Laseroterapija

Pitanja - Odgovori

PROF. DR MILICA L AZOVI

MEDICINSKI FAKULTET UNIVERZITETA U
BEOGRADU
INSTITUT ZA REHABILITACIJU

Q: What is laser therapy

Q: What is the correct name (LLLT, LPT; LPLT, low power laser,
biostimulation)?
Q: Is laser therapy scientifically well documented?
Q: Where do I find such documentation?
Q: But I have heard that there are dozens of studies failing to find any
effect of LLLT?
Q: Which lasers can be used in medicine?
Q: Can therapeutic lasers damage the eye?
Q: How do I know which laser I should buy?
Q: How come some LLLT equipment has power in watts and some only in
milliwatts?
Q: Which frequency (pulsing) should be used for the various therapies?
Q: Which type of laser is best suited to which job?
Q: Can carbon dioxide lasers be used for LLLT?
Q: How deep into the tissue can a laser penetrate?
Q: Can LLLT cause cancer?
Q: What happens if I use a too high dose?
Q: Are there any contraindication?
Q: Does LLLT cause a heating of the tissue?
Q: Does it have to be a laser? Why not use monochromatic non coherent
light?
Q: Does the coherence of the laser light disappear when entering the
tissue?
Q: Do therapeutic lasers produce so-called soliton waves?

Definicija lasera sadrana je u samom njegovom

nazivu koji predstavlja skraenicu za:
Light
Amplification by
Stimulated
Emission of
Radiation,
u prevodu: pojaanje svetlosti pomou
stimulisane emisije zraenja.

2.Q: What is the correct name: LLLT, LPLT,

therapeutic laser, soft laser, MID laser or
biostimulation?
A: Regarding the therapy, we have chosen to use the term
LLLT (Low Level Laser Therapy).
This is the dominant term in use today, but there is still a
lack of consensus.
In the literature LPLT (Low Power Laser Therapy) is also
frequently used.
Regarding the laser instrument, we have chosen to use the
term "therapeutic laser"
rather than "low level laser" or "low power laser", since
high-level lasers are also used for laser therapy.
The term "soft laser" was originally used to differentiate
therapeutic lasers from "hard lasers", i.e. surgical lasers.
Several different designations then emerged, such as "MID
laser" and "medical laser".

"Biostimulating laser" is another term, with the disadvantage

that one can also give inhibiting doses.
The term "bioregulating laser" has thus been proposed. An
unsuitable name is "low-energy laser".
Other suggested names are "low-reactive-level laser",
"low-intensity-level laser", "photobiostimulation laser"
and "photobiomodulation laser".
"LPT - Laser Photo Therapy" is a recently suggested term,
and winning acceptance.
Thus, it is obvious that the question of nomenclature is far from
solved.
This is because there is a lack of full agreement
internationally, and the names proposed thus far have
been rather unwieldy.

Feel free to forget them, but remember LLLT until

agreement is reached on something else.

3. Q: Is laser therapy scientifically well

documented?
A: Basicly yes.
There are more than 130 double-blind positive
studies confirming the clinical effect of LLLT.
More than 3000 research reports are published.
Looking at the limited LLLT dental literature alone
(370 studies already in 1999), more than 90% of
these studies do verify the clinical value of laser
therapy.
About 250 papers are annually published in peer
reviewed scientific papers.

4. Q:Where do I find such documentation?

A: The book "Laser Therapy Handbook" is the
best reference guide for literature
documentation.
Abstracts from scientific papers can be
found on PubMed,
http://www.pubmed.com

5. Q: But I have heard that there are dozens of studies

failing to find any effect of LLLT?
A: That is true.
But you cannot just take a any laser and irradiate for any
length of time and using any technique.
A closer look at the majority of the negative studies will
reveal serious flaws.
Look for link under Laser literature and read some examples.
But LLLT will naturally not work on anything.
Competent research certainly has failed to demonstrate
effect in several indications.
However, as with any treatment, it is a matter of dosage,
diagnosis, treatment technique and individual reaction.
Se link critic on critic.

5. Ali ja sam uo da postoje desetine studija

nepronalazei nikakvog efekta na LLLT?
O: To je tano.
Ali ne moete jednostavno uzeti bilo laser i zraenje za bilo
koju duinu vremena i koristei bilo koju tehniku.
Blii pogled na veinu negativnih studija e otkriti ozbiljne
nedostatke.
Potraite link ispod Laser literature i itate neke primere.
Ali LLLT e, naravno, ne radi ni na ta.
Nadleni istraivanje svakako nije uspeo da pokae snagu
u nekoliko indikacija.
Meutim, kao i kod svakog tretmana, to je stvar doze,
dijagnoze, tehnike leenja i individualnog reakcije.
Se link critic on critic.

6. Koji laseri se mogu koristiti u medicini?

A: Primeri lasera koji se mogu koristiti u medicini,

kako za hirurgiju tako i za terapiju:
Terapijske laseri (gde mehanizam delovanja nije
zasnovan na toplotnom efektu)
Toplotni laseri (za hirurgiju ili estetsku upotrebu)

Laser

Wavelength

Use

GaAs

904 nm (super
pulsed)

Treatment of deep
problems (back,
shoulders, knees,
head ache etc)

GaAlAs

780-808-890 nm
(cont. or chopped)

Also deep problem,

often a complement
ot the GaAs-laser

InGaAlP

630-700 nm

Treatment of skin and

mucose problems

HeNe

633 nm

Alternative to
InGaAlP (see above)

Therapeutic lasers (where the

mechanism is not based oh heat)

Thermal lasers (for surgery or esthetic use):

Termal Laser
Laser

Wavelength

Use

Ruby

694 nm

Hair removal (for Q-switch type: tattoo

bleaching)

Nd:YAG

1064 nm

Coagulation of tumors, eye surgery

(cataracts)

Ho:YAG

2130 nm

Crushing of kidney stones, surgery

Er:YAG

2940 nm

Dental drill, laser peeling of wrinkles and

scars

KTP/532

532 nm

Coagulation of blood vessels, hemangioma.

Alexandrite 755 nm

Hair removal (for Q-switch type: tattoo

bleaching)

CO2 laser

10600 nm

Surgery and laser peeling of wrinkles and

scars

Argon

514 nm

Eye surgery (treatment of retinopathy)

7. Q:Can therapeutic lasers injure your eyes?

A: Yes and no! Read the following:
Any strong light source - laser or not - can injure an
eye.
There are strong lasers that can cut in plastic and even
steel. They can injure eyes and tissue, but laser pointers
and therapeutic laser can normally not. Read more
below:
The following factors are of importance regarding the
eye risk of different lasers:
The output power (strength) of the laser. It is fairly
obvious that a powerful laser (many watts) is more
hazardous to stare into than a weak laser.

The divergence of the light beam

A parallel light beam with a small diameter is by far
the most dangerous type of beam.
It can enter the pupil, in its entirety, and be focused
by the eye's lens to a spot with a diameter of
hundredths of a millimetre.
The entire light output is concentrated on this small
area.
With a 10 mW beam, the power density can be up to
12,000 W/cm2
The exposure time. To burn the retina, a certain
energy is needed. Energy is power multiplied by time,
so exposure time is important.

The wavelength of the light

Within the visible wavelength range, we respond to
strong light with a quick blinking reflex.
This reduces the exposure time and thereby the light
energy which enters the eye.
Light sources which emit invisible radiation, whether
an infrared laser or an infrared diode, always entail a
higher risk than the equivalent source of visible light.
Radiation at wavelengths over 1400 nm is absorbed by
the eye's lens and is thus rendered safe, provided the
power of the beam is not too high.
Radiation at wavelengths over 3,000 nm is absorbed by
the cornea and is less dangerous.

The distribution of the light source

In an eye, like in a camera, the image of the source is
projected on the retina/film. In a laser, the source is very
small, so it is depicted as a point (compare with a
burning glass where you get a picture of the sun in the
focus "point").
For example: a clear light bulb is apprehended as a
more concentrated light source than a so-called "pearl"
light bulb.
A laser system with several light sources placed
separated from each other (often called multi probe)
constitutes a smaller hazard to the eye than if the entire
power output was from one laser source, because the
light sources separate placement means that they are
reproduced in different places on the retina.

In conclusion
Lasers in general are much less dangerous than people
think.
No person has become blind by a laser. A few people
have got injuries. Normally they will not notice such
an injury. Even in the worst cases (where the inury is
extensive and in the midle of the fovea) the
consequensies are much less than any injury caused by
stones, knifes, dart arrows, fireworks, dry branches int
the forrest etc.
See further the presentation named:
What lasers can make you blind?

Laseri su generalno mnogo manje opasno nego to

ljudi misle.
Nijedna osoba nije postala slepa od lasera.
Nekoliko ljudi ima povrede. Normalno nee primetiti
takvu povredu. ak i u najgorim sluajevima (kada je
inuri je obiman i u Midle na fovea) su consekuensies
su mnogo manje nego bilo povrede izazvane
kamenjem, noevima, Dart strele, vatromet, suve
grane int da Forrest itd
Vidi dalje prezentaciju pod nazivom:
Koji laseri mogu da vas oslepe?

8. Q:How do I know which laser I should buy?

A: The laser market is very complicated and full of
pitfalls.
How do you know which instruments are good?
What is expensive?
Will it be expensive in the long run to buy
something cheap?
Before you know it, you've signed on the dotted line. All
lasers are given a laser class.
This classification is only to indicate the possible eye
risk and has nothing to do with the possible
efficktiveness in treatment.

How do I know which laser I should buy?

There are four laser classes where class 4 is the
strongest and class 1, 2 and 3A and 3B are less
hazardous to eyes.
Lasers in CD players and for reading bar codes are
usually class 1 lasers while surgicla and industial
lasers usually are class 4 lasers.
Here are a number of questions which you should ask
both the salesman and yourself.
You would be well advised to read these carefully in
case you regret not doing so later on!

"Laser instruments" have been sold which do not

even contain a laser, but LEDs or even ordinary light
bulbs.
These instruments have been sold for between US
$3,000 - $10,000. How can you acquire proof that the
instrument really does contain a laser?
2 In a number of products, laser diodes have been
combined with LEDs.
This is often kept secret and the salesman has only
talked about a laser.
Are all light sources in the apparatus (except guide
lights and warning lights) really lasers?

Is a strong laser better than a week?

No, not necessarily.
There is an optimal dose for what ever treatment - let's
say that you want to administer 10 joules to a certain
area.
If the laser output is 1 watt, it takes 10 seconds to give
10 joules.
With a 100 mW laser it takes 100 seconds to produce
10 joules.
Further, it has become clear that also treatment
time should not be too short or too long.
As high power has become a more and more common
sales argument, it can be difficult to achieve both
optimal dose and optimal treatment time.

4 For oral work and wound healing, InGaAlP and

GaAlAs are the most common types, with GaAlAs as
the most versatile one.
For injuries to joints, vertebrae, the back, and
muscles, that is, for the treatment of more deep-lying
problems, the GaAs laser is the best documented.
For veterinary work, a laser is needed which is
designed so that the laser light can pass through the
coat, and penetrate to the desired depth.
For superficial tendon and muscle attachments, the
required depth can be reached with the GaAlAs laser.
However, research tells quite a different story.
GaAs further requires lower dosage than GaAlAs, so
nominal power is not everything.

5 Size, colour, shape, appearance and price vary a

great deal from manufacturer to manufacturer.
Because a piece of equipment is large, it does not
necessarily follow that its medical efficacy is high, or
vice versa.
The most important factor is the energy (dose) which
enters the tissue.
Make sure the laser you buy is designed so that all the
light actually enters the tissue.
Ask the salesman: how is the dose measured?
What dose is too high, and what is too low?

6 Many companies which import lasers have

deficient knowledge in terms of medicine, laser
physics, and technology.
In fact, there are many examples of companies
which have gone bankrupt.
If a piece of equipment is faulty, it may have to
be sent to the country of manufacture for repair.
How long would you be without your equipment
in such a case, and what would it cost to repair?
Can the importer document his expertise?

Who can you speak to who has used the

apparatus in question for a long period of time?
Is there a well-known professional who uses this
make?
What does it cost to change a laser diode or laser
tube, for example, after the guarantee has
expired?
Can you get written confirmation of this?
Try to get a list of references who you can call and
ask.

7 The difference between a colourful brochure

and reality is often considerable.
There are examples of brochures which describe
output ten times that which the equipment actually
provides.
How can you find out the real performance of the
equipment (e.g. its output)?
Are there measurement results from an independent
authority?
Is it possible to borrow an apparatus in order to
measure its performance?
Is there a power meter on the apparatus which can
measure what is emitted and show it in figures?
It is not enough simply to have a light indicator.

8 Some dealers know that their products are substandard.

This can often be seen by the fact that they are anxious
to get the customer to sign a contract.
If a product is good, the dealer will have no doubts
about selling it on sale-or-return basis, with written
confirmation of this.
What happens if the medical effects are not as
promised?
Is it possible to get a written guarantee of sale-orreturn?

9 In most countries, therapy lasers must be

approved (e.g. CE or FDA approval).
The approval certificate shows the laser type and
the class to which the instrument belongs, e.g.
laser class 3B.
There is also a certificate number.
A laser which is not approved may either not be a
laser, or might be sold illegally.

10 Many companies organize courses and "training"

events of markedly varying quality.
A serious importer or manufacturer takes pains to ensure
that his equipment is used in a qualified way, and makes
sure that the customer receives some training in its use.
What are the instructor's background and qualifications?
Has he or she published anything?
Is there a course description?
What does the training material cost?
Is a training course included in the cost of the equipment?
Is the training material included?
Is it possible to buy the training material only?

11. Development is going on at a fast pace.

Suddenly, you have out-of-date laser equipment
and a new and perhaps more efficient type of
laser comes onto the market.
What happens if your laser becomes outmoded?
Do you have to buy a new laser, or can your
equipment be updated with future components
lasers?
12. Is it possible to get education or a qualified
treatment manual?
Is literature included in the price?

9.Q: How come some LLLT equipment has power in

watts and some only in milliWatts?
A: A typical example is GaAs lasers.
As a GaAs laser always works in a pulsed fashion, the laser
light power varies between the peak pulse output power
and zero.
Then usually the laser's average power output is of
importance, especially in terms of dose calculation.
The peak pulse power value is of some relevance for the
maximum penetration depth of the light.
Some manufacturers specify only the peak pulse output in
their technical specifications.
"70 W peak pulse output" or even "70 000 mW power
output" naturally sounds more impressive than 35
milliwatts average output!

10.Q: Which frequency (pulsing) should be used for the

various therapies?

A: First we must differentiate between chopping and superpulsing.

Some lasers, like the GaAs laser, are always pulsed.
The pulses are very short but the peak power of the pulse is very high,
several watts, but the pulse duration is typically only 100 to 200 nano
seconds.
Ther lasers like the HeNe and the GaAlAs are normally continuous, but
can be pulsed by mechanical or electrical devices.
If a continuous laser is pulsed, the average output power will be lower.
With most GaAs lasers the power decreases with lowered frequencies
(unless there is a pulse train arrangement) and with chopped lasers we
typically loose 50% (50% duty cycle).
There is some evidence from cell studies that the pulsing can makes a
difference.
But the evidence from clinical studies is almost absent. Since GaAs is
always pulsed, we have to choose a frequency and then to use the
anecdotal evidence there is about what frequency is good for what.

11.Q: Which type of laser is best suited to which

job?
A: There are three main types of laser on the market:
HeNe (now being gradually replaced by the InGaAlP laser),
GaAs and GaAlAs.
* The InGaAlP- or HeNe-laser has been used a great deal
in dentistry in particular, as it was the first laser available.
They are especially good for and have been used for wound
healing for more than 40 years.
One advantage is the documented beneficial effect on
mucous membrane and skin, and the absence of risk of
injury to the eyes.
A Japanese researcher has even treated calves with
keratoconjunctivitis with excellent results, that is,
irradiation of the eye through the eye lid. Because HeNe
light is visible, the eye's blink reflex protects it.

Normal HeNe output for dental use is 3-10 mW,

although apparatus with up to 60 mW is available.
An optimal dosage when using a HeNe laser for
wound healing is 1-4 J/cm2 around the edge of the
wound, and approximately 0.5 J/cm2 in the open
wound.
HeNe lasers are used to treat: skin wounds,
wounds to mucous membrane, herpes simplex,
herpes zoster (shingles), gingivitis, pains in skin
and mucous membrane, conjunctivitis, etc

The GaAs laser is excellent for the treatment of pain

and inflammations (even deep-lying ones), and is
less suited to the treatment of wounds and mucous
membrane.
Very low dosages should be administered to mucous
membrane!
Most GaAs equipment is intended for extraoral use, but
there are special lasers adapted for oral use.
The GaAs laser is, like GaAlAs and InGaAlP lasers, a
semiconductor laser.
This means that there is no sensitive fibre-optic light
conductor which runs from the laser apparatus to the
probe, but just a normal, cheap, robust electric cable.
Optimum treatment dosages with GaAs lasers are lower
than with HeNe lasers.

The GaAs laser is most effective in the treatment: of

pain, inflammations and functional disorders in
muscles, tendons and joints (epicondylitis,
tendonitis and myofacial pain, gonarthrosis, etc.),
and for deep-lying disorders in general.
GaAs can, nevertheless, be used successfully on
wounds in combination with HeNe or InGaAlP, but
the dosages should be very low
under 0.5 J/cm2.

The GaAlAs laser can have a wavelength in the

interval 750 to 980 nm and has become increasingly
popular.
Most common wavelength is 808 nm.
As they are very easy to run electrically, small
rechargeable lasers have been put on the market,
often not much larger than an electrical toothbrush.
(They can run on normal or rechargeable batteries.).
GaAlAs lasers have appeared on the market with
an output of over 500 mW.

200-300 mW laser diodes are now relatively

cheap and the GaAlAs laser gives "a lot of
milliwatts for the money".
Recently, GaAlAs lasers have appeared on the
market with an impressive output of over 500
mW.
In Europe, GaAlAs laser with powers above 500
mW can only be used by doctors and dentists,
being Class 4 lasers.

12.Q: Can carbon dioxide lasers be used for LLLT?

A: Yes.
Therapeutic laser treatment with carbon dioxide lasers
has become more and more popular.
This can always be achieved with an additional lens of
germanium or zinc selenide, if it cannot be done with the
standard accessories accompanying the apparatus.
It is interesting to note that the CO2 wavelength cannot
penetrate tissue but for a fraction of a mm (unless focused to
burn).
Still, it does have biostimulative properties.
So the effect most likely depends on transmittor
substances from superficial blood vessels.
Conventional LLLT wavelengths combine this effect
with "direct hits" in the deeper lying affected tissue.

13. Q: How deep into the tissue can a laser penetrate?

A: The depth of penetration of laser light depends on
the light's wavelength, on whether the laser is superpulsed, and on the power output, but also on the
technical design of the apparatus and the treatment
technique used.
A laser designed for the treatment of humans is rarely
suitable for treating animals with fur.
There are, in fact, lasers specially made for this purpose.
The special design feature here is that the laser
diode(s) obtrude from the treatment probe rather like
the teeth on a comb.
By delving between the animal's hair, the laser diode's
glass surface comes in contact with the skin and all the
light from the laser is "forced" into the tissue.

A factor of importance here is the compressive

removal of blood in the target tissue.
When you press lightly with a laser probe against
skin, the blood flows to the sides, so that the
tissue right in front of the probe is fairly empty of
blood.
As the haemoglobin in the blood is responsible
for most of the absorption, this mechanical
removal of blood greatly increases the depth of
penetration of the laser light.

There is, however, a limit at which the light intensity

is so low that no biological effect of the light can be
registered.
This limit, where the effect ceases, is called the
greatest active depth.
In addition to the factors mentioned above, this
depth is also contingent on tissue type,
pigmentation, and dirt on the skin.
It is worth noting that laser light also penetrate
bone (as well as it can penetrate muscle tissue).
Fat tissue is more transparent than muscle
tissue.

For example: a InGaAlP laser with a power output of

35 mW has a greatest active depth of about 10 mm
depending on the type of tissue involved.
A GaAlAs probe of some strength has a penetration of 35
mm and a GaAs laser has a greatest active depth of
between 30 and 40 mm (sometimes down to 50 mm),
depending on its peak pulse output .
If you are working in direct contact with the skin, and
press the probe against the skin, then the greatest active
depth will be achieved.
N.B. Clothes will reduce penetration between 80 and
100% depending on thickness and colour.

14. Q: Can LLLT cause cancer?

A: The answer is no.
No mutational effects have been observed resulting from
light with wavelengths in the red or infra-red range and of
doses used within LLLT.
But what happens if I treat someone who has cancer and is
unaware of it?
Can the cancer's growth be stimulated?
The effects of LLLT on cancer cells in vitro have been studied, and
it was observed that they can be stimulated by laser light.
However, with respect to a cancer in vivo, the situation is rather
different.
Experiments on rats have shown that small tumours treated with
LLLT can recede and completely disappear, although laser
treatment had no effect on tumours over a certain size.

It is probably the local immune system which is

stimulated more than the tumour.

The situation is the same for bacteria and virus

in culture.
These are stimulated by laser light in certain
doses, while a bacterial or viral infection is cured
much quicker after the treatment with LLLT.

15. Q: What happens if I use a too high dose?

A: You may have a biosuppressive effect or just a
non optimal effect.
That means that, for instance, the healing of a
wound will take longer time than normally.
Very high doses on healthy tissues will not damage
them.

16. Q: Are there any contraindications?

A: No, no medical contraindications. In most
countries there are legal contraindications, i.e.
you should not treat cancer or some other seious
deseases.
Pregnancy is not a contra indication if treatment is
done with common sense.
Pacemakers are electronical and are not influenced
by light.
The most valid contraindication is possible lack of
adequate medical treatment.

17. Q: Does LLLT cause a heating of the tissue?

A: Principally yes - all light will cause some heating if
absorbed by tissue.
However stronger laser types.
like GaAlAs lasers in the 300-500 mW range may
cause a noticeable heat sensation, particularly in hairy
areas, dark tattoo and on sensitive tissues such as lips.
The amount of melanin in the skin is an important
factor; dark skin will be more heated than fair skin.
The biological effects have nothing to do with heat.
Due to increased circulation there is usually an increase
of 0.5-1 degrees Celcius locally.

18.Q: Does it have to be a laser?

Why not use monochromatic non coherent light?
A: Monochromatic non coherent light, such as light
from LED's can give good effect on superficial tissues
such as wounds.
In comparative studies, however, lasers have shown to
be more effective than monochromatic non coherent
light sources, especially in deep tissue.

19. Q: Does the coherence of the laser light

disappear when the light is scattered in the
tissue?
A: No. The length of coherence, though, is shortened.
Through interference between laser rays in the tissue,
very small "islands" of more intense light, called speckles
occur.
These speckles will be created as deep as the light reaches
in the tissue and within a speckle volume, the light is
partially polarized.
It is easy to show that speckles are formed rather deep
down in tissue and the existence of laser speckles prove
that the light is coherent.

20. Q: Do therapeutic lasers produce

so-called soliton waves?
A: No. Such claims are just sales tricks.

Are all the negative LLLT studies really negative?

1.400 articles were reviewed for this analysis, the
emphasis being on double-blind studies.
Of the 135 localised double-blind studies, 85
reported positive findings.
Certain studies were also included merely on the
grounds that they are among the most frequently
cited.
The 1.400 articles reviewed for this analysis are now
being stored in computerised form.

Positive from negative

Having traditionally concentrated on studies positive to
LLLT, over the last few years we found ourselves
becoming more and more interested in those studies
with a negative spin: provided they have been properly
carried out, they may be able to show us the parameters
that do not appear to work.
Naturally, negative reports must always be taken
seriously, but the fact that a given study has been unable
to demonstrate the effectiveness of LLLT does not
necessarily mean that the method studied is incapable
per se of producing results within the indication in
question.
All that it shows is that the parameters selected for
the study were not sufficiently effective.

U studijama koje negiraju efekat laseroterapije

koriene su razliite visoke energetske doze
lasera (3,9 J/cm2, 5,8 J/cm2, 22.5 J/cm2), to govori u
prilog jasnog dozno-zavisnog efekta u odnosu na
kliniki suspstrat.
Izraenu kontradiktornost u vezi efikasnosti LLLT
verovatno odreuje i odsustvo elementarnih
kriterijuma u dizajniranju studija.

Negative from negative

LLLT is a relatively young science that has only just
emerged from its Sturm und Drang period, and it
might perhaps be unfair to criticise the earlier negative
studies.
Many medical researchers then had - and indeed still
have - a rather diffuse knowledge of physics, and
qualified books on the physics of laser therapy were
long in appearing.
In many cases, the only information available to
researchers on doses, methods of treatment and
suitable indications came from the manufacturers or
agents, while over-optimistic, ignorant salesmen often
laid traps that would ensnare both themselves and the
researchers.

Important parameters
A. Wavelength
That biological effect is significantly related to
the wavelength of the light emitted by the laser has
been demonstrated in numerous studies.
Today, the wavelengths most commonly used for
therapeutic purposes are 633 nm (HeNe lasers), 635
nm, 650 nm, 660 nm, 670 nm (InGaAIP lasers),
780 nm, 820 nm, 830 nm (GaAIAs lasers), 904 nm
(GaAs lasers), and 10600 nm (CO2 lasers)
Except for GaAs and CO2 lasers, all these lasers
usually produce a continuous beam but may also be
pulsed.

B. Dose
The most important parameter in LLLT is always the
dose, often referred to as "fluence".
By dose (D) is meant the energy (E) of the light directed
at a given unit of area (A) during a given session of
therapy.
The energy is measured in J (joules), the area in cm2,
and, consequently, the dose in J/cm2.
Mathematically, this may be expressed as follows:
E
D = ---- [J/cm2]
A

B. Dose
Assuming that the power (P) output of the laser
probe remains constant during treatment, the energy
(E) of the light will be equal to the power multiplied
by the time (t) during which the light is emitted.
The dose may then be calculated as follows:
Pxt
D = ---[J/cm2]
A
E=Pxt

The preferred method of pulsing a HeNe laser is to use some

form of mechanical switching device or shutter, such as a rotating
pierced disc, the useful proportion of the time during which light
is emitted by the laser normally being fixed at a given value (duty
cycle), most often 50%.
In other words, light is permitted to pass through the disc for 50%
of the total operating time (and is blocked for the remaining 50%).
This enables use of the concepts of mean power (Pm) and
maximum power.
In the example given here, the mean power is 50% of the
maximum power.
If the laser is pulsed at mean power, the above formula will apply,
giving:
Pm t
D = ------A

[J/cm2]

GaAs lasers always pulse, the duration of each pulse

being extremely short, and in these lasers the
maximum power is always much, much greater than
the mean power.
This type of pulsing is often referred to as superpulsing.
In GaAs lasers, the duration of the pulse is normally in
the region of 100-200 ns (nanoseconds) and the
maximum power is typically 1 - 20 W (watts).
Assuming, for example, that the duration of the pulse
is 150 ns and that the maximum power is 10 W, each
pulse emitted by the laser will have an energy of 1.5 J
(microjoules).

If the laser emits 100 such pulses per second (a pulse

frequency of 100 Hz), its mean power output will be
0.15 mW (milliwatts).
A pulse frequency of 1000 Hz gives a mean output of
1.5 mW, etc.
In other words, the mean power output varies
with the number of pulses emitted per second.
By applying these relationships, it is often possible to
obtains doses or other parameters not explicitly
stated in the article under review.

C. Power density

Power density, indicating the degree of concentration of the power

output, has also increasingly proved to play a major role.
It is measured in watts per square centimetre (W/cm2).
If, for example, a circular area having a diameter of 5 mm (approx.
0.2 cm2) is illuminated with a laser operating at a power output of
100 mW, the biological effects are quite different from those
produced by illuminating a circular area of 5 cm diameter (approx.
20 cm2) with the same laser.
In the first case, the power density is 100 times greater than the
second.
Some studies have concluded that the power density may be of
even greater significance than the dose.
This parameter is very seldom indicated in the articles we have
studied.
It must also be remembered that the power density varies within the
area illuminated - normally, it will be greatest at the centre.

Typical traditional laser instruments

Whenever possible, we also reviewed the brochure
or brochures describing the instrument used for the
study.
The power output of the first commercial
therapeutic lasers was very low.
HeNe instruments often achieved an output of 1 - 2
mW at the laser tube, while the losses sustained in
the optical fibres were frequently 50% or more.
Further-more, the laser was sometimes pulsed
(usually switched to produce a duty cycle of about
50%), thereby reducing the power/mean output
power sent to the tissue by another half.

Dose development
A number of early positive reports on the clinical
effects of very weak HeNe lasers suggested that there
was cause for some optimism - and scepticism, too.
Among them are Walker (1983) [E1] (calculated at
approx. 0.005 J per point) and
Snyder-Mackler (1988) [E2, 3] (calculated at approx.
0.01 J per point), reporting on the effect of very weak
HeNe lasers.

It must be remembered that Mester had been working

with doses of around 1 J as far back as the early
seventies.
Later, in an article published in 1971 [E4] he
recommended a dose of 1.5 J/cm2 as conducive to
wound healing.
The HeNe laser he used had an output of 25 mW at the
laser.
For a long time Mester's papers attracted little
attention in the West, since they were published in
relatively unknown journals.
Later, in 1981, Kana [E5] published a study on the
healing of open skin wounds in which he presented
an analysis of the biological effect of 4, 10 and 20 J
therapy.

The instrument he used was an HeNe laser producing an

output of 25 mW from the laser tube.
Mester's and Kana's experience of doses suitable for
wound healing still hold good today.
Although HeNe lasers with a power output of 25 mW were
extremely expensive at the time, it cannot be held that
information on suitable doses was not then available.
It should be noted, too, that the treatment of pain
requires larger doses than does the healing of open
wounds.
It seems that a large proportion of the negative studies
concentrated mainly on testing the reliability of studies such
as [E1, 2 and 3] without regard to existing knowledge of
reasonable doses.