Slide 2

Laser therapy utilizes penetrating photonic energy to achieve physiological and biochemical
changes within the targeted tissues. Also known as “photobiomodulation therapy” (PBMT)

Modern science seeks to unleash its true hidden potentials for improving the quality of life on
our planet. It has also been widely used in medicine, for instance to alleviate diseases such as
rickets, reduce the painful effects of psoriasis, and more recently, aid in surgical intervention.

Slide 3

Various forms of heliotherapy (light therapy) have been practiced around the world for centuries.
Physicians and healers in Ancient Greece, Egypt, and Rome – including renowned Greek
historian Herodotus in the 6th century B.C. – all realized the benefits of such therapy (Ellinger,

1957). Likewise, the Inca and Assyrian cultures worshiped the sun with the belief that it would
bring them health. Around 1500 B.C., Indian medical literature described treatments combining
herbal medicine with natural sunlight to treat non‐pigmented skin. There are records in the
Buddhist literature from around 200 A.D.

Niels Ryberg Finsen, a Faroese physician and scientist of Icelandic descent, is widely regarded
as the original proponent of phototherapy. In 1903, he was awarded the Nobel Prize in Medicine
and Physiology for the successful treatment of diseases using phototherapy; specifically, lupus
vulgaris, a skin infection caused by Mycobacterium tuberculosis.

Shortly thereafter, in 1916, Albert Einstein postulated the theory of lasers to support his Theory
of Relativity.

On May 16, 1960, Theodore Maiman produced the first ruby laser at the Hughes Aircraft
Research Laboratory in Malibu, California, basing his new creation on Albert Einstein’s
explanation of stimulated emission of radiation, coupled with Townes’ and Schawlow’s 1958
work with optical masers. Several years after the invention of the laser, Dr. Endre Mester –
considered the founding father of laser therapy became the first to experimentally document the
healing effects of lasers.

Slide 4
Light is one of the most interesting and mysterious elemental components of our known
universe. It is intangible, yet able to transfer energy due to the mass effect of photons which
enables light to do work and exert force on other molecules.

Photons, strictly speaking, are specific packets of electromagnetic energy that give light its mass
and therefore allow it to do work.

Niels Bohr proposed a more closely related concept to that of today’s laser energy in that this
was related to a specific atomic model where electrons in specific atoms and molecules could
alter their energy state to a higher or lower level, depending on energy applied, without being
destroyed. These theories launched the quest for production of a coherent stimulated emission of
radiation that would become known as laser energy.

Slide 8

Radiation is the transmission of energy from one point to another with or without an intervening
material medium.

Electromagnetic radiation, which is produced by lasers, requires no medium for its transmission
because it can travel through the vacuum of space. It can also travel through matter in the form
of gases, liquids, or solids. The speed and direction of the propagation of radiation will be
changed upon the transition from one medium to another in the form of heat. Atomic radiation
usually requires a change in mass, and the energy transmitted is the kinetic energy or the moving
particles.

Wave theory the optical phenomena of visible light such as reflection, refraction, diffraction,
interference, and polarization. It also describes the behavior of high-energy cosmic rays, X-rays,
and other ultraviolet radiation as well as lower energy infrared, microwave, and radio waves. The
wave theory does not adequately describe all of the behaviors of electromagnetic radiation,
especially when dealing with high-energy reactions of nuclear particles.

Planck modified the wave theory to describe the exciting discoveries of the photoelectric effect,
light emitting diodes, fluorescence, photochemistry, and laser. His quantum theory, or photon
theory, describes how materials can be stimulated to produce laser energy.

Light is generally described in terms of wavelength and frequency and travels at a speed, c: c =
2.998 * 108 m/s
At the same speed, c, frequency and wavelength are inversely related for these two different
colors of light. The wave possessing a larger wavelength will have a lower frequency and less
energy while the higher frequency wave will have a shorter wavelength and higher energy.

Visible light is perceived within a narrow band of wavelengths between 400nm (violet) to 700nm
(red). Wavelengths shorter than 400nm are ultraviolet, and wavelengths greater than 700nm are
infrared. Cosmic rays have the shortest wavelengths, on the order of 10 -13 to 10-15 m, and radio
waves have the longest wavelengths, up to one meter.

Slide 9

Entire electromagnetic spectrum shows that visible light occupies an extremely narrow
bandwidth. Red light is visible at around 700nm, and blue light is visible at around 400nm.
Wavelengths larger than 700nm are referred to as infrared because the frequency of the radiant
energy is lower than that of red light. Likewise, wavelengths shorter than 400nm are referred to
as ultraviolet because the frequency of the radiant energy is higher than that of violet light.

Planck advanced the photon theory by postulating that the energy carried by an
electromagnetic wave cannot be endlessly subdivided into eversmaller increments, but that
radiant energy consists of indivisible units referred to as a quantum.

Slide 10,11

A photon is a massless particle of radiant energy that moves at the speed of light in a straight
line. It may be considered a wave train of finite length, or a wavelet.

The quantum theory states that there is a precise value of energy associated with each photon.
The photonic energy (ep) is directly proportional to the frequency (f) of the wavelet: ep = hf

All light in the universe originates as a quantum-level energy change resulting in the spontaneous
emission of a photon. Photons are generated and absorbed by molecules or compounds and have
predictable energy levels. Each molecule has unique physical characteristics regarding
absorption and emission of photonic energy. This emitted light is a characteristic wave of
photons that can be collimated, amplified, or refined to transfer its energy to do work on a host of
materials and tissues.

A variety of compounds, when stimulated, are able to produce differing wavelengths of laser
energy. Each specific wavelength has a different effect on specific target material or tissue.
Laser light is distinctly different from other light in many ways. To illustrate, let us compare it
with the “white light” produced from an incandescent light bulb. The product of the laser is light,
which is composed of the previously described discrete energy packets known as photons.
Photonic energy is also released from heat generated through resistance to a metal coil in a light
bulb and indeed, a photon is a photon whether it comes from a camp fire, a light bulb, or laser.
Light from the laser and the light bulb differs fundamentally in how its photons are generated,
organized, confined, and transmitted. When you look at a glowing light bulb, you see white light
that is composed of various wavelengths radiating in all directions at varying amplitudes and
frequencies at all origins of time. As you walk away from the glowing glass bulb, its light
appears dimmer until the light is no longer detectable. The various wavelengths produced from
the light bulb cancel each other out over time and distance. In the laser beam, however, photons
are emitted in parallel and in phase with each other and collimated.

Photons produced from a single compound or atom producing consistent energy released at the
same wavelength, amplitude, frequency, and time are considered a laser beam. This property is
known as coherence

We can also see that a light bulb produces a “white” color. This is because the white light
contains all of the colors and wavelengths in the visual portion of the electromagnetic spectrum.
Multiple photon emission of this nature is considered polychromatic. If you put a glass prism in
front of the light bulb, you will refract the different wavelengths and see the rainbow effect
spread out as a continuum of distinct color emissions. Laser energy passed through the same
glass prism will produce light of only one wavelength and hence one color. A laser produces a
beam of one type of photon and is classified as monochromatic.

Slide 12

Laser Generation

Three things are needed to produce a functional laser: (1) an optical resonant cavity
that contains (2) the lasing medium and (3) an external energy source. The type of
lasing medium (gas, liquid, or solid) within the optical resonator determines the
wavelength of laser light produced. The resonant optical cavity is generally a tube
or cylindrical structure, and its length is much greater than its width. A highly
reflective mirror caps one end of the resonant cavity and a partially transmitting
but highly reflective mirror is at the opposite end cap. This is required to allow the
laser light to emerge from the resonator for functional use. The energy source can
be another laser or, more commonly, electricity (either radio frequency or direct
current). The process of exciting the medium within the resonator is called
pumping.

Slide 13

Classification

Class 3B lasers can have a power output up to 500 mW and wavelengths in the
range from 300 nm up to the far infrared

What power setting should I use for this procedure?” is the most common question a new laser
surgeon may ask. The fact is, depending on the type of procedure and type of laser energy to be
used, there is no one correct answer.

Slide 14

Anders, J. et al. (2015) Low‐level light/laser therapy versus photobiomodulation therapy.

‘A form of light therapy that utilizes non‐ionizing forms of light sources, including lasers, LEDs,
and broadband light, in the visible and infrared spectrum. It is a nonthermal process involving
endogenous chromophores eliciting photophysical (i.e., linear and nonlinear) and photochemical
events at various biological scales. This process results in beneficial therapeutic outcomes
including but not limited to the alleviation of pain or inflammation, immunomodulation, and
promotion of wound healing and tissue regeneration’.

Application of laser therapy in conjunction with regenerative therapies such as stem cell or
platelet‐rich plasma injections is properly termed “photobioregeneration”.

Slide 15

This spectrum runs from very short gamma rays to very long radio waves. Visible light is in the
~380–400 nm (violet) to ~700–780 nm (red) range. Therapeutic lasers emit in the 620 nm (red)
to 1200 nm (near‐infrared) range. Optimal penetration in tissue requires wavelengths that
minimize scattering and reflection at the tissue surface and absorption by unwanted
chromophores. At the shorter wavelengths, 600–800 nm, a significant quantity of photonic
energy is absorbed by melanin, hemoglobin, and oxyhemoglobin chromophores. Consequently,
these wavelengths are better suited for therapy applied to superficial areas. At longer
wavelengths, above 1100– 1200 nm, water is the primary incidental absorber. When the photonic
energy is absorbed by these incidental unwanted chromophores, it is then unavailable to cause a
biological, biochemical, or physiological response.

To effectively penetrate to and treat deeper target cells, therapy lasers should emit in the 800–
1000 nm range. This range is referred to as the “therapeutic” or “optical” window for PBMT

Slide 16

Coherent: Light that radiates in a very orderly fashion from its source. Collimated: Tight,
strong, and concentrated (as of a laser beam).

A measure of the density of energy delivered to the surface of the target tissue. Expressed in
J/cm2. The dose describes the prescribed amount of photonic energy delivered to a precise area.

There are no global dosages appropriate for every patient. In veterinary medicine, no two
patients are alike. All have different hair thicknesses, coat colors, body types, and skin
thicknesses and colors, and each will have an individual response to therapy.

Induction, transition, maintenance phases

you are not so naive. You have seen x‐rays that have allowed you to peer inside the body. light
gets absorbed by the cones in your eyes, which causes chemical reactions that lead to electrical
signals that affect your chemistry and even your mood, your behavior, and your health

energy of light is directly proportional to its frequency (and therefore inversely proportional to its

wavelength).

Slide 21

local vasodilation and increased microcirculation from release of NO contribute to

PBMT increases the nociceptive threshold by inhibiting Aδ and C nerve fibers,

When there is injury to a tissue, damaged cells release a myriad of inflammatory mediators,
including prostaglandins, interleukins, arachidonic acid, serotonin, substance P, bradykinin, and
glutamate.

Specialized sensory nerve fibers, nociceptors, collect this chemical information. Once this
“inflammatory soup” of information reaches a specific level (the pain threshold), the nociceptors
convert the chemical signal to an electrical impulse. The conversion of these chemicals into a
nerve impulse is called transduction.

The second step in the pathway involves sending the electrical signal to the spinal cord. There
are three main types of afferent nerve that accomplish transmission of the pain signal, A‐beta, A‐
delta, and C fibers. The A‐beta fibers are responsible for low‐threshold, or non‐painful
information, such as touch, pressure, vibration, movement, and proprioception. The A‐delta
fibers are covered in myelin, which helps to transmit the signal quickly. A‐delta fiber stimulation
is responsible for the withdrawal reflex and for sharp, acute pain. A‐delta fibers respond to
thermal and mechanical stimulation. C fibers are likewise activated by thermal and mechanical
stimulation, but also by chemical stimulation. They are un‐myelinated fibers, which causes them
to transmit their signals more slowly. They are responsible for slow, burning pain, which can
intensify. C fibers have been implicated in the formation of chronic pain. Some C fibers have
very high pain thresholds, meaning that they require a very large physical or chemical
stimulation to activate a transmission response. These “sleeping” C fibers are found in places
such as articular cartilage and tooth pulp canals, where intense, intractable pain can commonly
become an issue.

Aggressively blocking the awakening of sleeping C fibers holds great value in the pre‐emptive
treatment of chronic pain

Modulation will also initiate the release of endogenous opioids in response to transmitted pain
signals, which work at opioid receptors found in the periphery, spinal cord, and brain to inhibit
the release of excitatory neurotransmitters.
The last phase of the pain pathway is perception, the integration and recognition of the sensory
information.

serotonin

Serotonin is an excitatory neurotransmitter peripherally, but also works in the dorsal horn to
modulate the pain response. Laser therapy increases serotonin levels (Walker, 1983). Serotonin
enhances mood, instilling the feeling of general well‐being.

Beta endorphin

Beta‐endorphins are produced by the pituitary in response to a pain stimulation that is sent from
the hypothalamus. In the periphery, they bind to opioid receptors pre‐ and post‐synaptically and
block the release of substance P, an excitatory neurotransmitter. In the spinal cord and central
nervous system (CNS), increases in beta‐endorphins cause a decrease in the production of
GABA, and consequently increase the production of dopamine. Large increases in dopamine
signal the pleasure center in the brain. Because of the effect of PBMT on the release of
endogenous beta‐endorphins, we can expect to have a decreased need for exogenous opioid use
(Cramond et al., 1994; Sprouse‐Blum et al., 2010).

Acetylcholine

Acetylcholine is an inhibitory neurotransmitter. PBMT has been shown to increase the activity of
acetylcholine receptors in damaged muscle (Nicolau et al., 2004; Rochkind and Shainberg,
2013). Acetylcholine is an important component in both the autonomic pathways in the CNS and
peripheral‐muscle motor function. Increases in acetylcholine decrease the discharge frequency of

excitatory neurons and increase the frequency of inhibitory neurons. Ongoing clinical
investigation continues to prove that the use of pharmacologic drugs that increase the
concentration of acetylcholine (such as neostigmine) is beneficial in the treatment of pain.

Bradykinin

When tissue is injured, a key component of the inflammatory soup that establishes the
transduction of nociception is bradykinin. Some of the first in vitro work showed that bradykinin
stimulation of action potentials in C fibers was blocked by laser irradiation.

NO
Nitric oxide (NO) levels are increased in injured and hypoxic cells. Consequently, it seems
counterintuitive to suggest that increasing NO levels can reduce pain; however, NO plays an
important role as a neurotransmitter as well as a chemical messenger between cells. The
increased levels of intracellular NO at the site of injury will essentially block the mitochondrial
production of adenosine triphosphate (ATP) and oxygen by binding to cytochrome c oxidase
(CCO). CCO is the key photoreceptor of PBMT induced by near‐infrared light (Kim, 2014;
Passarella and Karu, 2014). Once laser stimulation of the cell occurs, NO becomes unbound,
allowing increased cellular metabolism. Unbound NO, which diffuses easily between cells,
works to relax vascular smooth muscle, promoting vasodilation, and thereby oxygenation. A key
component of pain relief may stem from the removal of inflammatory mediators from the site of

injury by an increase of vascular blood flow. Increased unbound NO levels have been shown to
inhibit sensory afferents in the peripheral nervous system and activate endorphin release within
the CNS, likely by increasing cyclic guanosine monophosphate (cGMP) production.

Nerve cells

Nerve cell action potentials are decreased when there is injury to a nerve cell, causing a
decreased pain threshold. Through application of photonic energy to nerve cells, we can increase
the resting potential closer to the normal transmission voltage. At the same time, the speed of
transmission of the nociceptive signal can be decreased by blocking the depolarization of C fiber
afferents

Slide 29

When treating intraoperatively and the target tissue can be visualized, the laser settings should
deliver a dose of 3–4 J/cm2. The tissue being targeted is often sensitive and traumatized, so we
recommend not exceeding 4 W power.

Slide 35

Laser therapy for improved wound healing and other dermatologic conditions is one of the most
studied and widely used applications of the technology.

Laser therapy aims to restore the normal biological

function of injured or stressed cells. “Normalization” is the key word when it comes to laser
therapy (Tuner and Hode, 2002). The cellular effects of photobiomodulation therapy (PBMT)
can be classified as either primary effects, which are light‐induced, or secondary effects, which
occur in response to the primary effects (Hawkins and Abrahamse, 2007).

In primary effects, a direct photochemical reaction occurs when photons emitted by the laser
reach the mitochondria and membranes of cells (e.g., fibroblasts, keratinocytes, and endothelial
cells) and the photonic energy is absorbed by endogenous chromophores (mitochondrial
cytochromes, porphyrins, and flavoproteins) and converted into a chemical kinetic energy within
the cells. This causes an improved efficiency of the respiratory chain within the mitochondria,
due to changes in membrane permeability, improved signaling between mitochondria, nucleus,
and cytosol, and increased oxidative metabolism, which enables more adenosine triphosphate
(ATP) to be produced (Karu, 1989). In addition, reactive oxygen species (ROS) such as nitric
oxide (NO) and superoxide dismutase (SOD) are produced, and there is a shift in the redox state.

Secondary effects lead to the amplification of the previously mentioned primary photoreactions.
Calcium is released from the mitochondria into the cytoplasm with changes in intracellular
calcium levels (Tuner and Hode, 2002), which stimulates cell metabolism and the regulation of
the signaling pathways responsible for the events required for wound repair, such as cell
migration, DNA and RNA synthesis, cell mitosis, protein secretion, and cell proliferation. A
cascade of metabolic effects results in various physiological changes at the cellular level, such as
activation of fibroblasts, macrophages, and lymphocytes, growth factor release, neurotransmitter
release, vasodilation, collagen synthesis, and improvement of cell membrane permeability and
the function of the Na+/ K+ pump. Laser therapy has a positive effect on prostaglandin
production, mediating neutrophil activation, lymphocyte accumulation, and other inflammatory
effects. Increased metabolic activity increases oxygen and nutrient availability, leading to
enhanced protein and enzyme production. These factors ultimately lead to normalization of cell
function.

Slide 48

The central nervous system (CNS) and the nerves of the

peripheral nervous system are very accessible to light

therapy, usually lying less than 2 cm below the skin

surface.
A bioinhibitory power density of approximately 300 mW/cm2 at the target tissue level will
produce analgesia. Biostimulatory power densities of approximately 10 mW/cm2 at the target
tissue level will decrease inflammation and stimulate tissue regeneration. Thus, the use of
photobiomodulation therapy (PBMT) can result in either analgesia or the repair and regeneration

of damaged nervous tissue. This makes PBMT of extreme clinical importance in the treatment of
a number of small‐animal neurological diseases.