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Tissue Healing with Laser
LLLT's accelerating impact on the regenerating process
Don Fitz-Ritson,
DC, FCCRS(C), DACRB(USA)
A method currently used to
accelerate the wound healing process is hyperbaric therapy. But this does not
always work, and is particularly a problem for the elderly, bedridden and others
with slow healing processes. However, the enhancing effect of LLT on microcirculation
and wound healing (3) (4) is likely to aid in treatment by accelerating the regenerative
process of the tissues.
 CASE
HISTORY
A 74-year-old male presented with a non-healing diabetic wound
on the right heel at the insertion of the Achilles tendon into the calcaneous.
The wound had been active for six months and the patient reported to have just
finished 65 sessions of hyperbarbic therapy, with no response. The patient used
a special brace on his right leg to aid in walking. Four years previously, the
patient's left leg had been amputated five inches below the knee.
The
concern was that if the wound continued to be active it would erode the Achilles
tendon at its insertion, and consequently the leg would have to be amputated at
the end of the month.
After 12 laser treatments had been
administered
in one month, the patient's neurosurgeon was pleased with a decrease in the active
inflammatory process and an initial regeneration of new muscle tissue. Amputation
was delayed for a month.
At the end of the second month, the active inflammatory
process was further decreased and regenerated muscle tissue had filled in the
cavities, which were present. Surgery was cancelled.
By the end of the third
month, the patient began to walk using a regular running shoe.
Continued
therapy was geared to healing a small area at the lateral aspect of the Achilles
tendon at its insertion into the calcaneous, and to then strengthen the tendon
and tissues in the area.
REVASCULARIZATION
Revascularization is one of the most important stages of wound healing. The
laser (5)(6) has been shown to be very effective in initiating revascularization
in injured tissue and increased blood flow. (7) More fundamental features of laser's
effect on tissue and wound healing have also been shown to occur. Whelan(8) identified
that certain tissue regenerating genes could be manipulated to greatly enhance
the natural would healing process. Cultured human keratinocytes, endothelial cells
and fibroblasts, when exposed to laser, caused the production of transforming
growth factor, (9) and laser increases the transforming of fibroblasts into myofibroblasts.
This is a very important step in wound healing, because the myofibroblasts have
filaments which enable them to contract and shrink the wound, (10) and laser decreases
the inflammatory process, (11) reducing edema reduction and enhancing lymph flow.
(12) RESEARCH FINDINGS
Irradiation of 3 and 4 J/cm2 increased
cell numbers about threefold to sixfold compared to control cultures. The energy
density of 3 J/cm2 remarkably increased cell growth, with no effect on procollagen
synthesis, as demonstrated by immunoprecipitation analysis. (13) Infrared laser
radiation (frequency 500 Hz) was more potent in stimulating repair of skin wounds
than 300 Hz radiation. (14) Also, the type of laser used contributes significantly to the healing effects,as shown by Zeinoun.(15) He found that there were clearly fewer myofibroblasts when a CO2 laser was used compared to corresponding
scalpel excisions known to heal by contraction. The lack of contractile myofibroblasts,
therefore, is suggested as the reason for the minimal degree of contraction in
CO2 laser excision wounds.
The strength of the wound is also affected
by the application of LLLT. With low-power laser irradiation at 830 mm, applied
daily over 0-4 days and 3-7 days, it was found at 11 or 23 days post-treatment
that the tensile strengths of wounds were significantly enhanced in a murine diabetic
model. (16) Reddy (17) showed that after 14 days of laser treatment to the repairing
Achilles tendons of rabbits, when the tendons were subjected to biochemical analyses
they revealed a 26 precent increase in collagen concentration in the laser photostimulation
group, indicating a more reapid healing process in treated tendons compared to
controls.
When the repairing medial collateral ligaments (MCL) of rats
were exposed to a single high dose of laser therapy, this resulted in increase of the collagen fibril diameters, when comparing
experimental and control groups. (18) This would explain why a single dose of
low-energy laser therapy improves the tensile strength and stiffness of repairing
MCL at three and six weeks after injury. (19)
The laser protocol was instituted
after conventional management protocols were shown to be ineffective. The rate
and quality of healing of these previously refractory wounds following use of
infrared laser energy may be related to local increases in nitric oxide oxide concentration. Increases in nitric oxide previously
have been demonstrated to correlate with vasodilatory and anabolic responses.
(20) DISCUSSION
From case history results and the references
cited, laser therapy is seen as beneficial in enhancing the healing of wounds.
However, more research is needed to understand the effects of each specific laser
parameter, so that improved efficacy can be achieved for the patient.
The
above information should provide food for thought for the chiropractic profession.
On a daily basis, for example, we treat chronic back pain patients. What percentage
of these patients have pathologies in their deep spinal muscles, such as the multifidus
muscles? Would pathologies in the muscles benefit from a course of laser therapy? If so, could this improve the
efficacy of our manipulative intervention?
These and other questions need
to be addressed as the profession accepts the challenges of providing more cost-effective
health care to the public.
References:
1. Basford J. Laser Therapy: Scientific Basis and Clinical
Role. Orthopedics 1993; 16: 541-547.
2. Karu T. Molecular mechanism of the therapeutic effect
Of low-intensity laser irradiation. Lasers in the Life Sciences 1988; 2:53-74.
3. Turner J, Hode L, editors. Low Level Laser Therapy:
Clinical Practice and Scientific Background. Prima Book
Publishers 1999. p135-139.
4. Simunovic Z, Ivankovich AD, Depolo A. Wound healing of
animal and human body sport and traffic accident
injuries using low-level laser therapy treatment: a
randomized clinical study of seventy-four patients with
control group. J Clin Laser Med Surg 2000 Apr; 18(2):
67-73.
5. Barkovskii VS. Effect of laser radiation on the process
of tissue vascularization after damage. Arkh Patol
1983;45(8):72-6.
6. Zhao Y, Yasudam S, Yammoto M, et al. He-Ne Laser
Irradiation against rat adjuvant arthritis. Jap J Assoc
Phys Med. Balneol Climatol 1990;53(2):95-100.
7. Schaffer M, Bonel H, Sroka R, et, al. Effects of 780 nm diode laser irradiation on blood microcirculation: preliminary findings on time-dependent T1-weighted contrast-enhanced magnetic resonance imaging (MRI). J Photochem Photobiol B 2000 Jan;54(1):55-60.
8. Whelan HT, Buchmann EV, Dhokalia A, et al. Effect of
NASA light-emitting diode irradiation on molecular changes for wound healing in diabetic mice. J Clin Laser Med Surg 2003 Apr; 21(2):67-74.
9.Danno K, Mori N, Toda K, et, al. Near-infrared
irradiation stimulates cutaneous wound repair:
laboratory experiments on possible mechanisms.
Photodermatol Photoimmunol Photomed 2001
Dec;17(6):261-5.
10. Poureaau-Schneider N, Ahmed A, Soudry M. Helium-Neon
Laser treatment transforms Fibroblasts into
Myofibroblasts. Am J Path 1990, Abs. 137,171-178.
11. Medrado A, Pugliese L, Reis S, Influence of low
level laser therapy on wound healing and its
biological action upon myofibroblasts. Lasers Surg
Med 2003;32(3):239-44.
12. Lievens P. The influence of laser irradiation on the
motricity of lymphatical system and on the wound
healing process. Intl. Congress on Laser in Med &
Surgery, Bolgna June 26-28, 1985.
13. Pereira A, Eduardo Cde P, et al. Effect of low-power
Laser irradiation on cell growth and procollagen synthesis of cultured fibroblasts. Lasers Surg
Med 2002;31(4):263-7.
14. Korolev I, Zagorskaia N. The effect of infrared laser
radiation of different frequencies on the healing of
skin wounds. Vopr Kurortol Fizioter Lech Fiz Kult 1996
May-Jun;(3):8-10.
15. Zeinoun T, Nammour S, Dourov N, et al. Myofibroblasts
In healing laser excision wounds. Lasers Surg Med 2001;28(1):74-9.
16. Stadler I, Lanzafame R, Evans R, et,al. 830-nm
Irradiation increases the wound tensile strength in a diabetic murine model. Lasers Surg Med 2001;28(3):220-6.
17. Reddy G, Stehno-Bittel L, Enwemeka C. Laser
Photostimulation of collagen production in healing rabbit Achilles tendons. Lasers Surg Med 998;22(5):281-7.
18.Fung D, Ng G, Leung M, et,al. Effects of a herapeutic
Laser on the ultrastructural morphology of repairing medial collateral ligament in a rat model. Lasers Surg Med 2003;32(4):286-93.
19.Fung D, Ng G, Leung M, et, al. Therapeutic low energy
Laser improves the mechanical strength of repairing medial collateral ligament. Lasers Surg Med 2002;31(2):91-6.
20. Horwitz L, Burke T, Carnegie D, Augmentation of Wound
Healing Using Monochromatic Infrared Energy
Exploration of a New Technology for Wound Management.
Advances in Wound Care 1999; Jan/Feb: 23-29.
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