Class IV Laser in Non-invasive Laser Therapy
Miroslav Prochazka, M. D., Head Doctor of the Private Rehab Clinic Jarov, Prague, CZ
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Abstract

The title must have awakened curiousness of every supporter of non-invasive laser therapy, or at least a bit of amusement. Since the very first small steps on the long and manifold path of laser medicine we have been aware that despite dynamic development of this technique, yet there is a couple of firm reference points. Laser will always mean radiation of light with perfect coherence and monochromaticity. We will never direct a laser in the eye and we will always mind also other contra-indications. Lasers in class IIIa and IIIb are intended for applications in terms of non-invasive laser therapy (LLLT), whilst class IV lasers are meant for use in surgical specialties ... Or perhaps, maybe it is not quite so ?

Output power is one of the most important parameters of a laser, indirectly affecting also the spectrum of possible applications as well as time required to perform therapy. Years back, low level laser therapy (LLLT) manufacturers had provided devices fitting into class IIIa, often with output power not exceeding 3 or 5 mW, especially HeNe sources which were mainly used for superficial conditions, such as wound healing. Expansion of application spectrum of LLLT into pain management and therapy of locomotive apparatus clearly pointed to the need of higher output levels and, similarly, led to implementation of other wavelengths with deeper penetration in tissue (IR). Nowadays, therapists usually work with infrared laser probes with 300 and more milliwatt of power, and values of 450 - 500 mW represent an imaginary boundary for both manufacturers and therapists, behind which laser devices are classified in laser class IV, with all consequences in terms of hygienic rules and labour safety applicable. There is no need to remark that hand in hand with increasing output of non-invasive lasers, as well as due to long-term clinical experience, higher and higher dosages of energy are also being administered.

Arndt-Schultz Law stipulates that effect of therapeutic laser appears when a certain threshold limit of irradiated energy is exceeded, and is rising till a level called plateau of effect is reached. As soon as the plateau is reached, further increasing of energy dosage has allegedly no influence on desired result of therapy. On the contrary, from a certain level on (literature indicates ca 16 J/cm2) the effect of laser is purportedly decreasing. However, in my opinion this applies only (though not quite unequivocally) to in-vitro experiments with cellular cultures, not taking into consideration (as it is practically impossible) the whole complex of effects of laser on living organism within the frameworks of therapy of a defined syndrome or complaint, comprising systematic effect, analgesic and antalgic effect, antiphlogistic and vasodilatation effect, biostimulation etc. Vice versa, in clinical practice it is obviously necessary to declare that the higher dosage of energy is irradiated, the better therapeutic effect is achieved. Furthermore, in case of deep seated applications we must take into account substantial loss of energy in the course of penetration of laser beam through tissue structures (skin, subcutaneous fat, muscles, sinew, bone). That is why we have been meeting with significant increase of recommended dosages of energy in treating deeply located conditions. However, this is only a nominal increase; in fact the real irradiated dosage of energy into the target structure is lower just due to high absorption in tissue. Herat a certain sufficient real amount of energy in the target area must be accomplished, which is unfortunately something that can hardly be achieved working with lasers with too low output power. Apart from that we have to note that higher output of our device equals shorter therapy time, which is in terms of laser therapy more than a substantive factor. Practical experience of our clinic, which has been working as a supervisory and consultatory workplace for almost the whole of the country, allows us to state that preponderance of clinical fiascos of LLLT is caused by underdose.

Lack of power is something that surgical high power lasers surely do not suffer from. In fact, any class IV surgical laser can be used for therapeutic irradiation. Thus we are well familiar with Nd:YAG laser inducing analgesic effects prior to a preparation in dentistry, or in treatment of arthritis in rheumatology. Argon and KTP lasers are routinely used for teeth whitening, though they have also been tested in dermatological applications, such as treatment of psoriasis. Ruby laser had been used by Endre Mester as the first laser for biostimulation and wound healing, furthermore proving to be useful in healing up bed sores, varicose ulcers and shingles. Excimer and Alexandrite lasers are capable of treating some superficial dermatologic conditions, whilst high power diode lasers can manage treatment of painful joint ailments. The advantage of all those lasers is their ability to irradiate high dosages of energy on large areas. However, it is necessary to defocus the beam or to scan it over the skin so that concentration of high dosages of energy to a little spot, leading to thermal damage of tissue, be eliminated. On the other hand, high price of those lasers is a serious disadvantage, almost disqualifying them economically for the use in laser therapy, because comparable results can be obtained with lasers the price of which is roughly 10 to 50 times lower.
Our clinic had also been using a CO2 surgical laser which was used in co-operation with a dermatologist and a surgeon to handle various minor excisions of superficial skin efflorescences. In several patients we had also tried the effect of therapeutic irradiation in short application times and from a distance. Those patients were suffering from torpid, long lasting therapeutic interventions not affected by pain in joints (especially with decompensated arthrosis) or sinews (epicondyllopathy). We were able to irradiate values of hundreds of J/cm2 in time equal to 5 - 10 seconds. Majority of patients treated in this way noticed significant subjective relief after this therapy.

Recently we have had an opportunity to test a very interesting therapeutic laser working with an output up to 4 Watts at the end of the probe. This is a parameter classifying the device positively in class IV, with all the conditions of operation resulting from that. Two semiconductor diodes, each with 2 W output, working in 980 nm and 810 nm wavelengths respectively, are the source of laser radiation. The manufacturer rationalizes the use of the two wavelengths claiming that 810 nm penetrates as much as into 8 cm depth in the tissue, whilst 980 nm wavelength is being caught mainly in superficial layers of skin, thus inducing desired chain of reflexive changes. Simultaneous application of both the wavelengths in therapy thus contributes to optimizing therapeutic effect.

The laser can work in different frequency modes, and it is also possible to set output power of the probe individually for every patient (in 1 mW increments within the range of 0 - 4.0 W). It is possible to use two different frequency modes, either modulated or in pulses, the former being intended for treating deeply seated pathological and painful conditions, the latter used mainly for analgesic purposes. Combination of various frequency modes is recommended, as well as combination of short point treatments of the most painful spots with area irradiation of the whole of the treated site with total irradiated amount of energy in the order of hundreds of J/cm2.

The 980 nm wavelength induces a sense of warmness in treated patients; therefore it is useful to carry out a simple "heat test" of patient’s toleration. Patients should feel warmth after about seven seconds of application of continuous beam, in this case an ideal output power for a patient is set. In the course of initial application we never continue in therapy in the event that the patient denotes subjective unpleasant feelings. With regard to explicit thermal effect of this therapy, practically always after irradiation a light erythema appears on treated part of the body. No side effects of the therapy have been noticed.

Therapy with a powerful laser with 4 W output and in special short-term CW and frequency modes appears to be an interesting way to further development of LLLT in pain management. A sophisticated device, utilizing a combination of two IR wavelengths can prove its advantages in clinical use, especially in treating patients where "classical" non-invasive lasers do not achieve much clinical success. The price, which is substantially higher than ordinary price of therapeutic lasers, although obviously not reaching the amounts common for surgical lasers, may present a certain obstacle in major expansion. Some applicants may also be discouraged by the necessity to observe hygienic rules which are stricter for class IV lasers when compared with rules for the use of common class IIIb therapeutic lasers.

Laser therapy of human herpes simplex lesions

By Arturo Guerra Alfonso and Pedro José Muñoz, Clinic "Leonardo Fernández Sánchez" , Cienfuegos, Cuba.
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Herpes simplex is an illness caused by the human herpes virus types 1 and 2 that generally present a primary lesion, with periods of latency and a tendency to relapse. It is also known as Button of fever or Bladder of fever. According to the World Health Organisation (WHO) an international prevalence of about 60% is observed (1, 2). 

An experimental study was carried out, where 232 patients affected by the Herpes simplex type 1 virus were treated. All patients attended the clinic "Leonardo Fernández" of the area 3 of the municipality of Cienfuegos, during the period of January 2001 to January 2003, with the objective of determining the time of recurrence of the labial Herpes in the groups, studied before and after treatment, and to evaluate the effectiveness of the Laser of low power in the treatment of the infection of the virus.

Two groups were selected (study and control) with 116 patients in each group, distributed and classified according to the clinical stage in which they went to consultation. In the study group the patients were offered treatment with a LASERMED 670 DL, a GaAlAs diode laser (30mW – 40 sec) in the prodromal stage and stage of vesicles; or (20mW – 2 min) in the crust stage and in lesions infected secondarily. To all these patients was also applied radiation among the vertebras C2-C3 where the resident ganglion of the virus is located during the latent periods (30mW - 30sec). 

The control group was offered indicated treatment with antivirals (Aciclovir in cream and in pills) and other palliative therapies. 

After having carried out the analysis of the data obtained, the following results were obtained:

Chart No. 1                                                           

The patients of the study group. Distribution according to the frequency of annual recurrence of the labial herpes before and after receiving treatment. 

When analyzing the chart No.1 it is observed that the groups of patients that had Labial Herpes with high frequencies of recurrence (after being treated with Laser and to wait one year to evaluate their effectiveness), reported recurrence for more elongated periods of time and 32 patients didn't even have any more recurrence.

Chart No.2                                                                                        

The patients of the control group. Distribution according to the annual recurrence frequency of the labial herpes before and after receiving treatment.

In the chart No. 2 the same previous aspects are reflected but in the control group. As can be observed the cases diminished in number, although discreetly; those that presented more recurrence and of equal number of recurrencies increased in number of patient in the periods of more lingering recurrence. In this group 2 patients reported not to have had more lesions during the analyzed year.

Chart No.3                                                                     

The patients of both groups. Distribution according to the annual recurrence frequency of the labial herpes after receiving treatment.

In the chart No. 3 are compared both groups as for the annual frequency of recurrence after having received the corresponding treatment. When analyzing this, the superiority of the group treated with Laser becomes evident.

Chart No. 4                                                                                       

The patients' of both groups. Distribution with relationship to the clinical stage in that we intervened and the time of cure of the same ones.

As can be observed in the chart 4, in the study group 100% of the prodromal stages, 95% of the vesicular ones and 91% of crust stages were able to cure during the first 48 hours. The patients with lesions infected secondarily needed more than 48 hours to cure, although they never surpassed 5 days. 

These results, although astonishing, are corroborated by authors like Tunér and Schindl where they highlight that a treatment with laser in the initial stages of the Labial Herpes has a percentage of superior success compared to conventional treatments, besides achieving an almost immediate relief of the symptoms (3, 11). 

In the control group remarkable differences are appreciated when comparing them with that of the study group. The therapy with Aciclovir in early stages (the first 72 hours) has been broadly suitable for many professionals and their use against the Labial Herpes has been studied by some authors (5).

CONCLUSIONS 

- The periods of annual recurrence in the study group were prolonged considerably after having received the treatment, while in the control group so evident changes were not shown. 

- In the prodromal period the patients treated with Laser all cured in the first 48 hours, while those treated conventionally needed from 3 to 4 days to cure. - In the vesicular period and of crust, those of the study group cured in majority during the first 48 hours, while those of the control group needed more than 5 days. 

- In infected lesions those treated with Laser cured mainly from 3 to 4 days, while those treated with medications needed more than 7 days to cure.

References:

1. Santana JC. Atlas of pathology of the buccal complex. Havana: Editorial scientific-technique, 1985:30-34. 

2. Eversole LR. Buccal pathology. Diagnosis and Treatment. Havana: Editorial scientific-technique, 1985:82-87. 3. Tunér J, Hode L. Low level laser therapy - clinical practice and scientific background. 1999. ISBN 91-630-7616-0. 

4. Parker J et al. The effects of laser therapy on tissue repair and pain control: a meta-analysis of the literature. Proc. Third Congress World Assn for Laser Therapy, Athens, Greece, May 10-13 2000; p. 77.  

5. Vélez-González M et al.  Treatment of relapse in herpes simplex on labial and facial areas and of primary herpes simplex on genital areas and area pudenda with low power HeNe-laser or Acyclovir administrated orally. SPIE PROC. 1995; Vol. 2630: 43-50 

6. Garrigó MI, Valiant C. Biological Effects of the radiation Laser of low power in the repair hística. Rev. Cub Estomat, 1996; 33(2). 7. In: Simunovic Z, editor: Lasers in Medicine and Dentistry. Vitagraf, Croatia, 2000. 

8. Valiant C, Garrigó MI. Laser therapy in the treatment of dental affections. Ed. Academy, Havana, 1995: 30-32. 

9. Valiant C. Cuban Experience in the application of the Laser of low power. I study international: Application of the Laser of low power in dentistry. CIMEQ, City of Havana, April 2001. 

10. Garrigó MI. Clinical procedures with Laser in bucodental illnesses. I study international: Application of the Laser of low power in dentistry. CIMEQ, City of Havana, 2001. 

11.Schindl A, Neuman R. Low-intensity laser therapy is an effective treatment forrecurrent herpes simplex infection. Results from a randomized double-blind placebo-controlled study. J Invest Dermatol. 1999: 113 (2): 221-223.

CLINICAL EFFECTS OF FOCALISED AND DEFOCALISED CO2 LASER ON EQUINE DISEASES
Arne Lindholm1, Ulf Swensson1, Eje Collinder2*
*1 Mälaren Equine Hospital, Hälgesta 1, S-193 91 Sigtuna, Sweden
2 Microbiology and Tumor Biology Centre, Karolinska Institutet, von Eulers väg 5, S-171 77 Stockholm, Sweden

ABSTRACT
CO2 laser has been used for five years at Mälaren Equine Hospital, as an alternative treatment of some equine diseases. The application of CO2 laser has been studied for evaluation of its appropriateness for treatment of the equine diseases sarcoids, lameness in fetlock joints or pulmonary haemorrhage. During the last five years, above 100 equine sarcoids have been removed by laser surgery (CO2 laser) and so far resulting in significantly few recurrences compared with results from usual excision surgery. In one study, acute traumatic arthritis in fetlock joints was treated three times every second day with defocalised CO2 laser. The therapeutic effectiveness of CO2 laser in this study was better than that of the customary therapy with betamethasone plus hyaluronan. During one year, chronic pulmonary bleeders, namely exercise induced pulmonary haemorrhage, has been treated with defocalised CO2 laser. Six racehorses have been treated once daily during five days. Until now, three of these horses have subsequently been successfully racing and no symptoms of pulmonary haemorrhage have been observed.
These studies indicate that CO2 laser might be an appropriate therapy on sarcoids and traumatic arthritis, and probably also on exercise induced pulmonary haemorrhage. Other treatments for this pulmonary disease are few.

INTRODUCTION
At Mälaren Equine Hospital, the last five years CO2 laser has been used as an alternative for treatment of some equine diseases. For treatment of the equine diseases sarcoids, traumatic arthritis in fetlock joints and exercise induced pulmonary haemorrhage CO2 laser has been used as described below. Clinical effects of these laser treatments are briefly reported and if they might be appropriate modes of treatment.

CO2 LASER
The authors have used a CO2 laser, 25 W, with a scanning device, focalised or defocalised. The laser consists of a CO2 emitter with a wavelength of 10,600 nm. A visible Helium-Neon laser radiation (Wavelength 632.8 nm) superimposed on the CO2 emitter showing the area covered by the laser beam. With the scanning device the beam of the guide light HeNe and the CO2 laser can be transformed from the shape of a point into a line. The user has to adjust and set the length of this “line”, as well as the height of the movement, to cover the area of the tissue to be treated. At the scanner there is a timer that automatically switches off the radiation after the desired treatment time set by the user. In that way, the scanning device automatically directs an equal amount of radiation over the actual tissue. To achieve the desired amount of radiation to the tissue per cm2, the user has to combine the following parameters: Watt, time and tissue area. This scanner has the advantage of being able to shed the radiation equally over the treated tissue in a controlled manner to avoid the risk of side effects, such as burning, or uncontrolled over/underexposure.

SARCOIDS
Equine sarcoids are defined as unique, benign, non-metastasising but locally aggressive, fibroblastic skin tumours (1), but they have no relation to human sarcoidosis (2). The etiology of sarcoids has been contentious, but both epidemiology and clinical behaviour of sarcoids strongly suggest the involvement of an infectious agent (both retroviruses and papilloma viruses have been implicated), although numerous attempts of isolation have met little reward. However, equine sarcoids are found world-wide and comprise the most common tumour in equine practise. The lesions appear solitary or multiple, sometimes at sites of previous wounds. Although rarely pruritic or painful, the lesions have a reputation for being notorious difficult to treat due to locally aggressive, infiltrative growth, high rates of recurrence after excision, large size, multiple lesions and/or localisation to sites compromising excision, like eyelids (3). The clinical manifestations of sarcoids are very variable. Solitary or multiple lesions can appear at any part of the body surface and growth rate and size may vary from small, inactive nodules to large masses of aggressive growing, secondary infected flesh, giving the impression of infiltrating surrounding tissues. After the initial appearance, individual sarcoids may retain static for years or fluctuate in size over a period of time and occasionally regress, sometimes only to reappear later at previous or new sites. Laser surgery has sometimes been used for treatment of sarcoids (4).
The major problem associated with sarcoids in equine practise is the high incidence of recurrence after surgery. The recurrence rate of approximately 50 % within three years after excision, of which the majority recurred within six months, has been reported (5). Because of this great recurrence after treatment with classical excision surgery we have used laser surgery to remove 105 sarcoids during the last four years.
These sarcoids were situated on penis, preputium eyelids, close to eyes and on the nose, back, neck and different other places in the skin. The horses were tranquilised intramuscularly with detomidine, 0.5 ml Domosedan® and butorphanol, 0.8 ml Torbugesic®. Thereafter the skin was clipped and sterilised with alcohol after which a local anaesthesia was performed with 2% Carbocain®
Method for laser incision: The body of the tumours were lifted up and an articulated arm with a 125 mm handpiece at 25 Watts in a continuous mode focalised to a spot light focus (0.2 mm spot size) was used back and forth until the tumour was separated from its base. After removal of the sarcoid the area site for the sarcoid and the skin edges were sealed until complete haemostasis was achieved by heat. This heat was achieved by using the handpiece laser defocalised, at a distance from the tissue area that the spot size was 2-3 mm and coagulation took place. The skin wound was left open without sutures. The wound was then kept clean, but no other treatment was performed afterward.
Out of cases older than 6 moths, 25 % recurred and 75 % are recovered. This material comprises mostly Swedish Warmbloods, mean age of the horses was seven years and mean time for the wound after surgery to be healed was ten days.
This result might indicate for further use of CO2 laser on sarcoids. Especially when sarcoids are localised on troublesome sites for surgery with a scalpel, such as eyelids, in the skin close to the eye-globe, penis, preputium etc. - laser surgery should be the most successful method.

TRAUMATIC ARTHRITIS
CO2 laser for treating traumatic arthritis in equine fetlock joints, and their clinical effects, has been evaluated together with a comparison with the effects of cortisone treatment. Before treatment, the horses were placed in a stock under sedation with detomidine intramuscularly, 0.5 ml Domosedan® and butorphanol, 0.8 ml Torbugesic®. Our aim was to estimate the clinical effects of the customary intra-articular treatment with betamethasone (?M) plus hyaluronan (HA) and of CO2 laser, as modes of treatment upon traumatic arthritis in fetlock joints. The intra-articular dose of ?M was 2 ml Celeston® bifas®; 6 mg/ml, the intra-articular dose of HA was 2 ml Hylartil© vet 10 mg/ml, and the dose of the defocalised CO2 laser was 60 Joule/cm2 tissue surface; six minutes per treatment lateral and medial. The joints were treated three times: on day 1, 3 and 5. No pain or side effects from that laser treatment were noticed.
Altogether, 144 horses constituted the experimental animals and 285 fetlock joints with acute traumatic arthritis were included; 114 fetlock joints were treated with CO2 laser and 171 treated intra-articularly with ?M + HA, which is the most common treatment of traumatic arthritis in fetlock joints. Thereafter, the lameness of the treated fetlock joints was re-evaluated 3-4 weeks after treatment. The recovered fetlock joints: 92 of the fetlock joints treated with CO2 laser, 80.7 %, and 116 of the fetlock joints treated with ?M + HA, 67.8 %. This amount of recovered joints after CO2 laser-treatment was significantly higher than that after ?M + HA – treatment.
The authors assume that CO2 laser might be the best treatment for synovitis in horses, particularly acute traumatic arthritis in fetlock joints. The mechanism behind this effect of the laser treatment, however, remains relatively unknown.

EXERCISE INDUCED PULMONARY HAEMORRHAGE
Until today, we have treated six race horses (4 Thoroughbreds, 2 Standardbreds) diseased of so-called exercise induced pulmonary haemorrhage with defocalised CO2 laser. Before treatment, the horses were placed in a stock under sedation with detomidine intramuscularly, 0.5 ml Domosedan® and butorphanol, 0.8 ml Torbugesic®. The dose of defocalised CO2 laser was 60 Joule/ cm2 skin surface over each lung, corresponding to about 20 minutes/side. The lungs were treated once daily at 5 consecutive days. This group of horses treated for exercise induced pulmonary haemorrhage is interesting, but too small to draw finite conclusion from. However, three of these horses have after laser treatment started and won race, and this result may encourage us and/or others to use CO2 laser upon this pulmonary disease, as other treatments are rare. In all horses of this group, the number of macrophages decreased post treatment.

REFERENCES
1. Jackson, C. (1936) The incidence and pathology of tumors of domestic animals in South Africa. Ondertepoort J. Vet. Sci. Anim. Ind. 6: 16; 241-248; 375-385; 429.
2. Stannard, A.A. and Pulley LT (1978) Tumors of the skin and soft tissues. In: Tumors in Domestic Animals, 2nd ed, JE Moulton (ed), University of California Press, Berkley, Los angeles, pp: 16-74.
3. Broström, H. (1995) Equine sarcoids. A clinical, epidemiological and immunological study. Thesis, Swedish University of Agricultural Sciences, Uppsala, Sweden.
4. Palmer, S.E. (1989) Carbon dioxide laser removal of a verrucous sarcoid from the ear of a horse. JAVMA 195; 1125-1126.
5. Ragland, W.L. (1970) Equine sarcoid. Equine Vet. J. 2, 2-11.

*Correspondence author:
Eje Collinder
Microbiology and Tumor Biology Centre
Karolinska Institutet
von Eulers väg 5
S-171 77 Stockholm
Sweden

Philip Gable, B App Sc P.T. G Dip Sc Res (LLLT) MSc, Australia
Jan Tunér, D.D.S., Sweden

The anecdotal and researched evidence for the effects of Low Level Laser Therapy (LLLT) on the stimulation of bone have been reported for over 20 years. This has been in the form of local as well as systematic effects – including contra-lateral effects. Reports of stimulation of rabbit radii fractures and mice femurs were made as early as 1986 and 1987 with irradiated bones healing faster than controls and contra-lateral non-treated fractures similarly demonstrating faster healing times. Over the following decade and a half, further studies have also investigated and demonstrated that LLLT is effective for the stimulation of bone tissue.
The reasons for this have been attributed to the general effects of LLLT and its ability to increase the rates of healing through mitochondrial ATP production and alteration in the cellular lipid bi-layer. Additional hypothesis include the subsequent capacity of irradiated cells to alter their ion exchange rate and thus influence the catalytic effects of the specific enzymes and substrates. These in turn initiate and promote the healing process completing the cascading cycle of events.
In the area of bone specific research, Dr. Tony Pohl of the Royal Adelaide Hospital in South Australia, has provided a new theory that postulates that the majority of fluid transfer and exchange within living bone is predominantly influenced by the lymphatic circulation.
LLLT is well documented and known as having effects that influence the lymphatic circulation and wound healing process. A coupling of these two areas of theory can demonstrate a positive description and explanation of the predominant effects of LLLT in bone stimulation. In reality, LLLT’s effects on bone may well be a further consequence of its actions on the lymphatic circulation.

Reports of stimulation of Rabbit radii fractures were made by Tang in 1986 and similar reports by Trelles in 1987 on mice femurs. In both situations the irradiated bones healed faster than the controls. In another study by Hernandez-Ros, in 1987, LLLT demonstrated stimulation of fresh fractures on Sprague-Dawley rats that were fractured bilaterally. The unexpected results of this study were that the contra-lateral fractured non-treated limb also healed faster than the control group. Over the following decade and a half further studies (Yamada 1991; Pyczek, Sopala et al. 1994; Ozawa 1995; Horowitz 1996; Yaakobi 1996; Saito and Shimizu 1997) have also investigated and demonstrated that LLLT is effective for promoting the stimulation of bone healing. Recently Nicolau and colleagues (2002) from Brazil demonstrated the positive effect of LLLT on the stimulation of bone in mice with latent promotion of bone remodulation at injury sites without changes in bone architecture, increased bone volume and increased osteoblast surface through increased resorption and formation of bone with higher apposition rates. A positive effect on bony implants has been demonstrated by Dörtbudak (2002) and Guzzardella (2003). The effect of laser irradiation on osteoblastic cells has been reported by Yamamoto (2001) and Guzzardella (2002).
The reasoning for this amelioration in all experimental circumstances, based on electron microscopy as well as macroscopic histological evidence, was concluded to be due to i.a. improved vascularisation as a consequence of blood vessel formation, absorption of the haematoma, macrophage action, fibroblast proliferation, chondrocyte activity, bone remodeling from increased osteoblastic activity and deposition of calcium salts.
These changes and evidence based studies attribute the macro- and microscopic effects to the known and accepted general actions of LLLT and its ability to increase rates of healing through stimulation of ATP production, (Karu 1989; Smith 1990) promoting repair and polarization of the cellular lipid bilayer (Fenyo 1990) as well as LLLT’s capacity to affect cells through alterations in their exchange rate of ions (Robinson and Walters 1991) and influences the catalytic effects of the specific enzymes and substrates (Pouyssegur 1985; Karu 1988) which in turn initiate and promote the healing process.
More recent work by Dr. Tony Pohl, an internationally renowned Orthopaedic Surgeon from the Royal Adelaide Hospital in South Australia and lecturer at the Adelaide and South Australian Universities, has given rise to a new theory on bone circulation through reconsideration of fluid and protein transfer within bone (Pohl 1999). This theory suggests that the general understanding of the circulatory action within bone has been incorrect. Pohl postulates that the majority of fluid transfer and exchange within the living bone is predominantly influenced by the lymphatic rather than the vascular circulation. This is justified through studies on bone fluid input and output levels that have demonstrated that the venous and arterial aspect of circulation alone cannot account for the demonstrated levels of output nor the presence of free radical molecules which exceed those of the vascular input. Furthermore, the diameter of large protein cells within the bone exceed the diameter of the vessels that form the terminal aspects of the circulatory system making it impossible for them to have been delivered via this system. Consequently, an additional circulatory system must be present that will account for both the increased output and the presence of the large diameter protein cells as well as the free radicals.
If LLLT is then considered within the context of this new theory on bone circulation and the contribution of the lymphatic circulation then a further logical reasoned deduction for the action of LLLT on bone stimulation can be made. LLLT has a well documented and known effect influencing the lymphatic circulation. This has been demonstrated from the early works of Lievens, (1985) that demonstrated the influence of "Laser Irradiation" on the motricity of the lymphatic system and on the wound healing process. This is supported by several wound studies that demonstrate that the levels of protein rich exudates in non-healing wounds increase markedly from exposure to LLLT. This demonstrated action is determined to be as a result of the increase in lymphatic circulation (Robinson and Walters 1991; Gabel 1995). More recent work at the Flinders Medical Center in Adelaide South Australia has been completed and presented at the World Association of Laser Therapy conference in Tokyo Japan (Anderson, Carati et al. 2002). This study has demonstrated the positive effects of LLLT on the lymphatic circulation and its consequential benefits to the post mastectomy patient.
An understanding of the existing knowledge of the effects of LLLT on the lymphatic system combined with the hypothesis of bone fluid transport provides a coupled theory that would demonstrate a positive description and explain of the predominant effects of LLLT in bone stimulation.
In the trauma situation of direct or indirect damage to the bone, including fractures and periosteal induced damage such as stress fractures, the tissue damage leads to compromises that include but are not limited to, physical blockage from the trauma and waste / debris, increased fluid and circulatory viscosity from added cellular content within the lymphatics, lower speed motility and energy deficit in the tissue and cells from the loss of ATP production as a general effect from the trauma, cell changes and inability of mitochondria to function at the normal higher level to promote self repair and regeneration.
LLLT with its known general effects and specific direct effects on the lymphatic system would act to stimulate mitochondria ATP that increases cellular and circulatory motility as well as directly influencing lymphatic flow. LLLT also promotes increased permeability in interstitial tissue and facial layers (Gabel 1995) reducing stagnation and blockage. These actions would assist the increase in lymphatic flow and consequently the circulation within the affected bone. There is also a hypothetical potential that the presence of LLLT by increasing lymphatic circulation does so by virtue of an increase in the diameter of the lymphatic vessels, not just by increased flow rates within the vessel at an unchanged diameter. This diameter increase, if definitively present, would also explain the presence of large diameter protein cells within the normal bone circulation that cannot be attributed to the vascular circulation and would additionally explain a facilitated process for removal of debris and larger protein cells passing out of traumatized areas that is additionally stimulated by the use of LLLT.
Stimulation of bone healing by LLLT has till now has been generally classified as a consequence of the general healing effects of LLLT. In reality LLLT’s effect on bone may well be a further consequence of its actions on the lymphatic circulation.

References:

Anderson, S, Carati, C et al. (2002). Low Level Laser Therapy (LLLT) as a Treatment for Postmatestectomy Lymhoedema. WALT 2002, Tokyo Japan.

Coombe, A R et al (2001). The effect of low level laser irradiation on osteoblastic cells. Clin Ort Res. 4: 3-14.

Dörtbudak, O et al (2002). Effect of low-power laser irradiation on bony implant sites. Clin Oral Implants Res 13(3):288-292.

Fenyo, M. (1990). Theoretical and Experimental Basis of Biostimulation by Bioptron, Bioptron AG, Monchaltorf, Switzerland.

Gabel, C. P. (1995). “Does Laser enhance bruising in acute sporting injuries.” Aust. J. Physio. 41(4): 267-269.

Gabel, C. P. (1995). The effect of LLLT on slow healing wounds and ulcers. Health Sciences. Darwin, Northern Territory.

Guzzardella, G A et al (2002). Laser stimulation on bone defect healing: An in vitro study. Lasers Med Sci. 17(3): 216-220.

Guzzardella, G A et al (2003). Osseointegration of endosseous ceramic implants after postoperative low-power laser stimulation: an in vivo comparative study. Clin Oral Implants Res. 14: 226-232.

Horowitz, I. et al. (1996). “Infrared spectroscopy analysis of the effect of low power laser irradiation on calvarial bone defect healing in the rat (abstract).” Laser Therapy 8: 29.

Karu, T. I. (1988). “Molecular mechanism of the therapeutic effects of low intensity laser radiation.” Lasers in Life Science 2: 53-74.

Karu, T. I. (1989). Photobiology of low-power laser therapy. London, Harwood Academic Publishers.

Lievens, P. (1985). The influence of "Laser Irradiation" on the motricity of the lymphatical system and on the wound healing process. International Congress on Laser in Medicine and Surgery., Bologna.

Nicolau, R A., Jorgetti, V, Rigau, J et al. "Effect of low power laser Ga-Al-As (660nm) in the bone tissue remodulation in mice”

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(This paper is extracted from seminar paper for WALT 2002 Congress, Japan)
By Malini Chaudhri Ph.D.,D.L (Alma Ata), New Dehli, India

Golf in India, especially for National team members, is a struggle against intensely difficult climatic conditions. In this trial, two women’s teams training for international tournament served as placebo for laser therapy and Laser Acupuncture on the field of training. Ladies Golf Union Captain, National Golf coach and Golden Greens Golf Course Managing Director jointly sanctioned the trial for the Women’s Team training for Queen Sirikit Cup 02, in Malaysia, and the Juniors Team training for Asia Pacific Juniors in Taiwan 02. There were several individual entries who also participated in the trial, creating a group of eleven members in total.

The trial was based on an elaborate model identifying four modalities of laser application to serve as a mono therapy on the training field, to take care of correction, and prevention of injury and health setbacks. Laser irradiation and Trigger point stimulation were given for localized, peripheral conditions, whereas single point laser acupuncture and auriculotherapy were given for systemic effects of the CNS. An assortment of problems ranging from headaches, cervical pain, lumbago, tendinitis and skin allergy were treated effectively through these modalities.

However a unique condition was observed during the trial that affected the players at the onset of the six-day training. There were recurrent reports of exhaustion, lethargy, lack of motivation and a difficulty in maintaining concentration throughout 18 holes of golf. As laser acupuncture was one of the therapeutic modalities involved the condition was diagnosed as a depletion of Kidney Jing and Yin essence affecting all the players, based on the climatic conditions to which players were exposed. This diagnosis is revealed in Chapter Three of the Yellow Emperor’s Classic, and the remedy is available through laser acupuncture.

A close look at the climate showed conditions of escalating heat of about 38 degrees C, coinciding with the onset of summer. The first week of April in North India marks a transition from spring to summer, when the body utilizes immense stores of energy for effective adaptation. The trees are flowering creating high pollen count in the atmosphere. The heat is dusty, static and dry, creating dehydration of fluid stores from the body. At this time the players were exposed to seven hours of exposure to peak heat. Most of them had collected from different parts of India after several weeks of high school examination study during which they were off golf training, indicating they were probably not in peak athletic form.

Oriental medicine pays careful attention to environmental affects on the body and this is useful for golfers who are unaware of the hazards of climate. Whereas laser therapy in sports medicine conventionally approaches therapy as localized, based on overloading, overuse, sprains, strains and nerve compression, the circumstances of sport in tropical countries as India show the need for therapy that is systemic and centralized. Western medicine recognizes that heat conditions of 38 degrees C approaches danger zone for athletes. 40 degrees C and above can cause a permanently degenerative effect on the hypothalamus and indeed can prove fatal in heat stroke and dehydration. In addition, exposure to harmful UV rays from the sun cause skin allergies, and glare from the sun causes headaches. Laser acupuncture in conjunction with laser therapy acts on the autonomic nervous system on the field to assist golfers through the hazards of climate.

The Yellow Emperors Classic from which acupuncture theory is derived pays much attention to health imbalances through the seasons, and Chapter three makes reference to the climatic conditions corresponding to a change of season approaching summer as bringing on the Jian Jue syndrome when the body is overworked and the Yang overheats causing a depletion of Kidney Jing and syncope of the yin fluids causes consumption of yin fluids. The TCM (Traditional Chinese Medicine) Kidney is essentially different from the Kidney of Western Medicine which treats it specifically as an organ. In Oriental Medicine the Kidney stores genetic essence or ancestral chi, and frames the constitution of the individual. Whereas health is a balance of Yin and Yang function, TCM regards Kidney Jing as the root of Yin and Yang in the body. When climate causes a depletion of Jing the energy drain is touching constitutional stores, which creates a feeling of energy loss at the deepest level where the person can no longer cope. Subsequent injuries that arise from a depletion of Jing essence are likely to respond slowly to any therapy as the Kidney reservoir is inherited and the Jing stores have to maintain the body throughout a lifetime. The loss of Jing is permanent and irreversible. Most of TCM theory of health is based on nourishing Kidney Jing and illness is attributed to weak Jing constitution. When Jing stores are drained there is energy loss at the deepest level and motivation, concentration and will power are likely to be affected. Indeed TCM claims that Kidney stores Zhi, in its higher octave or soul nature, Zhi referring to the inherited will power, goals and ambitions of the individual that are going to shape the life achievements of the individual. The Jian Jue syndrome naturally will affect Zhi, or the motivation and will power of the player under the hazardous climatic circumstances.

Dr Michael Tierra, OMD, (1) has conveyed most lucidly the correspondence to Kidney Yin and Kidney Yang in Western Medicine. The TCM kidney encompasses the urinary system, balance of mineral electrolytes, as well as the entire endocrine system including prostaglandins and neurotransmitters. The adrenal gland functions and release of glucocorticoids (the most significant stress buffer for athletes) is also regulated by Kidney Yin. Kidney Jing stores the root of Yin and Yang of the entire body, and regulates homeostasis through the sympathetic nervous system or Kidney Yang, and the parasympathetic nervous system or Kidney Yin. The availability of ATP and ADP is also considered to be a function of Kidney Jing whereby cellular energy may be generated at all times.

Whereas each acupuncturist has his own experience with specific points, this trial tested the point Kidney 5 for the stimulation of the Kidney pathway to prevent loss of Jing. The likely results of this point are that further deterioration will immediately be prevented. The laser used was the Medicom Maestro 830nm 30 mw probe, 1168 Hertz delivered at 1 joule/cm 2 , approx 33 seconds. 1168 hertz was selected because Kidney is a mesodermal organ forming the musculoskeletal structure and Nogier recommends Freq C, 1168 hertz for mesodermal tissue.
The laser was applied at a distance of half centimeter on this point daily during the six-day trial. All players showed maximum tenderness on this point. Laser stimulation of an acupuncture point activates the nearby points via photon emissions, in this case transmitting neuronal impulses to Kidney 1, well known for its restorative capacity and Kidney 7, which balances fluid losses. In addition to the activation of the sensory neural pathway this point sits in close proximity to the adrenal reflex, aiding stress relief. As the acupuncture pathways are represented in the hypothalamus the centralized effects are likely to be rapidly experienced.

Whereas at the start of the trials there were numerous reports of lethargy, poor motivation and poor concentration, it was noted that by the third day of the six-day trials there were substantially fewer complaints. Kidney 5 was given everyday with Spleen 6 and players indicated a return to normalcy despite intensified training. The treatment was effective as no further calamities were reported during the week. Motivation and concentration also improved simultaneously

Bibliography:

1)Tierra. OMD. Online articles. http://www.planetherbs.com/articles/kidneys.html. Integrating the traditional Chinese Understanding of Kidneys into Western Herbalism

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The following photo sequence has been contributed
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