye would think. Look here when the 60.6 mW laser is measured after passing through the same finger:

 0.27 mW remains, 60.33 mW lost! So do not trust your eyes when you try to find out about penetration.

And if you think that irradiating through clothes is a good idea, check here:

http://www.youtube.com/watch?v=MkGJvvWD1vw

By Jan Tunér

“The work of revealing pseudoscience can be compared to the work of a dustman. If the garbage is collected today, it doesn’t mean that there will be no garbage tomorrow. But if no garbage was collected, the result would be even worse”

(L Sprague de Camp, The Fringe of the Unknown, 1983, s 201)

In 1994 the Swedish company Biolight had a full page advertisement in one of the leading Swedish newspapers. The product presented was an ingenious new concept of treating pathological conditions with light. It was said to be very useful for wound healing, and a contract had just been signed with a UK company working in this field. The market for treating non-healing wounds in the UK was estimated to many million pounds. Investors were invited to buy shares. And the investors arrived. Biolight managed to raise almost 1 million UKP. No one in the biostimulation business had ever managed to do this before.

So, what is Biolight and how did the company use the investors’ money? Well, it is an LED machine, emitting a combination of different wavelengths with preset modes of pulsation. Monochromatic infrared light at 956 nm and red light at 637 nm with light power 55.3 W/m² and total amount of energy 1.5 J/cm² is reported in a clinical study on wound healing. The method is said to be patented. Looks interesting.

Well, the patent regards the type of pulsing. And since little is known about the effects of pulsing, and anyone could build a similar device, just changing the pulsing pattern a little, the patent seems to be of limited value. One smart detail, though, was the “credit card”. When the device was delivered, a smart card was inserted into the device to make it work. And after a number of operating hours, the card was empty and a new card had to be bought. Brilliant idea!

With all this money, one would expect Biolight to be able to sell well. But annual sales were around UKP 35 000. Two Swedish studies on wound healing were sponsored, and showed limited but positive results (1, 2). A study on gingivitis was performed but not accepted for publication. A few animal and cell studies have been presented at congresses (3). But in the end all that money was gone.

Now Biolight is making an identical effort. Full-page advertisement, stating “Breakthrough on several new markets”. Again the bait is a contract with a US company, accepted to sell to the US Defence (hundreds of companies are). And the market is estimated to 20 billion euro, in Europe alone. This is true, but what about the potential of grabbing even a fraction of this market? Investors will be disappointed again.

Is Biolight a pseudoscientific product? Not really, we all know that different kinds of light have an effect of e.g. wound healing. But the problem is the megalomaniac claims of the company and its marketing methods. The scientific documentation for laser therapy was scant in 1994 and that for LEDs even less, to say the least. Today, the evidence for laser therapy and even LED therapy has increased a lot. With all this knowledge, the superiority of a very particular combination of LED pulsing lights seems even more remote. Most serious LLLT/LED companies could today provide better documentation about their products than Biolight can. But only one has had a talent to make stock market investors pay the salaries of the “inventors” for almost two decades. Well done.

References:

1. Schubert V, Zander M Analysis of the measurement of four wound variables in elderly patients with pressure ulcers. Adv Wound Care. 1996;9(4):29-36.

2. Schubert V. Effects of phototherapy on pressure ulcer healing in elderly patients after a

falling trauma. A prospective, randomized, controlled study. Photodermatol Photoimmunol Photomed. 2001;17(1):32-38.

3. http://www.biolight.se/wp-content/uploads/2011/06/Kliniska-studier-i-sammanfattning.pdf (summary of studies, in Swedish)

By Jan Tunér

In recent years there has been a lot of publicity about the dangers of the green laser pointers. Most media reports indicate that these lasers can harm the eye permanently. Is this true or false? Let us consider some facts:

1. Rascals have been pointing their green laser pointers at airplanes and cars. This is of course not acceptable. Those who have been “attacked” have been taken to hospitals and doctors have reported eye injuries. Has indeed anyone been injured permanently this way? Answer: No!
2. Still, what really count are the media (and medical) reports that these lasers can damage your eyes. Believing in this, the attacked person is not only irritated by the light, he is also afraid. And a frightened pilot/driver is not a very good one. So even if he is “only” partially blinded by the ray, he is in addition a danger through his own fantasies.
3. Now, it seems that I am implying that these lasers are not at all dangerous. You are right.  At least as far as the ocular hazard goes. Several media reports have actually mentioned the output of the laser – 5 mW. Suppose you try to hit an object of the size of a human eye, moving at 100-200 km/h from a distance of 100-400 m. Is it even possible? And if so, for how many milliseconds? And remember that the beam is not completely collimated, the beam is divergent and the power density decreases. Our eyes are very sensitive to green, so the actual strength of the beam is difficult to estimate by the naked eye.
4. Is there a power limit, then? Of course. Take a cheeseburger, and you are fine. Take 50 and you are in big trouble! In my lectures I often use a 60 mW green laser (properly measured) and circle the light right into my eyes from a distance of a few cm. My visual acuity is fine, I can show you records! And then what I do not do, but everybody else does, is to activate the blink reflex. The attacked pilot/driver would do so in less than a second.
5. So where is the limit? Green laser pointers of an output of 1500 mW can be obtained on the internet. Are they dangerous for our eyes? Of course. 300 times stronger than the 5 mW laser, being accused of causing permanent ocular damages. The limit is in the intensity and the time of exposure.  And the person using a 1000 mW+ green laser in the public arena is not a young thoughtless rascal, he is criminal.
6. Reading the above, you may think that I am “pro green lasers”. Not at all. I don’t even like them in lectures, because the light is too strong and rather irritating. They were a fancy gadget in the beginning, that’s all. The 2-5 mW red lasers are much better. And even though the green laser pointers on the low output side do not cause ocular hazard, they are a real nuisance, and I do support authorities forbidding their use in public places.  But right is right and wrong is wrong. And media is 90% wrong, and so are the various authorities.
7. Pilots are often seen wearing sun glasses. This is partly to look fancy but also to protect them from being blinded by the sun. They now often have auxiliary green light protective glasses. And many police cars are equipped with them. But you would have to wear them all the time to be protected; there is no time to put them on if you discover an “attack”. And if your employer is close fisted, he buys cheap protective glasses and you are hit by the infrared light in the beam (yes, there is) without knowing it.

So, summing up: The commonly used green laser pointers pose no threat to our eyes, but they can temporarily and partially blind a person, like a reflexion from the sun. The fear of the lasers poses a greater threat than the actual harm they are capable of doing. Still, the banning of them makes sense. But let us stick to the facts!

And if you don’t believe me, read this:

Ivandic BT, Ivandic T. Low-level laser therapy improves vision in patients with age-related macular degeneration. Photomed Laser Surg. 2008 Jun;26(3):241-5.

University of Heidelberg, Otto-Meyerhof Centre, Heidelberg.

boris.ivandic@med.uni-heidelberg.de

OBJECTIVE: The objective of this study of a case series was to examine the effects of low-level laser therapy (LLLT) in patients with age-related macular degeneration (AMD).

BACKGROUND DATA: AMD affects a large proportion of the elderly population; current therapeutic options for AMD are limited, however.

PATIENTS AND METHODS: In total, 203 patients (90 men and 113 women; mean age 63.4

+/- 5.3 y) with beginning (“dry”) or advanced (“wet”) forms of AMD (n = 348 eyes were included in the study. One hundred ninety-three patients (mean age 64.6 +/- 4.3 y; n = 328 eyes) with cataracts (n = 182 eyes) or without cataracts (n = 146  eyes) were treated using LLLT four times (twice per week). A semiconductor laser diode (780 nm, 7.5 mW, 292 Hz, continuous emission) was used for transconjunctival irradiation of the macula for 40 sec (0.3 J/cm²) resulting in a total dose of 1.2 J/cm². Ten patients (n = 20 eyes) with AMD received mock treatment and served as controls. Visual acuity was measured at each visit. Data were analyzed retrospectively using a t-test.

RESULTS: LLLT significantly improved visual acuity (p < 0.00001 versus baseline) in 162/182 (95%) of eyes with cataracts and 142/146 (97%) of eyes without cataracts. The prevalence of metamorphopsia, scotoma, and dyschromatopsia was reduced. In patients with wet AMD, edema and bleeding improved. The improved vision was maintained for 3-36 mo after treatment. Visual acuity in the control group remained unchanged. No adverse effects were observed in those undergoing therapy.

CONCLUSION: In patients with AMD, LLLT significantly improved visual acuity without adverse side effects and may thus help to prevent loss of vision.

P.S. If you are the owner of a green laser pointer, don’t throw it away. It is fine for herpes! But watch your eyes…

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