Low Level Laser Therapy
Time for a gut check
Howard B. Cotler, MD, FACS, FABOS, FAAOS
Nearly 2 million people each year suffer sports related injuries and end up in emergency rooms. 12
million people between the ages of 5-22 suffer sport related injuries resulting in 20 million lost days of
school and $33 billion healthcare costs.1 2 One out of three Americans have serious chronic pain each
year and cost the country $600 billion each year in medical bills, missed work and lost productivity.3
Sports medicine physicians are considered the most active epidemiologists who are concerned with
quantifying injuries for purposes of explaining causation and developing strategies to control, prevent
and recover from them.
New and old technologies and treatments have exposed a whole rathe of side effects, complications and
societal issues on the American people. It is now time for a gut check by returning back to basic
principles of correcting structural problems which are in need and learning to accelerate soft tissue
healing for a quicker and more complete return to life, work and sports and preferably in a cost effective
manner. These treatments must be conceptually sound, therapy driven and avoid costly side effects and
complications.
Low level laser therapy (LLLT) has been actively used for nearly forty years, during which time it has
been known for reducing pain inflammation and edema4. Also it has the ability to promote healing of
wounds, including deep tissues and nerves, and preventing tissue damage vial cell death. This article will
review the basic science of LLLT, give a brief historical perspective, explain how it works, discuss the
clinical studies, expose the controversies and complications, and lastly show this new technology and
techniques of applications which are immediately applicable to the injured professional and amateur
athlete. Lastly it should serve as a springboard toward more definitive studies for the injured athlete.
The use of light for treatment of disease has been around since 1903 when Dr. Niels Finsen was awarded
a Nobel Prize in recognition of his treatment of lupus vulgaris with concentrated light5. Low Level lasers
were invented in 1967 by Dr. Endre Mester in Budapest.6 Dr. Robert Furchgatt was the first to describe
light mediated vasodilatation in his nitric oxide research for which he was awarded a Nobel Prize in
1998.7 8
From a historical perspective we now know that light has a biological effect, but what we need to know
is how energy from lasers and light emitting diodes (LED) work on a cellular level and what are the
optimal light parameters for different uses.9
The power plants of the cells are mitochondria which are able to make cellular energy or adenosine
triphosphate (ATP) from pyruvate and oxygen. 10 11 12 When tissues are stressed or ischemic,
mitochondria make their own mitochondrial nitric oxide (MtNO) which competes with oxygen. The
MtNO binds to cytochrome c oxidase (CcO) which displaces oxygen. This subsequently reduces ATP
synthesis and increases oxidative stress which leads to inflammation. 7 8 13
Hypoxic/stressed tissues are affected by LLLT in 4 stages. Light energy is absorbed by cytochrome c
oxidase and triggers several downstream effects.12 Following LLLT, nitric oxide is released, ATP is
increased and oxidative stress is reduced. 14These biochemical intermediates affect components in the
cytosol, cell membrane and nucleus which control gene transcription, cell proliferation, migration
necrosis and inflammation.14 Cells in blood and lymph which have been light activated can travel a
distance for systemic effects. 15 16
The four common targets for LLLT are:
1.
2.
3.
4.
L – lymph nodes to reduce edema and inflammation 17
I – site of injury to promote healing and reduce inflammation 15 16
N – nerves to induce analgesia18 19 20
T – Trigger points to reduce muscle spasms.21
Penetration depth is determined by wavelength and power. The U.S. Navy research determined 810nm
to be optimal for penetration. 22Treatment times are in the range of 30 seconds to 1 minute. 2.5 Hz
pulse are recommended for improving repair and decreasing inflammation, while a continuous beam is
ideal for analgesia and tender points.
LLLT is FDA approved and CE certified. In some states a prescription is mandatory prior to treatment.
Treatment can be administered by a certified therapist, technician, x-ray technologist or physician.
European sports therapist have used LLLT for over a decade, yet they have only had a 50% success rate.
These inferior results may be accounted for by inconsistent laser parameters and dose. Recent advances
by NASA and Harvard Medical School have clarified the mechanism where there is a biphasic dose
response.
Side effects and complications can result from traditional treatments for musculoskeletal pathology.
Non-steroidal anti-inflammatories can cause ulcer disease, hypertension, bleeding and cardiac events.
Steroids (oral and/or epidural) can result in infections (including epidural), bleeding, ulcers, avascular
necrosis and tissue fragility. Studies have found LLLT to have no side effects or adverse event beyond
those reported for placebo.
Due to strong basic science research, clinical studies in rehabilitation medicine, and low complication
rate, LLLT should be considered as a first line treatment option.23 24 25 26 27Its safety profile provides a
persuasive argument, with the added benefits of accelerated healing, tissue remodeling, pain relief and
decreased inflammation. What is now needed are more modern prospective studies using newer
guidelines by clinicians to give a more complete picture of efficacy and cost effectiveness.
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