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SEMINAR ON LOW LEVEL LASERTHERAPY FOR BEAS HOSPITAL, EDITED BY JAN TUNER, DEVELOPED AND

PRESENTED BY MALINI CHAUDHRI. UNDER THE AUSPICES OF PUNJAB MEDICAL COUNCIL

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LOW LEVEL LASER THERAPY FOR HOSPITALS

MALINI CHAUDHRI. Ph.D. Dr.AcWALT, ISLSM ISLA, EMLA NAALT, LASER ANNALS, Swedish Medical Laser Society.

Has worked with Photomedicine since 1994 with Alma Ata (Hong Kong, Colombo,) Japan, USA, Czech Republic, and Sweden. Sponsored to USA in 2003. Based in R&D from India. Published scientific papers and developed a course, edited by Jan Tuner, Editor of Laser Annals.Specializes in Laser Acupuncture and Physio, technical training , therapy and research.

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INTEGRATIVE MEDICINE. SUPPORT WITHOUT DRUGS

TOPICS OF DISCUSSIONLLLT APPLICATIONS TO SUPPORT ALL DEPARTMENTS IN A HOSPITAL

WOUND HEALINGPAIN MANAGEMENTINFLAMMATION AND EDEMAMUSCULOSKELETAL DISORDERSLASER ACUPUNCTUREReview: PDT AND SYSTEMIC THERAPY

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MECHANISMSOF LLLT. LAWS OF

PHOTOCHEMISTRY

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ABSORPTION SPECTRA. For a photo reaction to take place there must be a photoacceptor. This is mainly cytochrome c oxidase in the mitochondria. Chromophores receiving light molecules that are active in photochemistry are melanin and haemoglobin.

ACTION SPECTRA Depends on the nature of the photostimulation. Wavelengths from 600nm to 950 nm are considered therapeutic. Coherent laser light involves photo excitation in the mitochondria that is conveyed to the nucleus. Increased ATP and DNA synthesis provides scope for reversing disease and targeting gene therapy. All cells having mitochondria respond to LLLT.Recent research has shown the infinite possibilities of the mitochondria to expand and generate photo pathways for added photo chemistry

Photo of Malini Chaudhri giving laseracupuncture to Jan Tuner in WALT, Japan

Das wavelength diagram of different light sources

J. Tuner, L. Hode: Laser Therapy

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LASER EFFECTS AND SAFETY• Photo thermal effects. Involve significant increase of

temperature in tissue (5 -10 C),and remodelling. CO2, ND Yag. Hair removal lasers, surgical lasers etc.

Class 4 laser

• Photo mechanical effects. This develops a steeper gradient during exposure. Q switch. Removing tattoos. Class 4 laser

• Photochemistry. No significant thermal effects. LLLT. Class 3 laser

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PHOTOCHEMISTRY

photo absorption -

photo action -

I I I Wound healing Relief of inflammation neurogenic painTissue repair pain,edema, acute injuries, acupuncturePrevention of tissue chronic diseases death

Cellular photoacceptor inmitochondria

Low level laser wavelength 600nm- 950nm

IIIIIIII

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NOTES ON EFFECTS OF LLLT

• Photoacceptors (Cytochrome c oxidase) can absorb low level lasers irradiation and transfer it inside mitochondria in order to provide cell energy (ATP) which is the product cytochrome c oxidase in the respiratory chain of the mitochondria. The stimulation of ATP synthesis results in increased cell activity. These changes influences macrophages, fibroblasts, endothelial cells, mast cells, bradykinin and nerve conduction speed.

• Biomodulatory effects of LLLT comprise the following:• Macrophages, lymphocytes, fibroblasts, endothelial cells and keratinocytes

proliferation; increase ATP synthesis and cell respiration, growth factors and• other cytokines release, change of fibroblasts to myofibroblasts; change in

inflammatory mediators level (histamine and prostaglandins); increase in oxygen transport and improve in glucose consumption; changes in cell membrane potential and permeability,

• sodium/potassium pump excitation and more calcium removal; vasodilation and angiogenesis (improve in tissue nutrition); collagen synthesis.

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What are the progressed physiological effects of laser light?

• - Proliferation on immune cells leads to the combat of inflammations and an accelerated• healing of wound as well as an increased endorphin disbursement, increase of the ATP• production and increased nervous cell potential.• - Increased leukocyte phagocytosis, boosted neovascularisation, increased collagen• formation and protein biosynthesis. It also leads to an improved cell respiration and• stabilization of the membrane potential.• - Enhancement of the proton gradient via the mitochondria membrane, generation of an• increased potential difference with increased phosphorisation of ATP (increase of 150%).• - No modification of intact cells.• - Energetic build-up of sick cells.• - Energy is to a large extent (more than 40%) used for ATP synthesis, in order to increase the• pump activity for maintaining the membrane potential.• - Membrane stabilization leads to blocking of impulses, reducing the transmissions of pain• sensations.• - The cell’s calcium content is regulated (diminished ATP synthesis leads to a an overflow of• the cell with calcium and activation of proteinasis, resulting in the death of the cell, the• necrosis).• - In the pre-necrotic state, cells suffer from acute lack of energy with sodium and calcium• streaming in, which can only be removed with the utmost pump activity. This pump activity• can only be enhanced by radiant energy.

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• LASER DOSE SELECTIONS ARE BASED ON THE ARNDT SCHULTZ LAW

• LOWER DOSES ARE BIOSTIMULATORY• HIGHER DOSES ARE INHIBITORY• LEDS ARE IN WIDESPREAD USE. HOWEVER THEY ARE

NOT BASED ON COHERENT LIGHT AND GENERATE • SUPERFICIAL EFFECTS SUITABLE FOR HEALING WOUNDS

• IN LASERS Areas of high difference in light intensity levels form• SPECKLES. Local differences in intensity create temperature

and pressure gradients across cell membranes which enhances permeability of the membrane so that photons may be active deeper.

•

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WOUND HEALINGLasers in the visible red spectrum are preferred for wound healing(or LEDS)

Helium Neon 634.8nm,670nm, 780nm in Continuous wave. LEDS. PDT

Supports dramatic healing of BedsoresOpen woundsAllergic or contact dermatitisInfectious and ulcerating woundsDiabetic ulcersSurgical woundsAcneBurns

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Mechanisms of wound healing• LLLT is beneficial for wounds of various etiologies and affects every molecule

involved. This includes• Increased ATP levels• Promotion and proliferation of migration of keratinocytes, endothelial cell and

fibroblasts.• Secretion of growth factor from macrophages• Increasing collagen synthesis• Increasing phagocytic and bactericidal activities of inflammatory cells.• Modulation and regulation of secretion of chemokines and cytokines

• These support the 3 stages of wound healing,• 1) Inflammation (immune cells migrate to the wound and close it to promote healing)• 2) Proliferation(new granulation tissue is produced to fill in the gaps with more collagen

production and increased epithelialization• 3) maturation( with wound closure keratins undergo stratification and differentiation to

restore the barrier without which wounds become chronic)

Oral Mucositis. Patients undergoing chemotherapy need LLLT

Photo: R-J Bensadoun, Nice

A Stye. The following day after HE NE laserPhotos courtesy Jan Tuner

TECHNIQUES FOR WOUND HEALING

Apply a probe to points in contact mode along the periphery of the wound to stimulate contraction. Incase of scanner apply over the wound at .5 cm distance from skin

Along the open area use the techniques drawn on the left or apply along the surface of the wound as a grid as below.Dose. 2-6J/sq cm

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These applications improve the effects of laser therapy on wound healing with lasers in the visible spectrum

Recommendations are from Tuner Hode

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PAIN MANAGEMENT• Pain management involves the use of lasers from the

634nm to 950nm. • The IR lasers may be Superpulsed, SP, (difficult to

calculate joules) and achieve a deep tissue response• Recent literature favors Continuous wave, CW, laser for

technical control of dosimetry and for progressive photochemical effects during a laser session and management of cummulative effects as per FDA requirements.

• In pain management, Professor Pontinen, has established a Pontinen Principle, which emphasizes the ethical responsibilty and capacity to treat pain in a single session of lasertherapy by maximizing the laser dosage and palpating the pain points to assess improvement.

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APPROACHES Laser irradiation/scanning.

Trigger point release

Laser acupuncture

Laser auricular acupuncture

Interstitial laser treatment

Increases synthesis of endorphins and bradykinin, decreased activity of C fibers, reduction of serotonin and nociceptors. Increased painthreshold

Relaxes muscles bands and reduces referred painbased on treatment of hyper-irritable points located in muscles that are shortened

This is an approach through the CNS to activate acupuncture pathways and create homeostasis

This is a photo pathway through the auricular nerves to stimulate a somatotopic representation of the human fetus in the ear, with respect to embryonic tissue

This is an invasive procedure in which a 5 mw laser fiber needle penetrates deep into the skin to deliver photons in a injured musculosketal condition

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MECHANISMS TO TREAT PAIN WITH LLLT

• a possible stabilization of nerve cell membranes, probably due to the more stable conformation of the lipid bilayers induced by LPT, and the associated integral proteins of the nerve cell membrane, the enhanced redox systems of the cell and an increase in ATP production have also been shown to restore neuronal membranes and decrease pain transmission.

• - Reduction of Inflammation and edema (-releasing of inflammatory cytokines like prostaglandin E2 and plasminogen activator could be reduced- less inflammatory cells were present in irradiated samples-

• - Reduction of inflammatory cell migration,• - Reduction of edema and inflammatory cytokines like TNF-α, interleukins 1 and 6• - The laser acts by inhibiting cyclooxygenase,• - Interrupting the conversion of arachido prostaglandin and also increases the production of B-

endorphin.• .• In addition to these, analgesic effects of lasers can be explained by the increase synthesis of

endorphin and bradykinin which results in decreased activity of C fibers and change in pain threshold, and also in reduction of serotonin and suppression of nociceptors

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PAIN MANAGEMENT

• evidences exist on the treatments effects of low level lasers on the synthesis, release and metabolism of various chemical nervous mediators like

• serotonin and acetylcholine in central nervous system, and• histamine and prostaglandin in peripheral nerves. The• increase in production of endorphin, the reduction of C fibers activity,

the decrease of bradykinin and the change in pain threshold can also explain the effects of low level lasers on pain

• The anti inflammatory effects of LLLT can be due to the augmentation of phagocytosis and increase of number and diameter of lymphatic vessels, decrease in permeability of blood vessels, repair of capillary flow and reduction of edema

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LYMPHEDEMA

LLLT has been noticed to reduce histamine release and accumulated lymph edema even at Stage 3.This application is useful for lymphedema of patients who have surgically removed nodes, or after chemotherapy- It is not proven in conditions that are genetic.- In treatment of wounds and sports injuries, the lymph

pathways have to be cleared through laser application techniques that are specific. This involves irradiating nodes, applying a technique called ‘woodpecker, and managing a dose that regenerates lymph vessels if needed. As with injured skin, injured lymph vessels may also be repaired with laser.

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TREATING PAIN THROUGH TRIGGER POINTS IN ORTHOPEDIC CONDITIONS

Sports injuries, surgeries, visceral organ diseases and orthopedic conditions including spinal curvature,Spondylosis, lumbago etc, will require an approach with laser to treat trigger points.

Pontinens Principle should be applied to maximize the dose till the painful trigger point is removed. The therapist may palpate the tender point to assess pain score, and determine effects before and after lllt.

Also manage referred pain

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Trigger Point therapy is an essential technique used in Physical therapy to manage pain.There is a large database of research from World Association of Laser therapy on precise dosimetry for each condition and muscle or tendon group.

The therapist must be acquainted with 1) the laser wavelength,2) anatomy of muscle and3) location of trigger point4) Recommended dosimetry in joules

Photo is of sternal division trigger points and referred pain in the eyes and face

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CHUKUKA ENWEMEKA. WALT EDITOR

Manual on WALT doses and trigger points is published online based on meta-analysis of scientific data

http://se-led-belt.com/wp-content/uploads/2012/10/Light_Therapy_by_Chukuka_Enwemeka_PhD.pdf.

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muscle or area no of joules points

Biceps humeri 1-2 8 Supraspinatus 2-3 10 • Minimum 5 Joules per point Infraspinatus 2-3 10 Minimum 5 Joules per point Cervical spine 2-4 15 • Minimum 6 Joules per point Lumbar spine 2-4 40 • Minimum 8 Joules per point Hip 2-4 40 • Minimum 8 Joules per point Knee medial 3-6 20 • Minimum 5 Joules per point

RECOMMENDED DOSES FROM WALT Using 780nm to 830nm single lllt probesin Physical therapy

Chronic and acute conditions must be differentiated

Stages of healing must be differentiated

Local and referred pain musat be differentiated

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LASER ACUPUNCTURE

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-LAP must be differentiated from needle acupuncture.-LAP treats single command points, wheras acupuncture approaches a yin and yang points related to 5 element disorders.- LAP must be differentiated from Trigger points

which treat the fascia and PNS. LAP treats the CNS and may speed up treatment effects.

- Refer to Laser acupuncture trial on women golfers, published in Laser World.

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LASER AURICULAR ACUPUNCTURE.

LASER FREQUENCIES.

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NOGIER FREQUENCIES AND CORRESPONDENCES

• Frequencies Body Ear (external face) • A Orifices: mouth, eyes, nostrils, navel, anus and

genitals Internal face of tragus, auricular meatus

• B Trunk: face and back Concha • C Limbs: arms and legs Anthelix andhelix

root • D Median line front and back, trunk and head

Pre-tragus area • E Skull, neck and vertebral column Descending

part of helix • F Face except nose and forehead Isthmus

• G Forehead (projection of frontal lobes) Lobule

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Frequencies and Value (Hz)• A 292 E 4672• B 584 F 73• C 1168 G 146• D 2336• Definition of frequencies by Drs Paul and Raphaël Nogier:

Extract from "The man in the ear", Maisonneuve, 1979, 255 p.• The "A" frequency is associated, in the animal kingdom, with non-organized, embryonic structures. It is

the frequency of the primitive living being; it is in sympathy with the cell in the crude, undifferentiated state. This frequency, the most archaic, can also be considered to be the most anarchic.

• The more elaborate "B" frequency is specific to the nutritional visceral system and is related to the primitive gastrointestinal apparatus.

• The "C" frequency indicates motor elements of the body. It reflects movement, the limbs, the renal system, the genital tract.

• The "D" frequency leads us to a higher level of organization, as it introduces the concept of symmetry, by selectively affecting certain unpaired organs, presenting the characteristic of being solitary, but anatomically symmetrical; for example the corpus callosum or the white commissure, two symmetrical cerebral structures, situated between the right hemisphere and the left hemisphere [...]

• The "E" frequency is that of the spinal cord and central nervous system, which perceives and communicates between functional units situated at different levels.

• The "F" frequency represents subcortical cerebral regions. These structures are found in the brain of higher animals, dogs, for example.

• The "G" frequency resonates with the most elaborate structures of the body, those of the cerebral cortex, the typically human part of the brain, which gives man the capacity to think, create and imagine.

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EXTRA. RUBACH. MECHANISMS OF PAIN CONTROL OF ACUPUNCTURE

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EXTRA. RUBACH. EMBRYONIC ORIGIN

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EXTRA. RUBACH

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AXEL RUBACH. EXTRA. BK PRINCIPLES OF EAR ACUPUNCTURE

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EXTRA. RUBACH

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Extra. RUBACH

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• ENSURE THAT YOU ARE CERTIFIED OR TRAINED TO APPLY LASER FOR A SPECIFIC PROTOCOL

• MANAGE APPLICATIONs THAT ARE DIAGNOSIS SPECIFIC : WHERE THE PROTOCOL IS DESIGNED

• ENSURE THAT YOU BELONG TO A LEGITIMATE AUTHORITY FOR INSTRUCTION

• DO NOT MAKE CLAIMS OR PROMISE TO CURE

• DOCUMENT ALL PROCEDURES AND RECORDS

• MANAGE ORGANIZATIONAL SKILLS• MANAGE COMMUNICATION SKILLS

TO INFORM THE CLIENT• STAY UPDATED IN RESEARCH AND

SCIENTIFIC LITERATURE

FDA.

APPROVAL FOR PRACTISE

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KEEP YOUR PRACTISE SAFE.WEAR PROTECTIVE GOGGLES AND PUT UP SAFETY SIGNS

• READ YOUR LASER MANUAL

• FOLLOW SAFETY GUIDELINES

• ENSURE THAT YOUR LASER IS CERTIFIED

• FOLLOW OSHA AND ANSI SAFETY GUIDELINES FOR LASERTHERAPY

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RECENT CONCERNSIn a recent editorial published by Tina

Karu in Photomedicine and Laser surgery, she has communicated that the time has come to consider LLLT a drug based equivalent.

She has been accountable in presenting the large and specific database of scientific achievements in all fields in 40 years.

Laser blood irradiation in biological cancer therapyEXTRA WEBER

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MALINI CHAUDHRI THANKS ISTE AND JAN TUNER AND THE BEAS HOSPITAL MANAGEMENT FOR THEIR SUPPORT

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LINKS

www.laserannals.comwww.walt.nuwww.laser.nuwww.centerforwellness.net

With European medical Laser Assoc.EMLA parliament