LaserTherapyintheTissueRepairProcess:A

LiteratureReview
Laserisoneoftheadvancesusedtoaccelerateandoptimizethetissuerepairprocess.2Theterm
laseristheacronymforLightAmplificationbyStimulatedEmissionofRadiationandemerged
fromresearchbyEinsteinin1917onthephysicalprinciplesofstimulatedlightemission.3In
1960,MaimanputEinsteinstheoryintopracticeandpublishedthefirstworkrelatingstimulated
lightemissioninthevisiblebandofthespectrum(l14694nm)fromtheexcitationofaruby
crystalbyahelicalphotographicflashlamp,fromwhichthelaserenergyemerged.4

Lasertherapy,alsoknownaslowlevellasertherapy(LLLT)hastheaimofphotoactivating
cellularmechanisms,leadingtothenormalizationoftheaffectedregionbypromotinga
reductioninedemaandtheinductionofanalgesiaaswellasanaccelerationofthetissuerepair
process.5,6Therapeuticlasersofferlowenergydensity,butwithahighenoughenergydensityso
thatthetargetcellcanusetheenergytostimulateitsmembraneororganelles.Laserradiationis
absorbedthroughcytochromesinthemitochondriaandconvertedintoenergybythecell(ATP),
whichactsinthesynthesisofproteinandtheaccelerationorstimulationof

cellproliferation.Thecellthusentersaphotobioactivatedstate,duringwhichitseekstoestablish
astateofnormalizationoftheaffectedregion,asintherepairphasefollowingtissueinjury.3

Lasertherapyhasbeenusedasanaidinthetissuerepairprocess.7,8Thus,theaimofthepresent
studywastocarryoutaliteraturereviewontheuseoflasertherapyinthetissuerepairprocess,
addressingdifferentlasersandparametersusedbytheauthors.

CurrentIndicationsofLowLevelLaser
TherapyinPlasticSurgery:AReview

L
owlevellasertherapy(LLLT)isgenerallydefinedasanexternaltreatmentoftissue

withasingleandstablewavelengthfromacoherentlightsourcethatdoesnotgeneratean

immediatedetectabletemperatureincreaseonbiologicaltissue.LLLTseemstopromote
theproliferationoffibroblastsandkeratinocytes,andmayheightenskinblood

microcirculation.1

Thenumberofpublicationsonthissubjecthasbeenincreasingsteadilyoverthelast10
years,withmanynewtherapeutictargets.AuthorshavetriedtoshowthatLLLT
improvespaincontrol,2musculoskeletaldisorders,3andoralmucositisincancerpatients.4
SinceOctober2009,nodeviceshavereceivedUnitedStatesFoodandDrug
Administration(FDA)clearanceforapplicationsotherthanthetreatmentofpain.

LLLTcontinuedLowpowerlighttherapyandwoundhealing
A 2014 review reports that phototherapy, by LASER (Light
Amplification by Stimulated Emission of Radiation) or LED (Light
Emitting Diode), is effective in promoting skin wound healing. The
biolog- ical effects, dependent on the irradiation parameters,
notably wavelength and dose, include decrease in inflammatory
cells, increased fibroblast proliferation, angiogenesis stimulation,
for- mation of granulation tissue and increased collagen
11
synthesis.

Low-level laser (light) therapy (LLLT) in skin:

stimulating, healing, restoring
Lowlevellaser(light)therapy(LLLT)isafastgrowingtechnologyusedtotreata
multitudeofconditionsthatrequirestimulationofhealing,reliefofpainand
inflammation,andrestorationoffunction.Althoughtheskinistheorganthatisnaturally
exposedtolightmorethananyotherorgan,itstillrespondswelltoredandnearinfrared
wavelengths.Thephotonsareabsorbedbymitochondrialchromophoresinskincells.
Consequentlyelectrontransport,adenosinetriphosphate(ATP)nitricoxiderelease,blood
flow,reactiveoxygenspeciesincreaseanddiversesignalingpathwaysgetactivated.
Stemcellscanbeactivatedallowingincreasedtissuerepairandhealing.Indermatology,
LLLThasbeneficialeffectsonwrinkles,acnescars,hypertrophicscars,andhealingof
burns.LLLTcanreduceUVdamagebothasatreatmentandasaprophylaxis.In
pigmentarydisorderssuchasvitiligo,LLLTcanincreasepigmentationbystimulating
melanocyteproliferationandreducedepigmentationbyinhibitingautoimmunity.
Inflammatorydiseasessuchaspsoriasisandacnecanalsobenefit.Thenoninvasive
natureandalmostcompleteabsenceofsideeffectsencouragesfurthertestingin
dermatology.
Page2

Increasingly,noninvasivetherapiesforskindiseaseandskinrejuvenationareused,
especiallyinWesterncountrieswhererelativelyhighdisposableincomesarecombined
withthedesireforanidealappearancefosteredbysocietalpressures.Althoughtheskin
istheorganthatisnaturallymostexposedtolight,itstillrespondswelltoredandnear
infraredwavelengthsdeliveredatthecorrectparameterswiththerapeuticintent.Low
levellasertherapy(LLLT)wasdiscoveredinthelate1960s,butonlyinrecenttimeshas
itbeenwidelyappliedindermatology.Theintroductionoflightemittingdiode(LED)
deviceshasreducedmanyoftheconcernsformerlyassociatedwithlasers,suchas
expense,safetyconcernsandtheneedfortrainedpersonneltooperatethem.Infact,
manyLEDdevicesaredesignedforhomeuseandarewidelysoldontheinternet.This
reviewwillcovertheuseofLLLTaspossiblytheultimatenoninvasiveapproachto
treatingtheskin.

Low-Level Laser (Light) Therapy and Its Mechanism of Action

LLLT,phototherapyorphotobiomodulationreferstotheuseofphotonsatanonthermal
irradiancetoalterbiologicalactivity.LLLTuseseithercoherentlightsources(lasers)or
noncoherentlightsourcesconsistingoffilteredlampsorlightemittingdiodes(LED)or,
onoccasion,acombinationofboth.ThemainmedicalapplicationsofLLLTarereducing
painandinflammation,augmentingtissuerepairandpromotingregenerationofdifferent
tissuesandnerves,andpreventingtissuedamageinsituationswhereitislikelyto
occur.1,2Inthelastfewdecades,nonablativelasertherapieshavebeenusedincreasingly
fortheaesthetictreatmentoffinewrinkles,photoagedskinandscars,aprocessknownas
photorejuvenation(Table1).Morerecently,thisapproachhasalsobeenusedfor
inflammatoryacne(Table1).3LLLTinvolvesexposingcellsortissuetolowlevelsof
redandnearinfrared(NIR)light.Thisprocessisreferredtoaslowlevelbecausethe
energyorpowerdensitiesemployedarelowcomparedtootherformsoflasertherapy
suchasablation,cutting,andthermallycoagulatingtissue.Recently,medicaltreatment
withLLLTatvariousintensitieshasbeenfoundtostimulateorinhibitanassortmentof
cellularprocesses.4

ThemechanismassociatedwiththecellularphotobiostimulationbyLLLTisnotyetfully
understood.Fromobservation,itappearsthatLLLThasawiderangeofeffectsatthe
molecular,cellular,andtissuelevels.Thebasicbiologicalmechanismbehindtheeffects
ofLLLTisthoughttobethroughabsorptionofredandNIRlightbymitochondrial
chromophores,inparticularcytochromecoxidase(CCO)whichiscontainedinthe
respiratorychainlocatedwithinthemitochondria,57andperhapsalsobyphotoacceptors
intheplasmamembraneofcells.Consequentlyacascadeofeventsoccurinthe
mitochondria,leadingtobiostimulationofvariousprocesses(Figure1).8Absorption
spectraobtainedforCCOindifferentoxidationstateswererecordedandfoundtobevery
similartotheactionspectraforbiologicalresponsestothelight.5Itishypothesizedthat
thisabsorptionoflightenergymaycausephotodissociationofinhibitorynitricoxide
fromCCO9leadingtoenhancementofenzymeactivity,10electrontransport,11
mitochondrialrespirationandadenosinetriphosphate(ATP)production(Figure1).1214
Inturn,LLLTaltersthecellularredoxstatewhichinducestheactivationofnumerous
intracellularsignalingpathways,andalterstheaffinityoftranscriptionfactorsconcerned
withcellproliferation,survival,tissuerepairandregeneration(Figure1).2,5,6,15,16
SeminCutanMedSurg.Authormanuscript;availableinPMC2014August08.

NIH-PA Author Manuscript NIH-PA Author Manuscript NIH-PA

Author Manuscript
Avcietal.

Page3

AlthoughLLLTisnowusedtotreatawidevarietyofailments,itremainssomewhat
controversialasatherapyfor2principlereasons.First,thereareuncertaintiesaboutthe
fundamentalmolecularandcellularmechanismsresponsiblefortransducingsignalsfrom
thephotonsincidentonthecellstothebiologicaleffectsthattakeplaceintheirradiated
tissue.Second,therearesignificantvariationsintermsofdosimetryparameters:
wavelength,irradianceorpowerdensity,pulsestructure,coherence,polarization,energy,
fluence,irradiationtime,contactvsnoncontactapplication,andrepetitionregimen.
Lowerdosimetricparameterscanresultinreducedeffectivenessofthetreatmentand
higheronescanleadtotissuedamage.1Thisillustratestheconceptofthebiphasicdose
responsethathasbeenreportedtooperateinLLLT1,18,19.Manyofthepublishedstudies
onLLLTincludenegativeresults.Itispossiblybecauseofaninappropriatechoiceof
lightsourceanddosage.Itmayalsobeduetoinappropriatepreparationofthepatients
skinbeforeapplicationofLLLT,suchas:lackofremovalofmakeupandoilydebris,
whichcaninterferewiththepenetrationofthelightsource,andfailuretoaccountforskin
pigmentation.17InappropriatemaintenanceoftheLLLTequipmentcanreduceits
performanceandinterferewithclinicalresultsaswell.Itisimportanttoconsiderthat
thereisanoptimaldoseoflightforanyparticularapplication.

Laserradiationornoncoherentlighthasawavelengthandradiantexposuredependent
capabilitytoaltercellularbehaviorintheabsenceofsignificantheating. 20Phototherapy
employslightwithwavelengthsbetween3901,100nmandcanbecontinuouswaveor
pulsed.Innormalcircumstances,itusesrelativelylowfluences(0.0450J/cm 2)and
powerdensities(<100mW/cm2).21Wavelengthsintherangeof390nmto600nmare
usedtotreatsuperficialtissue,andlongerwavelengthsintherangeof600nmto
1,100nm,whichpenetratefurther,areusedtotreatdeeperseatedtissues(Figure2). 4
Wavelengthsintherange700nmto750nmhavebeenfoundtohavelimited
biochemicalactivityandarethereforenotoftenused.1Variouslightsourcesusedin
LLLTincludeinertgaslasersandsemiconductorlaserdiodessuchasheliumneon
(HeNe;633nm),ruby(694nm),argon(488and514nm),krypton(521,530,568,647
nm),galliumarsenide(GaAs;>760nm,withacommonexampleof904nm),and
galliumaluminumarsenide(GaAlAs;612870nm).17AwiderangeofLED
semiconductorsareavailableatlowerwavelengths,whosemediumcontainstheelements
indium,phosphideandnitride.Onequestionthathasnotyetbeenconclusivelyanswered
iswhetherthereisanyadvantagetousingcoherentlaserlightovernoncoherentLED
light.22Whilesomemedicalpractitionerstreatdeeptissuelesionsusingfocusedlasersin
points,indermatologytheuseofLEDsisbecomingincreasinglycommonduetothe
relativelylargeareasoftissuethatrequireirradiation.

Low-level laser irradiation promotes the proliferation

and maturation of keratinocytes during epithelial
wound repair

Lowlevellasertherapy(LLLT)hasshowngreatefficacytoacceleratewoundrepair.
ThereareseveralstudiesshowingthebenefitsofLLLTinwoundhealingandinjury
recoveryduetoitsabilityofbiostimulation[13],whichoccursbytheinteractionof
visibleornearinfaredlightwiththecells,promotingtheexcitationofintracellular
chromophoressuchasendogenousporphyrins,mitochondrialandmembranal
cytochromesandflavoproteins[4].

Afterbeingabsorbedbymitochondrialchromophoresintheskincellsthephotons
increaseelectrontransport,adenosinetriphosphateproduction,nitricoxiderelease,blood
flow,reactiveoxygenspecies,andactivatesdiversesignalingpathwaysthatarelinkedto
beneficialeffectsindermatology[5].Amongthesebeneficialeffectsareskin
rejuvenation[6],reductionofacnescars[7,8],reductionofhypertrophicscars[9],and
healingofburns[10,11].Inaddition,fasterhealingofanasepticinjuredepitheliumi.e.
woundsmayalsobeachievedbyLLLT[12].

LLLTisanoninvasiveandsafetechniquethathasbeenwidelyusedtopreventandtreat
nonhealingulcers[13,14].Nevertheless,thereisalackofstudiesthatfocusonthe
maturationanddifferentiationofthewoundedepitheliumafterLLLTandthroughoutthe
healingprocess,althoughastudyhasdemonstratedthattheuseofgreenLEDsincreased
theproductionofHBEGFandVEGF[15],whichdopromotethemigrationof
keratinocytes[16].Mostofthepublishedliteratureisconcernedwiththeclinicaland
morphologicalresponseofwoundhealing[17,18]ortheresponseofmesenchymalcells
ineithersoft[19,20]orhardtissues[21,22]intissuerepair.

Themodulationofinflammatoryresponseandtheroleofstemcellshavealsobeen
assessedinseveralstudiesthatdealwithLLLTforwoundhealing[2325].Therefore,
thisstudysoughttoanalyzetheabilityofLLLTtostimulatethehealingprocessofskin
injuriesbyassessingtheproliferationcapacityandthematurationstateofKCs.Inorder
todoso,theexpressionofspecificcytokeratinsandproliferationbiomarkerswas
evaluatedinculturedKCsandalsoinmigratingKCsatthewoundedge.

LLLT,phototherapyorphotobiomodulationreferstotheuseofphotonsatanonthermal
irradiancetoalterbiologicalactivity.LLLTuseseithercoherentlightsources(lasers)or
noncoherentlightsourcesconsistingoffilteredlampsorlightemittingdiodes(LED)or,
onoccasion,acombinationofboth.ThemainmedicalapplicationsofLLLTarereducing
painandinflammation,augmentingtissuerepairandpromotingregenerationofdifferent
tissuesandnerves,andpreventingtissuedamageinsituationswhereitislikelyto
occur.1,2Inthelastfewdecades,nonablativelasertherapieshavebeenusedincreasingly
fortheaesthetictreatmentoffinewrinkles,photoagedskinandscars,aprocessknownas
photorejuvenation(Table1).Morerecently,thisapproachhasalsobeenusedfor
inflammatoryacne(Table1).3LLLTinvolvesexposingcellsortissuetolowlevelsof
redandnearinfrared(NIR)light.Thisprocessisreferredtoaslowlevelbecausethe
energyorpowerdensitiesemployedarelowcomparedtootherformsoflasertherapy
suchasablation,cutting,andthermallycoagulatingtissue.Recently,medicaltreatment
withLLLTatvariousintensitieshasbeenfoundtostimulateorinhibitanassortmentof
cellularprocesses.4

LowLevelLaserTherapyforWound
Healing:MechanismandEfficacy
LOWLEVELlasertherapy(LLLT)asatherapeuticmodalitywasintroducedbythe
workofMesterandcolleagues,whonotedimprovementinwoundhealingwith
2 13
applicationofalowenergy(1J/cm )rubylaser. Thisgeneratedanincreasedinterestin
understandinganddevelopingfurtherlowenergylasertechnologiesandapplications.

LLLTisdefinedbyseveralparameters.Theprimarydefiningfactorispowerwitha
3 1
rangeof10 to10 W.Othersignificantparametersincludeawavelengthbetween300
and10,600nm,apulserateof0(continuous)to5,000Hz,apulsedurationof1to500
milliseconds,aninterpulseintervalof1to500milliseconds,atotalirradiationtimeof
2 0 2
10to3,000seconds,anintensity(power/area)of10 to10 W/cm ,andadose(power
 2 2 2 4
irradiationtime/areairradiated)of10 to10 J/cm . Differencesintheparametersused
invariousstudiescomplicatetheissueofmakingmeaningfulcomparisons.

VarioussubstrateshavebeenusedtocreatethelasersusedforLLLT.Initialresearch
usedlasersbased

oninertgases,includingheliumneon(HeNe;632.8nm),ruby(694nm),argon(488and
514nm),andkrypton(521,530,568,and647nm).Subsequentstudieshaveused
semiconductorlaserdiodes,includinggalliumarsenide(GaAs;904nm)andgalliumal
uminumarsenide(GaAlAs;820and830nm)devices.MostLLLTresearchstudies,
perhapsowingtocostandavailabilityissues,haveusedHeNelasers,butmanynewer
5
studiesarepreferentiallyemployingthenewerGaAslasers.

Althoughmuchofthemechanismofactionoflasersontheskinismediatedvia
photothermaleffects,LLLTtypicallycausesloworimperceptibletemperaturechanges,
4,6
givingrisetothetermslowintensityorcoldlasers. Althoughanoticeable
temperatureincreasedoesnotoccur,biologicchangemaybeproducedbyLLLT.Were
thistobesubstantiated,itwouldnotbesurprisinggiventhatvarioustypesofelectro
magneticradiationandlighthavebeenusedtotreatvariousdermatologicconditionsvia
photochemicalandothermechanisms.Examplesincludetheuseofultraviolettherapyfor
psoriasisandhyperbilirubinemiaandphotodynamictherapyforactinickeratoses.
Recentadvancesinlightbaseddermatologictherapieshavereinvigoratedinterestinthe
potentialofLLLT,includingitsapplicationsinwoundhealing

InterestinthefieldofLLLThasbeenrekindledinconcertwithphilosophicalevolution
towardminimallyinvasivelasertherapies.Forinstance,owingtothepromiseof
reducedinconvenienceanddowntime,socallednonablativelasertherapyhaslargely
79
supplantedablativelaserresurfacingfortreatmentofthevisiblesignsofphotoaging.
Onlymilderythemaandedema,bothofwhichresolvewithinhourstodays,areevident
afternonablativetreatments,incontrasttoablativetreatments,whichmayentail
prolongedreepithelializationandpatientdiscomfort.

Evenmorerecently,lightemittingdiodes(LEDs)havebeentoutedasacomfortable,
potentiallyhighlyselectivelightbasedtherapyformanyindications.LEDsaresmall,
robustdevicesthatemitanarrowbandofelectromagneticradiationrangingfromthe
1012
ultraviolettothevisibleandinfraredwavelengths. Usuallygeneratinglowintensity
lightinthemilliwattdomain,LEDsareconfiguredonsmallchipsorconnectedtosmall
lamps.Forpatients,treatmentwithLEDsispainlessandquick,lastingafewminutesfor
theentireface.AlthoughthemechanismofactionofLEDsinnonablativetherapyisnot
entirelyelucidatedowingtothenoveltyoftheapplication,itisbelievedthatspecific
LEDlightparameters,orcodes,pho
tomodulatecertaincellularandsubcellularreceptors.Preciselydirectedphotomodulation
canthusupregulate,downregulate,orleaveunchangedintracellularcascadesthat
culminateintissueeffects.Unlikeconventionallightbasedtherapies,LLLTresembles
LEDphotomodulationinthatneitherispurportedtorequirehighenergies,significant
patientdiscomfort,orvisibletissueeffectstoeffectdesiredresults.

The use of therapeutic low-level laser has become widespread in veterinary

medicine. A number of illnesses and physical conditions are reported to respond
to laser therapy (photobiomodulation.) There is support in the scientific literature
for many of the physiologic effects claimed by proponents of laser therapy at the
biochemical level. At the level of the organism however, there is still significant
debate regarding the efficacy of laser in producing the desired clinical response.

Although a complete review of the data regarding the effect of laser light therapy
on biochemical and cellular mechanisms is beyond the scope of this
presentation, this overview is intended to provide a preliminary assessment of
the information that is currently available. Understanding the mechanisms and
effects of laser at the subcellular, cellular, systemic and organismal level will lead
to informed treatment decisions and more predictable clinical outcomes. This
review may also help highlight those therapeutic claims which are not currently
well supported by the literature and identify areas where further investigation is
warranted.

L-A-S-E-R stands for light amplification by stimulated emission. The light

produced by a laser is powerful because it has three unique properties: it is
monochromatic (a single wavelength), coherent (waves are in phase), and
collimated (waves are parallel.)

Lasers are usually named according to the technology by which the light is
created, i.e. gas, chemical, solid state, semi-conductor, etc. The technology
roughly determines the wavelength or lengths that can be produced by a
particular laser, although some can be adjusted to produce a wide range of
wavelengths. In medicine and surgery we are most familiar with the HeNe
(helium-neon) laser, which generates light by stimulating gas molecules to
release energy, the diode semi-conductor laser (eg. Gallium aluminum arsenide,
or GaAlAs) and the solid state YAG (yttrium aluminum garnet) laser which uses
garnet (or, historically, ruby) as its excitatory medium. Therapeutic lasers are in
the near infrared spectrum, just on the border of visible light and much shorter
wavelengths and/or lower intensities than are used for surgical applications.

lasers in the non-visible spectrum will not trigger the blink reflex, often a visible
aiming beam is built into the mechanism to avoid accidental

retinal exposure.
Lasers are classified by the FDA according to their intensity and occasionally
wavelength. This

classification system is intended to identify the risk of harm to the patient or user.
In general, therapeutic

lasers fall into the class IIIb or class IV categories. All surgical lasers are class IV.
Significantly, class IV

lasers are considered a risk for retinal damage from both direct and reflected
exposure. Unlike class IIIb

units, class IV laser light can be harmful even when reflected from a matte
surface (such as paper,

painted walls, or the patients skin.) Class IV lasers pose a risk for thermal
damage to tissues and they

are a combustion risk when applied to flammable materials. Because

Effectsoflowlevellasertherapyonthe
progressofwoundhealinginhumans:the
contributionofinvitroandinvivo
experimentalstudies
Atpresent,cutaneouslesionsrepresentadilemmaofglobalproportionsandinstigate
greatclinicalinterestbecauseofthehighmorbidityassociatedwithchangesinthe
normalhealingprocess.1Amongtheclinicalaspectsinvolvingthisissue,weemphasize
tissuerepairtimeinanefforttomaketheprocessquickerandmoreharmonious,reduce
possiblecomplicationsinlesionresolution,andallowanadequatechoiceoftherapy.To
dothis,familiaritywiththepathogenesisoftissuehealingisnecessary,aswellasan
understanding

ofthefactorsaffectingtheprocessandtheroleeachoneplaysinitsprogress,always
seekingaclinicaltreatmentthatoptimizesskinlesioncare.Amongthemethodscur
rentlyavailable,lowlevellasertherapy(LLLT)standsout.

Alliedhealthprofessionalsregularlycareforavarietyofskinwounds,suchas
abrasions,turfburns,surgicalincisions,andulcerations,whichareperhapsthemost
difficulttotreat.Fromacutewoundmanagementtoaugmentationofscartissue
remodeling,theclinicianseekstooptimizewoundcaretopromotehealing.Experimen
talinvitroandinvivostudieshavebeenunderdevelopmentsincethe1960s,andinthe
early1990s,LLLTwasapprovedbytheFoodandDrugAdministration(FDA)asan
importantmethodfortreatinghealingprocesses.24Recentresultsofastudydemonstrated
thatLLLTisaneffectivemethodtomodulatetissuerepair,thussignificantly
contributingtoafasterandmoreorganizedhealingprocess.5

Nevertheless,inspiteofthelargenumberofstudiesinvolvingthistechniqueanditswide
useinclinicalpractice,theprinciplesofitsactionincellsandtissuesarestillnotwell
understood.Theobjectiveofthisstudyistoreviewpathogeneticaspectsofsofttissue
repairtounderstandthemajorcomplicationsinskinlesionhealing.Inaddition,itaims
atformingaconcisecompilationofpublisheddatafromscientificliteraturetodateto
verifywhethertheuseoflowlevellaserinfluenceswoundhealing,sinceitsmechanisms
ofactionarenotfullyclearyet.

Title: Role of Low Level Laser Therapy (LLLT) in Pressure Sore Management

There are situations when patients are unfit for anesthesia or unwilling for surgery when plastic
surgeon has to make the wound heal by secondary intention. In such situations adjunct therapies
like Low Level Laser (LLL) helps in promoting wound healing. LLL are lasers with a wave-
length between 600 and 1000 nanometers and power from 5 to 500 Mw. The bio-stimulatory
properties of LLL has been found to accelerate wound healing, tissue repair and regeneration
Endre Mester, a Hungarian physician initiated the use of Low level laser therapy(LLLT) in 1960
which received FDA approval in the early 1990s.1 LLL do not produce any heat in contrast to
cutting or ablative lasers used in medicine. 2 When given for short duration and enery(<4J), they
have been found to have bio-stimulatory effects on wound healing. This property of LLLT of
accelerating wound healing has been used as adjuvant in the management of various wounds. We
present a 40 year old gentleman with post traumatic paraplegia with multiple pressure sores
(stage II) over bilateral scapular, trochanteric and sacral regions, unfit for anesthesia who was
treated successfully with LLLT as an adjuvant to pressure sore management. The properties of
LLL as described by Posten et al are dose 0.01 to 100 J, wave length 300-10,600 nm, pulse rate
0- 5000 hertz (cycles per second) and power output 0.001-0.1 watts.3
LLL are also known as low-power lasers, soft laser, cold laser, biostimulation laser, therapeutic

laser, and laser acupuncture. LLLT has analgesic, anti-inflammatory actions along with
stimulatory effects on wound healing, tissue repair and regeneration.5 At the cellular level, the

effects of LLLT are as follows6,7:

Increases cellular metabolism

Stimulates cell growth
Increase in proliferation of fibroblasts
Reduces fibrous tissue formation
Promotes cell regeneration
Increase in collagen synthesis
Reduces edema formation
Increase synthesis of growth factors
Decrease in inflammatory cells
Reduces synthesis of inflammatory mediators like substance P, bradykinin, histamine and

acetylcholine production
Stimulates production of nitric oxide
Stimulates nerve regeneration and function
Stimulates endorphins production
Stimulation of angiogenesis
Stimulation for formation of granulation tissue

The photobiological effects of LLLT depends on power, wavelength and duration of application. 8

The commonly used LLLT LASERS include include Gallium Arsenide Ga- As, Gallium

Aluminum Arsenide Ga-Al-As, Krypton, Helium Neon He-Ne, Ruby and argon Ar.3 It has been

used to treat acute and chronic pain, photo rejuvenation of photodamaged skin, wrinkles and

scars, hair loss, dentistry and wound management including burns. 9 LLLT has been found to be

effective as adjuvant therapy in wound management due to its biostimulatory properties. The use

of LLLT as an adjuvant treatment modality for treatment of pressure sores can augment and

accelerate wound healing.

LLL are also known as low-power lasers, soft laser, cold laser, biostimulation laser, therapeutic

laser, and laser acupuncture. LLLT has analgesic, anti-inflammatory actions along with

stimulatory effects on wound healing, tissue repair and regeneration.5 At the cellular level, the

effects of LLLT are as follows6,7:

Increases cellular metabolism

Stimulates cell growth
Increase in proliferation of fibroblasts
Reduces fibrous tissue formation
Promotes cell regeneration
Increase in collagen synthesis
Reduces edema formation
Increase synthesis of growth factors
Decrease in inflammatory cells
Reduces synthesis of inflammatory mediators like substance P, bradykinin, histamine and

acetylcholine production
Stimulates production of nitric oxide
Stimulates nerve regeneration and function
Stimulates endorphins production
Stimulation of angiogenesis
Stimulation for formation of granulation tissue

The photobiological effects of LLLT depends on power, wavelength and duration of application. 8

The commonly used LLLT LASERS include include Gallium Arsenide Ga- As, Gallium

Aluminum Arsenide Ga-Al-As, Krypton, Helium Neon He-Ne, Ruby and argon Ar.3 It has been

used to treat acute and chronic pain, photo rejuvenation of photodamaged skin, wrinkles and

scars, hair loss, dentistry and wound management including burns. 9 LLLT has been found to be

effective as adjuvant therapy in wound management due to its biostimulatory properties. The use

of LLLT as an adjuvant treatment modality for treatment of pressure sores can augment and

accelerate wound healing.

LLL are also known as low-power lasers, soft laser, cold laser, biostimulation laser, therapeutic

laser, and laser acupuncture. LLLT has analgesic, anti-inflammatory actions along with

stimulatory effects on wound healing, tissue repair and regeneration.5 At the cellular level, the

effects of LLLT are as follows6,7:

Increases cellular metabolism

Stimulates cell growth
Increase in proliferation of fibroblasts
Reduces fibrous tissue formation
Promotes cell regeneration
Increase in collagen synthesis
Reduces edema formation
Increase synthesis of growth factors
Decrease in inflammatory cells
Reduces synthesis of inflammatory mediators like substance P, bradykinin, histamine and

acetylcholine production
Stimulates production of nitric oxide
Stimulates nerve regeneration and function
Stimulates endorphins production
Stimulation of angiogenesis
Stimulation for formation of granulation tissue

The photobiological effects of LLLT depends on power, wavelength and duration of application. 8

The commonly used LLLT LASERS include include Gallium Arsenide Ga- As, Gallium

Aluminum Arsenide Ga-Al-As, Krypton, Helium Neon He-Ne, Ruby and argon Ar.3 It has been

used to treat acute and chronic pain, photo rejuvenation of photodamaged skin, wrinkles and

scars, hair loss, dentistry and wound management including burns. 9 LLLT has been found to be

effective as adjuvant therapy in wound management due to its biostimulatory properties. The use

of LLLT as an adjuvant treatment modality for treatment of pressure sores can augment and

accelerate wound healing

LASER (Light Amplification by Stimulated Emission of Radiation) since its invention in 1960

and its first utility in the biomedical field in 1983 continues to evolve and improve

technologically with the spectrum of its utility in the medical field expanding exponentially 3.

Commonly used LASERS for LLLT include gallium aluminum arsenide Ga-Al-As (805 or 650

nm), gallium arsenide Ga- As (904 nm), Krypton (521, 530, 568, and 647 nm), argon Ar (488

and 514 nm), helium neon He-Ne (632.8 nm) and ruby (694 nm). 2 LLLT has known to have bio-

stimulatory effects on wound healing to augment tissue repair and regeneration along with its

anti-inflammatory and analgesic effects.4It has also been used for photo rejuvenation of photo

damaged skin, wrinkles and scars.5

The following biological effects of low level laser therapy include decrease in inflammatory

cells, decreased synthesis of inflammatory mediators, increased secretion of growth factors,

increase in proliferation of fibroblasts, increase in collagen synthesis, stimulation of angiogenesis

& stimulation for formation of granulation tissue. 6 The photo biological effects of low level laser

therapy depends on the wavelength, dose, power and duration of application. 7 The biostimulatory

effects of low level laser therapy have been found to be effective as adjuvant therapy to

accelerate wound healing. Burn wound healing can be augmented by use of LLLT as an adjuvant

to other measures.8,9