Mr. Miroslav Prochazka, M.D.,
Private Rehabilitation Clinic "Jarov", Prague 3, CZ, 
tusita@mbox.vol.cz

Physiotherapy, i. e. application of physical means utilized in order to diminish pain or relax muscle spasms and the like, can be considered one of the cornerstones in rehabilitation medicine. In connection with excessive consumption of medicaments, especially of pain-killers, these techniques enjoy a certain renaissance.

Treatment with the use of non-invasive laser beam has been stepping forward within the frameworks of this therapy quite recently. Thanks to laser beam, physiotherapy can also enter the 21st century with honor, bringing new therapeutic offer, extremely rewarding in many clinical applications. Let us introduce some of its features, as they have been earned by our ten-years clinical experience.

Laser (an acronym of Light Amplification by the means of Stimulated Emission of Radiation) is a special kind of light emission (however, it is not a ionizing light as is is often regarded to by physicians and patients). Its specific effect, which can in higher power outputs even fulfil criteria of legendary rays of death created by sci-fi authors, is brought by three main features, it is totally monochromatic (only one wavelength), it is perfectly polarized and it is perfectly coherent (meaning that all light waves are evenly oriented in time and space).

From biological point of view, this beam has been, in lower outputs (up to 500 mW), endowed with a significant stimulative activity, which can be verified by microscopic and electron-microscopic, as well as by histo-chemical studies. These lasers can be named non-invasive lasers, soft lasers, low power lasers or low level lasers (LLLT).

Apart from this stimulative activity, which is widely utilized in clinical practice especially to support healing processes, there are also very strong antalgic and antiflogistic effects. A quick rise of these mentioned effects is also an advantage, enabling lasers to be utilized for example in sports medicine right in the field. A combination of stimulative and antiflogistic effects is very interesting for a specialist meeting a proliferous kind of inflammation, such as m. Dupuytrene or m. Peyronie (induratio penis plastica). 

Most contemporary therapeutic devices utilize semiconductor sources of laser beam, and though their output is rather high, they are small in size, very often as a fountain pen etc. Thanks to independent power sources (usually NiCd cells) and small size we have in our hands for the first time a possibility to apply a really efficient physiotherapy, wherever and whenever we need, with no time loss. Furthermore, these devices are well portable and thus a general practitioner can have an opportunity to apply a really efficient physiotherapy in the course of visiting patients...

A higher class in therapeutic lasers is represented by table-top computer-controlled devices. Some of them are highly sophisticated, with simple operation, many options and wide accessories. They are usually equipped with a large graphic screen, or a touchscreen, and their operation is usually very simple, sometimes limited only to picking of a multidisciplinary menu as these devices automatically adjust optimum parameters of therapy for each particular diagnosis. One or more laser probes with different wavelength and power, or a point probe and a scanner to treat large areas can be connected to the control unit simultaneously. Furthermore, there is a variety of application lightguides, irradiation heads, probe holders, auxilliary battery control units, printers of treatment protocols etc.

I want to underline the importance of parameters of individual laser diodes, i.e. on what wavelength the laser beam is emitted and what power output it works with. It is obvious that from the point of view of pain of locomotive apparatus, wavelength of an infrared beam appears most suitable - most frequently 780 or 830 nm (better penetration into deep-seated structures, the reach of sufficient therapeutic energy is reported in orders up to centimeters, i. e. on syndesmotic and joints structures etc.) with output power at least 30 mW. Lasers with the beam within the red part of the spectrum (most frequently 633 nm, 670 nm, 690 nm) are able to penetrate into milimeters of tissue only. However, in these few milimeters all emitted energy is absorbed and that is why we choose devices with 15 - 20 mW output exclusively for therapies on skin and mucosis.

From a clinician`s point of view we can also stress the fact whether the device is able to pulse the laser beam in frequency mode. Frequency mode enables us to adjust therapy purposely to the complaint we want to treat with a laser. Devices have either the possibility of setting numeric value of frequency mode, or they work with automatic adjustment where a particular frequency is set according to a particular complaint, disease or injury. In general, frequency of 10 Hz has proven successfull in analgetic treatments, whilst frequency of 5 Hz has appeared most stimulative. Frequencies after Nogiér (multiples of 1.14 Hz) are also applied very often, especially in laser acupuncture.

We have gained an excellent clinical experience with many devices, manufactured by numerous domestic as well as foreign manufacturers, in therapy of many illnesses and complaints. Let us but mention some of them, those which appear for a clinician most rewarding for non invasive laser therapy. You may realize with delight, that in some cases these are afflictions which have been hitherto considered "crus medicorum" - and especially here the offer of a new therapeutic method is very attractive for a clinician.

The first significant indication group for non invasive therapy laser is pain of locomotive apparatus of various aetiologies, acute and chronic. Talking about acute pain here we can mention distorsions, contusions and tissue wounds, characteristic especially for sports medicine. We have already mentioned that, thanks to small size of devices, excellent portability and indepencence on a power source, non invasive laser therapy is the only way how to apply physiotherapy right on the sports field. And it is even more advantageous if we imagine real effectiveness of this therapy. From the point of view of sports medicine, surgery and related disciplines, therapy of scars must not be omitted. Here is a red laser beam utilized more frequently. The result is especially cosmetic, but healing time is also accelerated, too. Laser is routinely used for treatment of keloid hypertrophic scars. As it will be explained later on, presence of fibroblasts is necessary for back-resorption of colagen and therefore scars up to one or two years old are ideal for laser therapy. Obviously, the use of a laser directly in the operation room is a perfect option, or even irradiation of the operation locality two or three days prior to the surgery, as well as during the surgery. This technique is being routinely acquired by a growing number of plastic surgeons in our country.

Acute effect can also be appreciated in therapy of vertebral algic syndromes, especially of torticollis acuta. In our clinic we routinely perform manipulations, and laser therapy has proven its benefits as premedication before manipulative indications. Prompt antalgic and myorelaxation effects make manipulations possible even in cases where we had been choosing several days of medicamentous therapy of reflexive muscular changes prior to the initial manipulation in the past.

In therapy of chronic vertebral pains, necessary aplications on larger areas can sometimes appear to be a disadvantage- for example in lower back pain. However, manufacturers supply scanners, i.e. optical scanning devices performing therapy on the whole of required area, with permanent presence of therapist during the session unnecessary.

We have already mentioned the effect on proliferous changes - electronmicroscopic techniques have proven that fibroblasts, when stimulated by a low-power laser beam, actively carry out back-resorption of produced colagen. This is utilized in treatment of proliferous inflammations - m. Dupuytrene, induratio penis plastica (let us mention that in about 10 per cent of cases both these clinicals appear simultaneously), as well as in therapy of other defects of locomotive apparatus where a pronounced pathogenesis of the illness in oedema or directly in syndesmotic overproduction can be anticipated (such as carpal tunnel syndrome, some kinds of shoulder joint pain).

Significant anti-flogistic effect can be seen with those disorders, where an inflammation creates essential part of aetiopathogenesis of subjective complaints - such as tennis elbow - or, as it is with some rheumatic diseases, inflammation is primary aetiological cause of painfull complaints. By the way, rheumatic diseases also create an interesting model from the point of view of simple verification of effects of non invasive laser therapy, which can be directly compared with necessary prescription of antiinflammatory medication (both steroid and non-steroid) and analgetic preparations.

Another interesting field of indications of non-invasive laser beam should not be left out - some ENT diagnoses. This therapy is very rewarding in treating relapsing tonsillitis (either direct irradiation of tonsils with a red laser beam through a special lightguide, or indirectly through neck skin with an IR laser. There is also a diagnosis particularly predestinated for laser therapy - tinnitus, where we irradiate procesus mastoideus of affected ear with an IR beam (obviously, after a proper examination and consideration of other possible therapeutic ways). Level of suffering of patients with tinnitus may be only a subjective matter, but gratitude of our patients after getting rid of this unpleasant syndrome, very often after years of other ineffectual therapies, is so great that we can well understand, from humanistic standpoint, the profit brought by this therapy. 

It is also important to mention contra-indications of non-invasive laser therapy. The first one is direct irradiation of an eye - that is also why patient and therapist are equipped with protective spectacles in the course of therapy. Irradiations of malignancies or potential pre-canceroses, direct application on ductless glands, and tendance of patients with an epileptic anamnesis by a laser pulsed in frequencies. Even though no teratogenic effect of non-invasive laser beam has never been evidenced, we avoid irradiation of underbelly of young and pregnant women. LLLT is is also contra-indicated for patients with cochlear implants.

LLLT is considered a treatment of the future amongst non-medicamental therapies not only of pains of locomotive apparatus. Unique clinical effects, simple operation of devices, practically zero risks, and no pain for patients (and thus ideal compliance) enable us to forecast a worldwide massive expansion of this technique within the next few years in offices of specialists as well as of general practitioners.

Prague, 14. 06. 2000