Allied health professionals regularly

care for a variety of skin wounds, such

as abrasions, turf burns, surgical
incisions, and ulcerations, which are
perhaps the most difficult to treat.
From acute wound management to
augmentation of scar tissue
remodeling, the clinician seeks to
optimize wound care to promote
healing.
4
 Experimental in vitro and in vivo
studies have been under development
since the 1960s, and in the early 1990s,
LLLT was approved by the Food and
Drug Administration (FDA) as an
important method for treating healing
processes.2-4
Recent results of a study
demonstrated that LLLT is an effective
method to modulate tissue repair, thus
significantly contributing to a faster and
more organized healing process.5
5
 Low level laser acts (biostimulative
light energy effect) on biological
tissues at cellular level. Absorbed laser
energy causes stimulation of molecules
and atoms of cells, followed by-
Stimulates cell activation processes
which in turn, intensify physiological
activities.
6
 Enhancement of
SOFT Tissue Healing.
Although there are no magical ways
to heal soft tissue wound, but there
are ways to help speed up the
healing process, and help debilitated
patient to recover earlier/ faster.
Proper medical management of the
wound.
Proper management of systemic
diseases.
Proper Nursing.
Nutritional Support.
Stem Cell therapy/ Gene-therapy.
Ultrasound therapy.
Low Level Laser therapy.
The beneficial effect of LLLT on wound healing
can be explained by considering several basic
biological mechanisms :
Firstly, there is a report [48] that laser increases
both protein and mRNA levels of IL-1 and IL-8
in keratinocytes. These are cytokines
responsible for the initial inflammatory phase
of wound healing.
Secondly, there are reports [49] that LLLT can
upregulate cytokines responsible for fibroblast
proliferation, and migration such as bFGF,
HGF and SCF.
Thirdly ,it has been reported [50] that LLLT can
increase growth factors such as VEGF
responsible for the neovascularization
necessary for wound healing.
Fourthly, TGF- is a growth factor
responsible for inducing collagen synthesis
from fibroblasts and has been reported to be
upregulated by LLLT [51].
Fifthly ,
There are reports [52, 53] that LLLT can induce
fibroblasts to undergo the transformation
into myofibloblasts, a cell type that expresses
smooth muscle -actin and desmin and has
the phenotype of contractile cells that
hasten wound contraction.
Laser mechanism of Action
on biological tissues can be
explained by-
1. Physical mechanism
2. Bio-chemical mechanism
The primary (physical) mechanisms
relate to the interaction between
photons and molecules in the tissue,
while the secondary mechanisms
relate to the effect of the chemical
(Bio-chemical) changes induced by
primary effects.
10
 Mechanism
of action Of LLLT on
Physical - tissue-

There are two primary forms of

physical effects generated by
laser irradiation on biological
tissues:
Photon-absorption ( the basis of
photobiological action, and
generated by all forms of light).
Internal conversion &
fluorescence of light also
generates Speckle formation,
which is unique to laser therapy.
11
 Mechanism
of action Of LLLT on tissue-

Biochemical - Action of Laser/Light photon

with mitochondrial respiratory chain
Cytochromecoxidase enzyme.
Cytochromecoxidase mediated
increase
in ATP production.
Cytochromecoxidase mediated singlet-
oxygen production.
Cytochromecoxidase mediated
Reactive oxygen species (ROS)
formation.
Cytochromecoxidase mediated
Photodiassociation and Nitric Oxide
Production.
12
Mechanism
of action Of LLLT on tissue-

Low Level Laser

Increases -
Cellular ion-exchange,
Tissue vascularization,
Lymphatic circulation,
Fibroblast,
And Activates -
Cytokines,
Growth factors and
Necessary hormonal activities for
tissue healing enhancement in the
proliferative stage thereby reduction
of pain & inflammation.
13
Current Issue
Materials & Method

Place of study:

15
Materials & Method

Duration of study:
The duration of this study was
one year (from Jan.- 2010 to
Dec.- 2010.
Type of study:
Prospective Randomized Case
Control study.
 Materials & Method

Patient:
Bedsore/ Decubitus Ulcer
Patients.
Materials: sample A total of 10 patients randomly
collected.
The sample was collected randomly
from admitted patients with
Bedsore in the back older than 12
weeks which has not cured by all
means of available conventional
medical management.
17
 Materials & Method
1. Patient suffering from bedsore more
Selection Criteria-
Inclusion Criteria : than 12 weeks.
2. Failed to heal by all means of
conventional therapy.
3. Male and Female ratio- 50:50.
4. Age between 55- 95 years old,
5. Hasnt previously treated with
LLLT.
 Materials & Method
Selection Criteria-
The patients were briefed
about the study and
Medico-legal written consent (Informed
Informed Consent: consent) was obtained
from all patients/ medico-
legal guardian for other
patients.
 Materials & Method

Machine: BioLux MD
Bio-Lux MD Ga- Al-
As Laser LLLT, Low Level Laser
( 660 nm ) Machine. (LED- Ga-Al- As 660).
Irradiance Parameters
LED Apparatus: BioLux MD
Beam source -
Incoherent-Ga-Al-As.
o Mode: Continuous wave
o Irradiance dose: 4- 8 J/cm2/min.
o Irradiance time: 1- 2 minutes
o Wavelengths Used: 660 nm.
o Total session: 25-35.
 Materials & Method
Method:
Ten (10) patients with bedsore
(on the back) were selected for
placebo-controlled, double-blind
study using low energy photon
therapy (LLLT).
Treatment was given three times
a week for 10 weeks, using
monochromatic (red) optical
sources; diode 660nm (GaAl-
660).
21
Method: Materials & Method

The patients who were

randomized to placebo
treatment received sham
therapy from an identical-
appearing light source from
the same delivery system.
22
 Materials & Method
Method: Treatment Protocol/ Schedule
(Dose, duration and wound parameter)

TABLE -1
Approach and methodology
Frequenc Wound Irradiation Energy Poin Time
week y Area/size Source Wave Fluency t

1-2 week 5/ week 6.8 cm2 LED-660 nm (Ga- Contin 6 joules/cm2 2 8 joules/min.
Al-As) uous

3-5 week 3/ week 5.7 cm2 LED-660 nm (Ga- Contin 4 joules/cm2 2 8 joules/min.
Al-As) uous

4-6 week 3/ week 4.4 cm2 LED-660 nm (Ga- Contin 4 joules/cm2 1 8 joules/min.
Al-As) uous

7-8 week 2/week 2.2 cm2 LED-660 nm (Ga- Contin 3 joules/cm2 1 8 joules/min.
Al-As) uous

9-10 week 2/ week Closed LED-660 nm (Ga- Contin 3 joules/cm2 1 8 joules/min.

Al-As) uous

23
 1. Subjective assessment:
Physical Assessment: Assessment done
Materials by doing comparison of wound healing
& Method treated by laser therapy to regular
stages of wound healing by natural
Efficacies process.
of treatment a. Colour
were evaluated b. Vascularity
c. Margin
by-
d. Depthness of wound.
2. Objective assessment:
Clinical assessment by -
a. Function of the affected area.
b. Mobility of the treated side.
c. Patient Compliance.
24
 Chronological Picture
View of
a Laser(LLLT) Treated
Patient.

Visualization of treatment
Progress by
1st,2nd,3rd week)
LLLT (LED-Ga-Al-As 660 nm)
of a patient -

4th,5th,6th week)

7th,8th,week)

9th,10th,11th,12th week) 25
In this study, the percentage of
the initial ulcer area remaining
unhealed in the LLLT and placebo
groups was 24.4% and 84.7%,
respectively (P = 0.0008).
The decrease in ulcer area
(compared to baseline) observed
in the LLLT and placebo groups
was 193.0 mm2 and 14.7 mm2,
respectively (P = 0.0002).
26
 TABLE -2

Morphology of the Wounds Before and After Therapy-

Wound Before debridement After debridement/ closure

Wound parameters- Prior to End of Prior to End of

Therapy Therapy Therapy Therapy

1. Margin Irregular & Partially Regular

indurated Sutured In tacked skin

2. Floor Unhealthy, Almost Healthy

Necrotic Oozing granulation tissue Covered Covered
Tissue

3. Base Spine bone Partially Clear Spine

Exposed granulation tissue bone covered Covered

4 Surrounding skin Inflamed and Partially Healthy Healthy Up to

scared mark Healthy

5. Discharge Profuse purulent Serous Discharge

Oozing pus No discharge No discharge

27
Low-level laser therapy is an important
method for the treatment of healing
processes, and several experimental
studies have been carried out in search
of a greater understanding of its
therapeutic possibilities.
The objective of this study was to review
pathogenetic aspects of soft tissue repair
to better understand skin lesion healing
and the role of low-intensity laser in the
progression of tissue healing.
28
In the past Laser / LED were shown
to be effective in wound
management but in different
degrees, some of those applications
showed significant improvement.
This study results efficacy of LLLT on
wound healing in human model, and
indicates that it can be a very
important adjunctive tool /modality
for chronic intractable wound
management, and in any way it is
not harmful to human being.
29
The result of this study reveals a
better Bedsore Healing by diode
laser (Ga-Al-As).
This study result also concludes
that better healing after irradiation
with Ga-Al-As, 660nm diode laser
in human model as an adjunctive
to regular medical management
that accelerates soft tissue wound
healing significantly and enhances
patient compliances.
This study has demonstrated
the potential of low level laser therapy
in the treatment of
Enhancement
Of
Human Bedsore
Healing.
In conjunction to Regular
Management.

31
A large multi- centric study
pointing important
Subjective i.e.
Mechanical,
Biochemical And
Histological As Well As
Objective
Clinical Parameters.

32
 Including -
laser protocol (dose, duration, type
of laser & mode of operation),
patient selection criteria and
procedure of therapy,
is highly desirable to make this
non-invasive and very effective
method of bedsore healing
available in medical science. 33
1. Mechanisms of Low Level Laser Therapy.
Michael R Hamblin a, b, c,* and Tatiana N Demidova a,d a Wellman Center for Photomedicine, Massachusetts General Hospital, b
Department of Dermatology, Harvard Medical School, c Harvard-MIT Division of Health Sciences and Technology, d Graduate
Program in Cell Molecular and Developmental Biology, Sackler School of Graduate Biomedical Sciences, Tufts University
School of Medicine
2. A.N. Pereira, P. Eduardo Cde, E. Matson and M.M. Marques, Effect of low-power laser
irradiation on cell growth and procollagen synthesis of cultured fibroblasts, Lasers Surg Med 31 (2002) 263-7.
3. J.C. Sutherland, Biological effects of polychromatic light, Photochem Photobiol 76 (2002) 164- 70.
4. T. Karu, Laser biostimulation: a photobiological phenomenon, J Photochem Photobiol B 3(1989) 638-40.
5. T.I. Karu and N.I. Afanas'eva, Cytochrome c oxidase as the primary photoacceptor upon laser exposure of cultured cells to
visible and near IR-range light, Dokl Akad Nauk 342 (1995) 693-5.
6. R.A. Capaldi, F. Malatesta and V.M. Darley-Usmar, Structure of cytochrome c oxidase, Biochim Biophys Acta 726 (1983) 135-48.
7. Szundi, G.L. Liao and O. Einarsdottir, Near-infrared time-resolved optical absorption studies of the reaction of fully
reduced cytochrome c oxidase with dioxygen, Biochemistry 40 (2001) 2332-9.
8. T.I. Karu and S.F. Kolyakov, Exact action spectra for cellular responses relevant to phototherapy,Photomed
Laser Surg 23 (2005) 355-61.
9. W. Yu, J.O. Naim, M. McGowan, K. Ippolito and R.J. Lanzafame, Photomodulation of oxidative metabolism and electron chain
enzymes in rat liver mitochondria, Photochem Photobiol 66 (1997) 866-71.
10. S. Passarella, He-Ne laser irradiation of isolated mitochondria, J Photochem Photobiol B 3 (1989) 642-3.
11. H. Friedmann, R. Lubart, I. Laulicht and S. Rochkind, A possible explanation of laser- induced stimulation and damage of
cell cultures, J Photochem Photobiol B 11 (1991) 87-91.
12. M. Eichler, R. Lavi, A. Shainberg and R. Lubart, Flavins are source of visible-light- induced free radical formation in
cells, Lasers Surg Med 37 (2005) 314-9.
13. K. Plaetzer, T. Kiesslich, B. Krammer and P. Hammerl, Characterization of the cell death modes and the associated changes
in cellular energy supply in response to AlPcS4-PDT, Photochem Photobiol Sci 1 (2002) 172-7.
14. [18] R. Lubart, M. Eichler, R. Lavi, H. Friedman and A. Shainberg, Low-energy laser irradiation promotes cellular redox activity, Photomed
Laser Surg 23 (2005) 3-9.
15. R. Duan, T.C. Liu, Y. Li, H. Guo and L.B. Yao, Signal transduction pathways involved in low intensity He-Ne laser-induced respiratory burst
in bovine neutrophils: a potential mechanism of low intensity laser biostimulation, Lasers Surg Med 29
(2001) 174-8.
16. F. Antunes, A. Boveris and E. Cadenas, On the mechanism and biology of cytochrome oxidase inhibition by nitric oxide, Proc Natl Acad Sci U
S A 101 (2004) 16774-9.
17. T.I. Karu, L.V. Pyatibrat and N.I. Afanasyeva, Cellular effects of low power laser
therapy can be mediated by nitric oxide, Lasers Surg Med 36 (2005) 307-14.
18. Y. Moriyama, E.H. Moriyama, K. Blackmore, M.K. Akens and L. Lilge, In Vivo Study of the Inflammatory Modulating Effects of Low-level Laser
Therapy on iNOS Expression Using Bioluminescence Imaging, Photochem Photobiol 81 (2005) 1351-5.
19. F.Q. Schafer and G.R. Buettner, Redox environment of the cell as viewed through
the redox state of the glutathione disulfide/glutathione couple, Free Radic Biol Med 30 (2001) 1191-212.
20. H. Liu, R. Colavitti, Rovira, II and T. Finkel, Redox-dependent transcriptional regulation, Circ Res 97 (2005) 967-74.
21. M. Yang, N.B. Nazhat, X. Jiang, S.M. Kelsey, D.R. Blake, A.C. Newland and C.J. Morris, Adriamycin stimulates proliferation of human
lymphoblastic leukaemic cells via a mechanism of hydrogen peroxide (H2O2) production, Br J Haematol 95 (1996) 339-44.
22. W.G. Kirlin, J. Cai, S.A. Thompson, D. Diaz, T.J. Kavanagh and D.P. Jones, Glutathione redox potential in response to differentiation and
enzyme inducers, Free Radic Biol Med 27 (1999) 1208-18.
23. S. Alaluf, H. Muir-Howie, H.L. Hu, A. Evans and M.R. Green, Atmospheric oxygen accelerates the induction of a post-mitotic phenotype in
human dermal fibroblasts: the key protective role of glutathione, Differentiation 66 (2000) 147-55.
24. T. Karu, Primary and secondary mechanisms of action of visible to near-IR radiation on cells, J Photochem Photobiol B 49 (1999) 1-17.
25. S. Young, P. Bolton, M. Dyson, W. Harvey and C. Diamantopoulos, Macrophage responsiveness to light therapy, Lasers Surg Med 9 (1989)
497-505.
26. Y. Fujimaki, T. Shimoyama, Q. Liu, T. Umeda, S. Nakaji and K. Sugawara, Low-level laser irradiation attenuates production of reactive
oxygen species by human neutrophils, J Clin Laser Med Surg 21 (2003) 165-70.
27. 27. laser irradiation stimulates interleukin-1 alpha and interleukin-8 release from cultured human keratinocytes, J Invest Dermatol 107
(1996) 593-6.
28. V.K. Poon, L. Huang and A. Burd, Biostimulation of dermal fibroblast by sublethal Q-switched Nd:YAG 532 nm laser: collagen remodeling and
pigmentation, J Photochem Photobiol B 81 (2005) 1-8.
29. N. Kipshidze, V. Nikolaychik, M.H. Keelan, L.R. Shankar, A. Khanna, R. Kornowski,
M. Leon and J. Moses, Low-power helium: neon laser irradiation enhances production of vascular endothelial growth factor and promotes
growth of endothelial cells in vitro, Lasers Surg Med 28 (2001) 355-64.
30. A. Khanna, L.R. Shankar, M.H. Keelan, R. Kornowski, M. Leon, J. Moses and N. Kipshidze, Augmentation of the expression of proangiogenic
genes in cardiomyocytes with low dose laser irradiation in vitro, Cardiovasc Radiat Med 1 (1999) 265-9.
31. A.R. Medrado, L.S. Pugliese, S.R. Reis and Z.A. Andrade, Influence of low level laser therapy on wound healing and its biological action
upon myofibroblasts, Lasers Surg Med
32. 32 (2003) 239-44. 32. E.J. Neiburger, Rapid healing of gingival incisions by the helium-neon diode laser, J Mass Dent Soc 48 (1999) 8-13,
40.
33. K. Branco and M.A. Naeser, Carpal tunnel syndrome: clinical outcome after low-
level laser acupuncture, microamps transcutaneous electrical nerve stimulation, and other alternative therapies--an open protocol study, J
Altern Complement Med 5 (1999) 5-26.
34. J. Irvine, S.L. Chong, N. Amirjani and K.M. Chan, Double-blind randomized controlled trial of low-level laser therapy in carpal tunnel syndrome,
Muscle Nerve 30 (2004) 182-7.
35. M.I. Weintraub, Noninvasive laser neurolysis in carpal tunnel syndrome, Muscle Nerve 20 (1997) 1029-31.
36. chindler A, et al. Increased dermal neovascular-ization after low dose laser therapy. 2nd Congress, World Association for Laser Therapy.
Kansas City. 1998.
37. Almeida-Lopes L, et al. Comparison of the low level laser therapy effects on cultured human gingival fibroblasts proliferation using different
irradiance and same fluence. Lasers in Surgery and Medicine. 2001. 29(2):179-184.
38. Samoilova KA, et al. Enhancement of the blood growth promoting activity after exposure of volun-teers to visible and infrared polarized light.
Part I: stimulation of human keratinocyte proliferation in vitro. Advance Article of 2004 Photochemical & Pho-tobiological Sciences. Published
on the web at http://www.rsc.org/is/journals/current/PPS/ppAd-vArts.htm. Sept 1, 2003.
39. Barber A, et al. Advances in laser therapy for bone repair. The Journal of Laser herapy. Vol.13. World Association of Laser
Therapy. 2000.
40. 52. Antonio L, et al. Biomodulatory effects of LLLT on bone regeneration. The Journal of Laser Therapy. Vol. 13. World Association of Laser
Therapy. 2000.
41. Shefer G, et al. Low energy laser irradiation pro-motes the survival and cell cycle entry of skeletal muscle satellite cells. Journal of Cell
Science. 2002. 115: 1461-1469.
42. Enwemeka CS and Reddy GK. The biological ef-fects of laser therapy and other modalities on con-nective tissue repair processes. The
Journal of Laser Therapy. Vol. 12. World Association of Laser Therapy. 2000.
43. Reddy GK, Stehno-Bittel L, and Enwemeka CS. Laser photo stimulation accelerates wound healing in diabetic rats. Wound Repair and
Regeneration. 2001. 9:248-255.
44. Stadler I, et al. 830 nm irradiation increases the wound tensile strength in diabetic murine model. Lasers in Surgery and Medicine. 2001. 28
(3):220-226.
45. Parizotto N, et al. Structural analysis of colagen fibrils after He-Ne laser photo stimulation. 2nd Con-gress, World Association for Laser
Therapy. Kansas City. 1998..
46. Simunovic Z, et al. Low level laser therapy of soft tissue injuries upon sport activities and traffic acci-dents: a multicenter, double-blind,
placebo-controled clinical study on 132 patients. Pain Center-Laser Cen-ter, Locarno, Switzerland. Abstract from II Congress of the Internat.
Assn for Laser and Sports Medicine, Rosario, Argentina. March 10-12, 2000.
47. 47. Y.S. Chen, S.F. Hsu, C.W. Chiu, J.G. Lin, C.T. Chen and C.H. Yao, Effect of low-power pulsed laser on peripheral nerve regeneration
in rats, Microsurgery 25 (2005) 83-9.
48. M. Miloro, L.E. Halkias, S. Mallery, S. Travers and R.G. Rashid, Low-level laser effect on neural regeneration in Gore-Tex tubes, Oral Surg
Oral Med Oral Pathol Oral Radiol Endod 93 (2002) 27-34.
49. P. Balaban, R. Esenaliev, T. Karu, E. Kutomkina, V. Letokhov, A. Oraevsky and N. Ovcharenko, He-Ne laser irradiation of single identified
neurons, Lasers Surg Med 12 (1992) 329-37.
50. K.R. Byrnes, R.W. Waynant, I.K. Ilev, X. Wu, L. Barna, K. Smith, R. Heckert, H. Gerst and J.J. Anders, Light promotes regeneration and
functional recovery and alters the immune response after spinal cord injury, Lasers Surg Med 36 (2005) 171-85.
51. S.O. el Sayed and M. Dyson, Effect of laser pulse repetition rate and pulse duration on mast cell number and degranulation, Lasers Surg
Med 19 (1996) 433-7.
52. R.A. Lopes-Martins, R. Albertini, P.S. Martins, J.M. Bjordal and H.C. Faria Neto, Spontaneous effects of low-level laser therapy (650 nm)
in acute inflammatory mouse pleurisy induced by Carrageenan, Photomed Laser Surg 23 (2005) 377-81.
53. A.D. Agaiby, L.R. Ghali, R. Wilson and M. Dyson, Laser modulation of angiogenic factor production by T-lymphocytes, Lasers Surg Med
26 (2000) 357-63.
54. S. Passarella, E. Casamassima, S. Molinari, D. Pastore, E. Quagliariello, I.M. Catalano and A. Cingolani, Increase of proton
electrochemical potential and ATP synthesis in rat liver mitochondria irradiated in vitro by helium-neon laser, FEBS Lett 175 (1984) 95-9.
55. M. Greco, G. Guida, E. Perlino, E. Marra and E. Quagliariello, Increase in RNA and protein synthesis by mitochondria irradiated with
helium-neon laser, Biochem Biophys Res Commun 163 (1989) 1428-34.
56. D. Pastore, M. Greco, V.A. Petragallo and S. Passarella, Increase in <--H+/e- ratio of the cytochrome c oxidase reaction in mitochondria
irradiated with helium-neon laser, Biochem Mol Biol Int 34 (1994) 817- 26.
57. Y. Zhang, S. Song, C.C. Fong, C.H. Tsang, Z. Yang and M. Yang, cDNA microarray analysis of gene expression profiles in human
fibroblast cells irradiated with red light, J Invest Dermatol 120 (2003) 849-57.
58. R.F. Lyons, R.P. Abergel, R.A. White, R.M. Dwyer, J.C. Castel and J. Uitto, Biostimulation of wound healing in vivo by a helium-neon
laser, Ann Plast Surg 18 (1987) 47-50. H.S. Yu, K.L. Chang, C.L. Yu, J.W. Chen and G.S. Chen, Low-energy helium-neon